Outpatient monitoring and treatment of chronic heart failure guided by amino-terminal pro-B-type natriuretic peptide measurement.

Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) is a strong and independent prognostic marker in patients across the spectrum of heart failure (HF) stages, including patients managed in the outpatient setting. Serial measures of NT-proBNP are more valuable than single measures for prognosis, and biologic variation of the marker should allow serial monitoring. Furthermore, given that NT-proBNP levels decrease in response to the addition of therapies with proven benefit for HF (including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, spironolactone, exercise therapy, and biventricular pacing), it is logical to expect that targeting therapy to decrease NT-proBNP levels may facilitate more optimal use of proven HF therapies and may reduce adverse clinical outcomes. The optimal strategy for NT-proBNP monitoring with regard to frequency of testing or whether to use standard or individualized targets is still being determined. Preliminary results are promising for targeting an outpatient NT-proBNP concentration of approximately < or =1,000 ng/L. Current data suggest that when NT-proBNP levels are not at goal or increase from prior measurements, the risk for hazard is increased. Adjustments in treatment and serial clinical follow-up with NT-proBNP retesting should be considered at frequent intervals until biochemical stabilization or achievement of a maximally tolerated medical program.