The past, the present, and the future of natriuretic peptides in the diagnosis of heart failure

Addition of natriuretic peptide testing with B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) to clinical evaluation has assisted diagnostic evaluation of heart failure (HF) since such testing was introduced; both peptides are embedded in major society guidelines and used globally. To exclude HF, lower cut-off values optimizing sensitivity and negative predictive value for BNP (35 pg/mL for ambulatory or chronic setting and 100 pg/mL for the acute setting) and NT-proBNP (125 pg/mL for ambulatory setting and 300 pg/mL for the acute setting) have excellent performance. The best value for BNP (400 pg/mL) and NT-proBNP (450, 900, and 1800 pg/mL for ages 50, 50-75, and >75 years) to identify HF optimize specificity and positive predictive value while balancing sensitivity and negative predictive value. Mid-regional-pro atrial natriuretic peptide (MR-proANP) is non-inferior to BNP or NT-proBNP for HF evaluation and may be of use as an adjunctive testing in patients with intermediate BNP/NT-proBNP concentrations or obesity. Targeted screening of asymptomatic high-risk populations appears to identify those with a signature of cardiovascular stress at high risk for HF onset; studies suggest potential ability to prevent onset of overt left ventricular dysfunction or clinical HF in high-risk patients through aggressive medical evaluation and intervention.