BNP or echocardiography for monitoring heart failure?

This editorial refers to Comparison of echocardiography and plasma B-type natriuretic peptide for monitoring the response to treatment in acute heart † by A. Gackowski et al. on page 1788 No-one would question the value of echocardiography for the initial assessment of patients with heart failure and it is now a mandatory investigation. Not only can the cause be frequently correctly identified, but important prognostic information can also be gleaned. In particular, the restrictive filling pattern seen with the Doppler mitral inflow velocities is recognized to be associated with a poor prognosis, especially if it does not normalize with initial treatment.1 The restrictive filling pattern is also associated with higher atrial natriuretic peptide (ANP) and brain natriuretic peptide levels (BNP) and both peptides correlate inversely with ejection fraction, and positively with pulmonary artery pressure.2 Although BNP is secreted by both atrial and ventricular tissue, in heart failure there is upregulation of ventricular production which is more important for BNP than ANP and circulating BNP levels are consistently elevated in untreated heart failure compared to normals. In response to changes in stretch, such as would occur with treatment, the changes in circulating peptide levels are more rapid for ANP than BNP. Nevertheless, BNP has been shown to be a powerful prognostic marker in both chronic and acute heart failure independent of standard echocardiographic parameters.3,4 What is not so clear is the value of BNP for the diagnosis of heart failure or for the monitoring of treatment. It would be marvellous to … *Correspondence to: Professor John E Sanderson, Department of Medicine and Therapeutics, 9th Fl Clinical Science Bldg, Prince of Wales Hospital, Hong Kong, SAR. Tel.: +852 2632 2064; fax: +852 2637 2396 (E-mail: jesanderson{at}cuhk.edu.hk).