Routine measurement of natriuretic peptide to guide the diagnosis and management of chronic heart failure.

Guide the Diagnosis and Management of Chronic Heart Failure To the Editor: We read with interest the viewpoint of Dr Milton Packer in a recent editorial1 accompanying a study examining the behavior of B-type natriuretic peptides in outpatients with congestive heart failure (CHF).2 Dr Packer1 suggested that B-type natriuretic peptides (BNPs) have not been shown to “improve upon the information derived from the patient-physician interaction” (p 2951). We disagree, citing data from the BNP (Breathing Not Properly) Multinational Study,3 in which the results of the results of BNP testing were superior to clinical judgment for the detection of CHF among patients presenting in an urgent fashion. Similar results are now pending for NT-proBNP. Dr Packer also asserted that no study has demonstrated that BNPs are superior to standard prognostic assessment in CHF. We would point out a recent study suggesting that N-terminal pro-BNP (NT-proBNP) results were superior to those of all methods for risk stratification among an outpatient heart failure population, even superior to the maximum oxygen uptake, which is the current gold standard for prognosticating outcomes in CHF.4 We also feel that Dr Packer’s1 characterization of BNP-guided therapy of outpatients with CHF as “an intellectual crutch to remind physicians to practice optimal medicine” (p 2952) is incorrect. We point out that the care of CHF patients is more often in the hands of non-cardiovascular specialists who may find biomarker-guided therapy useful to guide or ensure optimal therapy. Further, even when CHF patients are managed by a cardiovascular specialist, data suggest that there is room for improvement. We point out that Dr Packer’s comments are directly contradicted by the accompanying study,2 wherein only 57% of patients in a specialized CHF clinic were taking a -blocker, and no mention was made regarding the rates of treatment with spironolactone or biventricular pacing, presumably because of low rates of use. Lastly, we do not suggest that patients with low BNP or NT-proBNP levels should have therapies of proven benefit withheld or used in a suboptimal fashion. We enthusiastically agree with Dr Packer that we need to be excellent clinicians for our patients. We suggest, however, that in order to be excellent clinicians, we will need to continuously integrate our outstanding clinical skills with emerging tools that offer powerful diagnostic and prognostic information. As we learn more about BNP and NT-proBNP, we suggest that these markers will play an increasingly important role in the care of our patients with heart failure, without eroding the quality of care we deliver to these patients.