Cardiac congestion assessed by natriuretic peptides oversimplifies the definition and treatment of heart failure

• Published in: ESC Heart Failure 2021-10, Vol.8 (5), p.3453-3457
• Main Authors: Palazzuoli, Alberto, Mullens, Wilfried
• Format: Article
• Language: English
• Subjects: Blood; Compliance; Disease; Ejection fraction; Heart failure; Laboratories; Peptides; Pulmonary arteries; Ultrasonic imaging
• ISSN: 2055-5822; 2055-5822
• DOI: 10.1002/ehf2.13495

[...]congestion does not equal volume overload, and often, pressure and volume changes diverge, which complicates the identification and treatment of HF. [...]it is not surprising that the assessment of congestion through current clinical assessment correlates at best only moderately with the ‘gold standard’ of an invasive assessment. 4,5 Therefore, Harjola et al. 6 purposed a congestion score related to organ injury assessed through an integrated ultrasonographic assessment evaluating cardiac, lung and abdominal districts. BNP, B-type natriuretic peptide; IVC, inferior cava vein; LA, left atrium; LV, left ventricle; PASP, pulmonary artery systolic pressure NPs as HF hallmark A universal accepted threshold for NP's to include and/or exclude HF is far from being achieved. 12,13 Although NPs surely have diagnostic and prognostic importance in acute and advanced HF, they are of limited help to guide HF therapies. 14,15 In addition, the role of NPs to diagnose patients at risk for HF and those with structural heart disease without clinical evidence of congestion (Stages A and B) is questionable. 16 Atrial enlargement and left ventricular dilatation/hypertrophy are a natural attempt to avoid intracardiac pressure elevation in accordance with Laplace law. [...]NPs are not necessarily elevated, and HF diagnosis could be delayed and even missed if based only on laboratory test. 17 Additionally, clinicians should take into consideration different cut-offs for heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) before they can rule out patients from having HF. 18,19 Moreover, several cardiac conditions such as atrial fibrillation, pulmonary hypertension and elevated E/e1 ratio are associated with increased NP levels, whereas mitral regurgitation and pericardial constriction diuretic/decongestion treatment may decrease NP levels. 20,21 Finally, many other non-cardiac diseases, such as chronic kidney disease (CKD), anaemia, obesity, endocrine–pulmonary diseases and inflammatory disorders, differently impact NP levels. [...]the comparison of NPs in HF with troponin (TnT) in myocardial infarction does not appear to be reliable enough (Table 1). Whereas most of these drugs have demonstrated faster symptom control and improvement in central haemodynamics, none of these therapies have improved outcome. [...]the prospect of improved long-term prognosis with short-term drug therapy only aimed at congestion relief al