Page 163 - Biomarkers for risk stratification and guidance in heart failure

Chapter 7
adequate treatment of heart failure. On the contrary, improvement in renal function defined as a decrease in serum creatinine concentration might reflect expansion of the intravascular volume caused by progressive heart failure96. NT- proBNP might be helpful in identifying the cause of change in renal function; Worsening renal function in combination with a decrease in NT-proBNP might be caused by titration of evidence based HF medication or intravascular volume depletion. Worsening renal function combined with an increase in NT-proBNP can be caused by decreased renal perfusion as a result of worsening heart failure. Improvement in renal function in combination with a decrease in NT-proBNP might result from improved renal perfusion caused by successful treatment of heart failure. “Improvement in renal function” reflected by a decrease in plasma creatinine concentration combined with an increase in NT-proBNP is likely to be cased by expansion of the intravascular volume caused by progressive heart failure. The aforementioned assumptions are based on few studies and should be confirmed in large randomized trials.
7.5 FUTURE PERSPECTIVE OF BIOMARKERS IN HF: A BRIDGE TOWARDS PERSONALIZED MEDICINE?
The potential role of biomarkers in Heart Failure has been widely investigated (see figure 3). Last decade numerous biomarkers have been proposed, and validated, for risk assessment in heart failure. As mentioned before, natriuretic peptides have been the most investigated. In contradiction to the tremendous amount of research that has been done, apart from natriuretic peptides, biomarkers are still hardly used for risk assessment and treatment guidance of HF patients. In fact, even natriuretic peptide-guided therapy is still not advocated by the ESC guidelines due to previously discussed caveats in evidence. The most important reason for the reluctant use of biomarkers in current clinical practice is inability of these markers to reduce morbidity and mortality. Knowledge of individual risk in HF is mostly important if it can lead to reduction in morbidity and mortality. Thus far, only natriuretic peptides have such a proven effect, although only demonstrated in meta-analyses.57-61
Current treatment of HF with reduced left ventricular ejection fraction is based on one-size-fits-all approach with initiation of renin-angiotensin system blockers, beta-blockers and aldosterone antagonists and uptitration towards
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