Heart Failure Prevention, Diagnosis, and Management
Heart failure is a complex, progressive disease.1 Despite advances in treatment, about half of patients with heart failure die within 5 years of diagnosis.2 Any condition that affects the function of the heart and impairs ventricular filling or ejection can cause heart failure (see Sidebar).3 Onset may be acute (eg, after myocardial infarction) or insidious (eg, with progressive coronary artery disease).3
The American Heart Association (AHA) estimates that 6.5 million persons in the United States aged 20 or older have heart failure.4 The prevalence will only increase as the population continues to age and with improved survival after myocardial infarction; by 2030, an estimated 8 million Americans will have heart failure.4
Heart failure frequently presents with nonspecific signs and symptoms. Consequently, diagnosis may be delayed, leading to worse outcomes. Natriuretic peptides have been in use for management of patients with heart failure. To help prevent or detect heart failure, current guidelines now recommend measurement of natriuretic peptides as a screening tool.5,6
This article will discuss the role of natriuretic peptides and other biomarkers in the prevention, diagnosis, and management of heart failure, and focus on the 2017 update of the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) recommendations for the use of biomarkers in heart failure.5
Biomarkers in the Prevention, Diagnosis, and Management of Heart Failure
The 2013 ACC/AHA/HFSA guidelines were updated in 2017 to clarify the use of several biomarkers in patients at risk for heart failure, and those with suspected or known heart failure.5,6
In response to stretching caused by increased ventricular blood volume and other causes of myocardial stress, cardiomyocytes in the heart ventricles release a natriuretic peptide called proB-type natriuretic peptide (proBNP).1 In circulation, proBNP is cleaved into smaller peptides, including BNP and N-terminal proBNP (NT-proBNP). BNP is an active hormone that regulates fluid balance and blood pressure, whereas NT-proBNP has no established bioactivity. Either can be used for distinguishing heart failure from other causes of dyspnea in the emergency department.1
The ACC/AHA/HFSA guidelines now recommend natriuretic peptide–screening for patients at risk for heart failure who do not have cardiac disease or systolic dysfunction at baseline (eg, those with hypertension or diabetes mellitus).5 Elevated BNP and NT-proBNP have been associated with a higher risk of heart failure and cardiac events.6
For disease management, the 2017 guidelines recommend measuring natriuretic peptide levels in patients hospitalized for decompensated heart failure.5 Admission levels of natriuretic peptide are useful for predicting the hospitalization course, and predischarge levels are useful for establishing a postdischarge prognosis. Higher natriuretic peptide levels may suggest a worse prognosis and the need for more intensive monitoring and therapy.5 Unchanged from the 2013 guidelines is using natriuretic peptide levels to monitor patients with chronic heart failure. Increasing levels correlate with increasing disease severity.6
Importantly, natriuretic peptide levels are also elevated in a variety of disorders not associated with heart failure (eg, liver cirrhosis and hyperthyroidism). Consequently, results must be interpreted in light of additional data, including the patient’s clinical signs and symptoms.7
Cardiac troponin (cTN) I and T
Cardiac troponin (cTN) protein markers are useful in patients with acute decompensated heart failure. The cTN complex is integral to skeletal and cardiac muscle contraction and consists of 3 regulatory proteins.1 Of the 3, cTN I and cTN T are sensitive and specific markers of damage to heart muscle.1 Elevated cTN I and cTN T levels are associated with a higher risk of death and worse clinical outcomes. Consequently, the 2017 guidelines recommend measuring levels of these proteins to establish a prognosis for patients presenting with acute decompensated heart failure on hospital admission.5
Biomarkers of Myocardial Fibrosis
Galectin-3, soluble ST2 receptor, and high-sensitivity cardiac troponin are indicators of myocardial fibrosis.1 Elevated levels are predictive of hospitalization and death in patients with heart failure.1 Their prognostic value is additive to that of natriuretic peptide levels, and the 2017 guidelines indicate their measurement may be considered for additive risk stratification in patients with chronic heart failure.5
- Ibrahim NE, Januzzi JL Jr. Established and emerging roles of biomarkers in heart failure. Circ Res. 2018;123:614-629.
- Brito D, Cepeda B. Heart failure, congestive (CHF). StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2018. https://www.ncbi.nlm.nih.gov/books/NBK430873/. Updated October 27, 2018. Accessed February 1, 2020.
- Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol. 2016;13:368-378.
- Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139:e56-e528.
- Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137-e161.
- 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. Circulation. 2017;135:e1054-e1091.
- Inamdar AA, Inamdar AC. Heart failure: diagnosis, management, utilization. J Clin Med. 2016;5. pii: E62. doi:10.3390/jcm5070062