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Heart Failure Tests Can Improve Diagnosis & Care

Circulation; ePub 2017 Apr 26; Chow, et al

The use of biomarkers for the diagnosis and management of heart failure is an area of intense study and holds the promise of decreasing death and re-hospitalization though the use of novel tests for heart failure, which may be able to better guide the diagnosis and management of HF, according to a new scientific statement from the American Heart Association (AHA). The statement summarizes the existing literature and provides guidance for the utility of currently available biomarkers associated with HF, including natriuretic peptides, soluble suppressor of tumorgenicity 2, highly sensitive troponin, galectin-3, midregional proadrenomedullin, cystatin-C, interlukin-6, procalcitonin, and others. Among the conclusions and recommendations:

  • In community-based populations, measurement of natriuretic peptides (BNP or NT-proBNP) or markers of myocardial injury (TnI or TnT) alone adds prognostic information to standard risk factors for predicting new-onset HF.
  • Measurement of several new biomarkers, including sST2, Gal-3, GDF-15, and markers of renal function, alone or in a multimarker strategy, may be useful for providing additional risk stratification.
  • Measurement of BNP or NT-proBNP and cTn at the time of presentation is useful for establishing prognosis or disease severity in patients with acutely decompensated HF.
  • Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis is reasonable for additive risk stratification in patients with acutely decompensated HF.
  • Measurement of predischarge BNP or NT-proBNP during an HF hospitalization can be useful for establishing postdischarge prognosis.

Citation:

Chow SL, Maisel AS, Anand I, et al. Role of biomarkers for the prevention, assessment, and management of heart failure. A scientific statement from the American Heart Association. [Published online ahead of print April 26, 2017]. Circulation. doi:10.1161/CIR.0000000000000490.

Commentary:

This guideline suggests a great deal of excitement surrounding the use of biomarkers for the diagnosis and management of heart failure, while also suggesting caution in the clinical use of biomarkers. For instance, BNP, a commonly used biomarker, has a sensitivity of 90% and specificity of 76% at a cutoff of 100 pg/mL, so it is useful in the correct setting to corroborate a clinical diagnosis of CHF. However, testing with BNP would generate many false-positive diagnoses if used indiscriminately in populations with a low likelihood of CHF. Another example of an area of caution is the excitement around using BNP to guide heart failure treatment, treating to a low level of BNP rather than to clinical endpoints. The GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial, reviewed in the current guideline, was a prospective, randomized, controlled, multicenter clinical trial that evaluated using targeting BNP to adjust therapy for CHF and was stopped early for futility in showing any difference between the BNP and the clinically guided group.1 In summary, while biomarkers such as troponins and BNP have important places in practice, the use of emerging biomarkers for diagnosis and guiding therapy is an area of both increasing evidence and recommended clinical caution. —Neil Skolnik, MD

  1. Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: The International Collaborative of NT-proBNP Study. Eur Heart J. 2006;27:330–337. doi:10.1093/eurheartj/ehi631.