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The Roche Column

NT-proBNP: An aid to diagnosing heart failure

Nearly 25 million people suffer globally from heart failure1, and out of every five patients, one will die within a year of being diagnosed2. The risk for ventricular dysfunction, or heart failure, increases with age and its diagnosis carries a high morbidity rate and high mortality rate that exceeds many cancers. Chronic conditions of heart failure is among the greatest economic burdens to healthcare systems, but novel diagnostic solutions can provide healthcare professionals with the methods needed to improve a patient’s outcome and life expectancy with early detection.

Reliability is essential to diagnosis

The symptoms for heart failure are not distinct and can be linked to a number of other morbidities and physical conditions, limiting the accuracy in diagnosis, according to the European Society of Cardiology (ESC) Heart Failure Guidelines 20123. Early diagnosis of cardiovascular cases is key to a patient’s survival; thus fast intervention is an invaluable part of the healthcare cycle.

Measured by immunology methods, normal levels of BNP or NT-proBNP can rule out acute heart failure in the emergency setting. While elevated levels BNP or NT-proBNP cannot indicate heart failure alone, both can be used to screen and predict cardiac cases. In a risk prediction study, the Cardiovascular Health Study showed that elevated levels of NT-proBNP correlated to an increased risk of heart failure and confirmed that the biomarker could divide patients into lower and higher-risk groups5. In the primary care setting, NT-proBNP is an ideal biomarker for heart failure setting due to its ability to detect subtle preclinical cardiac changes. Approved by the FDA4, NT-proBNP can aid in the diagnosis of heart failure, assessing its severity, and detecting mild forms of cardiac dysfunction. The strong prognostic value of NT-proBNP with its sample stability at room temperature, delivers greater reliability in both outpatient settings and primary care settings. Healthcare professionals can use reliable measurements of the NT-proBNP, from assays such as Roche’s NT-proBNP laboratory or point of care assays, for patients who display signs of heart failure, to stratify and identify those at high risk of cardiovascular hospitalization and death.

International guideline recommendations

The importance of NT-proBNP in aiding the diagnosis, risk stratification and treatment monitoring is evident in heart failure patients due to its improved sample stability, longer circulating half-life6, and lower biological variability7. A number of international guidelines recommend the measurement of NPs for the diagnosis and management of heart failure. The ESC states that a normal NP level in untreated patients practically excludes significant cardiac disease and that the measurement of NPs should be considered for more prognosis details. Both the American College of Cardiology/American Heart Association and the Heart Failure Society of America, recommends testing NP levels in patients with dyspnea as well, especially if symptoms are related to heart failure8. At the same time, the National Institute for Health Clinical Excellence recommends NP measurements before an echocardiogram is done for a patient with suspected heart failure, who has not suffered any prior myocardial infarction.

Alongside other diagnostic tools available to evaluate high-risk patients for heart failure, NT-proBNP is a vital, useful and recommended additional test that can provide general practitioners, specialists or lab physicians with the reliability and precision needed to determine which patients can benefit from aggressive treatment. The NT-proBNP level is an independent and long-term predictor of new-onset heart failure and cardiovascular death that can improve clinical decision making with its strong negative predictive value and accurate results.

References

1 Hildebrandt, P., Collinson, P.O., Doughty, R.N., Fuat, A., Gaze, D.C. et al. (2010). Age-dependent values of N-terminal pro-B-type natriuretic peptide are superior to a single cut-point for ruling out suspected systolic dysfunction in primary care. Eur Heart J 31(15), 1881-1889. 2 Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K. et al. (2008). Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117(4), e25-146. 3 McMurray, J.J., Adamopoulos, S., Anker, S.D., Auricchio, A., Bohm, M. et al. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 33(14), 1787-1847. 4 Roche Diagnostics. Getting ahead: Coincidence or superior performance? 2009. 5 de Filippi, C.R., Christenson, R.H., Gottdiener, J.S., Kop, W.J., Seliger, S.L. (2010). Dynamic cardiovascular risk assessment in elderly people. The role of repeated N-terminal pro-B-type natriuretic peptide testing. J Am Coll Cardiol 55(5), 441-450. 6 Felker GM, Petersen JW, Mark DB. Natriuretic peptides in the diagnosis and management of heart failure. CMAJ 2006; 175: 611-7. 7 Rademaker MT, Richards AM. Cardiac natriuretic peptides for cardiac health. Clin Sci (Lond) 2005; 108: 23-36. 8 Jessup, M., Abraham, W.T., Casey, D.E., Feldman, A.M., Francis, G.S. et al. (2009). 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119(14), 1977-2016.


The Durbin Column

Should you fast while on medication?

As I write, many Muslims around the world are fasting during the holy month of Ramadan. Patients that are taking medicines or indeed even those who are pregnant are exempt from fasting. However, doctors around the world are increasingly voicing their concerns over the numbers of people who fast while on medication.

The degree to which patients are prepared to delay treatment or cancel medical appointments during Ramadan does of course vary from person to person. In the UK doctors have warned that we have some patients who are putting their lives at risk by delaying or stopping vital medication, including cancer treatments, in order to focus on their religious obligations.

Many campaigns by community groups and organisations have been aimed at educating those with chronic health problems such as diabetes, heart disease and high blood pressure – all of which are highly prevalent in the Middle East – about the risks associated with fasting. Other awareness programmes have focused on pregnant women, advising against fasting because of the risk of hypoglycaemia, ketosis and dehydration. Whatever the campaign, the fundamental message is always the same: patients should always speak to a physician about how to stay safe and healthy as possible during Ramadan.

We must remember that fasting is a personal decision, and if somebody with a medical condition wishes to fast, doctors are unable to stop them. I have written about the high rate of diabetes in the Middle East before, and a large number of campaigns in the region have focused on providing those with the disease all the information and medical advice necessary to ensure they do not suffer from complications as a result of fasting.

Diabetics who face a high risk of complications if they fast include pregnant women, patients who need insulin injections and those whose blood sugar levels severely fluctuate. Fasting diabetics are advised to see their doctor a month before Ramadan to arrange a plan of how it can be achieved without harm. A drop or rise in sugar level can cause symptoms such as shivering, cold sweats, heart palpitations and slurred speech.

Medical experts have advised that diabetics should not overeat when they break their fast as this can cause blood sugar levels to rise dangerously. Eating a few smaller meals as opposed to one large one after sunset is a much safer option. They are also advised to wake up before dawn to eat their second meal so that the period of fasting is shortened as much as possible, thereby reducing the risk of hypoglycaemia and dehydration. Finally, diabetics should test their blood sugar levels in the middle of the day and before they break their fast. This is particularly important in the first few days of Ramadan. Exercise is also encouraged, especially after the fast has been broken.

It is a common misconception that exercise should be reduced during the holy month, when in reality it is still important to keep healthy, maintain energy levels and keep active. Furthermore, many people gain weight during Ramadan as large amounts of food are consumed late at night followed by sleep, causing the body to slow down. With obesity a growing concern in the region this is another factor that individuals should consider when planning their meals after breaking the fast.

Most Muslims believe that fasting is one of the basic tenets of Islam and that they have to fast whether they have a medical condition or not. A little bit of care and attention to diet, as well as discussing your medication programme with your doctor a month before Ramadan begins, is all it will take to ensure that you have a safe and healthy month.

Durbin PLC is a British company based in South Harrow, London. Established in 1963, the company specialises in supplying quality assured pharmaceuticals, medical equipment and consumable supplies to healthcare professionals and aid agencies in over 180 countries. As well as reacting rapidly to emergency situations, Durbin PLC responds to healthcare supply needs from local project level to national scale programmes.

Web address: www.durbin.co.uk
Email: L.morgan@durbin.co.uk

 Date of upload: 16th Sep 2014

 

                                  
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