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Natriuretic peptide-guided therapy

Further research required for still-unresolved issues

Therapie unter Berücksichtigung des natriuretischen Peptids

Weitere Studien zu ungelösten Fragen erforderlich

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Abstract

It has been asserted that serial measurements of natriuretic peptides (NPs), i.e., B-type natriuretic peptide (BNP) or the amino-terminal fragment of pro-B-type natriuretic peptide (NT-pro BNP), could help modulate more accurately the intensity of drug treatment in patients with chronic heart failure (CHF). Nevertheless, there are still several open questions about the presumed role of NP-guided pharmacologic adjustment as a valuable strategy in this setting. In this review, we outline the main randomized controlled trials (RCTs) carried out to date regarding NP-guided therapy in CHF patients and we focus on some of the still-unresolved issues. In particular, we discuss which NP plasma level should be assumed as the optimal target level to be attained, and we debate the possible influence exerted by different age classes on clinical end points during NP-guided therapy. The possible advantages and limitations for the cardiovascular system arising from the functional activation of NPs in CHF patients are also discussed. Although the pooling of data derived from the RCTs demonstrates an overall effect of slightly significant improvement in clinical outcomes with the NP-guided approach, we have noted that there are some relatively large studies that failed to document a significant clinical improvement in terms of mortality and morbidity using an NP-guided strategy. Thus, in our opinion, larger and better conducted trials addressing the unresolved issues of NP-guided therapy should be undertaken in the future.

Zusammenfassung

Festgestellt worden war, dass die fortlaufende Bestimmung natriuretischer Peptide (NPs), d. h. des NP vom B-Typ („B-type natriuretic peptide“, BNP) oder des aminoterminalern Fragments des BNP (NT-pro BNP), sinnvoll als Handlungsleitschiene eingesetzt werden könnten, um die Intensität der medikamentösen Therapie bei Patienten mit chronischer Herzinsuffizienz („chronic heart failure“, CHF) genauer anzupassen. Trotzdem bleibt eine beachtenswerte Verwirrung über die unterstellte Rolle der NP-geführten medikamentösen Anpassung als sinnvolle Strategie in diesem Rahmen. In der vorliegenden Übersichtsarbeit stellen die Autoren die wesentlichen randomisierten kontrollierten Studien („randomized controlled trials“, RCTs) kurz dar, die bisher hinsichtlich der NP-geführten Therapie bei CHF-Patienten durchgeführt wurden, und weisen auch auf einige noch ungelöste Fragen dabei hin. Insbesondere wird diskutiert, welcher NP-Plasmaspiegel als optimaler Zielwert angenommen werden sollte, außerdem wird über den möglichen Einfluss verschiedener Altersklassen auf die klinischen Endpunkte während der NP-geführten Therapie sowie die möglichen Vorteile und Grenzen für das kardiovaskuläre System diskutiert, die sich aus der funktionellen Aktivierung von NPs bei CHF-Patienten ergeben. Auch wenn die gepoolten Daten aus den bisher abgeschlossenen RCTs den Gesamteffekt einer leicht signifikanten Verbesserung des klinischen Verlaufs beim NP-geführten Ansatz zeigen, stellen die Autoren fest, dass einige relativ große Studien bleiben, bei denen keine signifikante klinische Verbesserung hinsichtlich Mortalität und Morbidität bei Einsatz der NP-geführten Strategie dokumentiert wurde. Daher sollten ihrer Meinung nach in Zukunft größere und besser durchgeführte Studien zu den ungelösten Fragen der NP-geführten Therapie organisiert werden.

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On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Presidio Sanitario Intermedio “Elena d’ Aosta”, Cardiology Unit, Napoli, via Cagnazzi 29, 80137, Napoli, Italy

    R. De Vecchis & S. Cantatrione

  2. Institute of Hygiene and Preventive Medicine, Second University of Napoli, Napoli, Italy

    C. Esposito

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  1. R. De Vecchis
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  2. C. Esposito
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  3. S. Cantatrione
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Correspondence to R. De Vecchis.

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De Vecchis, R., Esposito, C. & Cantatrione, S. Natriuretic peptide-guided therapy. Herz 38, 618–628 (2013). https://doi.org/10.1007/s00059-013-3772-8

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