Dr. Simone Henne is a practising internist, cardiologist and emergency physician and head of an internal medicine practice in Hamburg.

Heart failure management:

Significance of natriuretic peptides (BNP, NT-proBNP)

Heart failure is still one of the diseases with a high disease burden: In your experience, what are the central challenges in the therapy and care management of heart failure patients?

Dr S Henne: "One of the most important challenges in the care of heart failure patients is certainly the follow-up therapy: the majority of patients are initially very well adjusted in the hospital before being discharged to outpatient care. Once the patients are back in everyday life, however, there is often an under-therapy of heart failure in the course. Whether internists or general practitioners in combination with cardiologists, many colleagues reduce the medication as soon as they have the impression that the patient is feeling better again. Since the patients often feel listless and their vitality impaired by the medication, they try to accommodate them and, for example, reduce the blood pressure medication. However, we now know from a large number of studies that maximum therapy in heart failure is also associated with the best outcome."

What is the best way to implement consistent follow-up therapy?

Dr S Henne: "It is important to follow the patient closely and well as soon as he or she is discharged from the clinic: The patient often only notices in the course of treatment that it is worthwhile to persevere. Especially in the first twelve months, it is important to offer the patient regular fixed appointments and to stand by him or her - even if he or she is not doing so well: If the cardiac biomarkers such as BNP and NT-proBNP or the findings in the heart ultrasound have improved in the course of the treatment, you can give the patient positive feedback and encourage him or her to continue the treatment - even if he or she feels tired.

How early or how well are patients with heart failure generally diagnosed? What is the role of general practitioners?

Dr S Henne: "When it comes to diagnostics, it is always noticeable that relatively little is done before the patient himself says that he has shortness of breath. Very few doctors actively look at the lower legs or the lungs before the patient mentions that his shoes are tight or that he has difficulty climbing the stairs.

In Hamburg and in urban areas, patients with more severe heart failure are usually closely linked to the heart failure consultations of the larger hospitals. Patients regularly present there every four months or every six months if their condition has improved. The patients then receive a heart ultrasound by a cardiologist every six months, for example. In between, the patient is closely monitored by an internist or general practitioner or their GP, who should check for the usual signs of heart failure such as oedema or breathlessness. I can imagine that diagnostics could be better standardised in everyday practice here as well: Guidelines or recommendations on control intervals and the necessary examinations would be helpful, especially for general practitioners and family doctors, so that diagnostics can be carried out in a more standardised and automated way - similar to how the quick test is anchored between doctor and patient nowadays. For most patients, it would be sufficient to check two to three points regularly."

Where do you see the best opportunities to optimise diagnostics and long-term care for patients in Germany? How helpful are natriuretic peptides (NP)?

Dr S Henne: "In our practice, patients are regularly discharged from hospital or clinic with an NP value, so we already know where the value is at discharge and we can use it as a guide. In practice, I also use the biomarker NT-proBNP value as a follow-up parameter. Of course, it depends on the condition of the individual patient. There are many patients between the ages of 40 and 60 who have heart failure due to cardiotoxic chemotherapy. Since I also work in sports cardiology, I train with these patients and determine the NT-proBNP initially and about every three months during the course, as well as during the course, in order to monitor the progress of the heart failure therapy measures. Ultimately, the NT-proBNP value in particular provides us with a good follow-up parameter for heart failure.

If the patient comes to the practice with acute shortness of breath and suspected acute heart failure, the determination of the initial NT-proBNP value serves as a guiding initial value. The NT-proBNP value is very helpful in the differential diagnosis of whether the dyspnoea symptoms are more likely to be caused by the lungs or the heart - especially if no heart ultrasound is available. In my opinion, the high sensitivity of NT-proBNP should be emphasised. NT-proBNP can also be used to better calculate the severity of existing heart failure.

According to surveys, general practitioners are less familiar with the difference between the markers BNP and NT-proBNP than, for example, cardiologists in private practice: How do you assess the relevance of a distinction between the markers for general practitioners and office-based cardiologists, respectively?

Dr S Henne: "When I think about my experience from the quality circles, very few GPs are aware of the differences between BNP and NT-proBNP. Even for cardiologists, the differences have not been very present so far. It is often assumed that BNP and NT-proBNP only differ in their measurement stability in terms of laboratory chemistry and that NT-proBNP is mainly characterised by a higher plasma stability. Here I have the impression that a lot of clarification work would still be necessary, especially since the selection of the markers is also mostly predetermined by the laboratory."

In your experience, which colleagues use the NP markers the most?

Dr S Henne: "That is certainly quite different. There are also individual general practitioners or family doctors in private practice who already use NT-proBNP as a follow-up parameter. But I don't assume that the majority of them regularly determine NP markers in heart failure. Some colleagues also determine the parameter sporadically before hospital admission."

What are the new developments in the management of heart failure?

Dr S Henne: "An important innovation concerns the introduction of a new class of drugs, the angiotensin receptor neprilysin inhibitors, abbreviated ARNI. For the first time, the new combination of active substances makes it possible to inhibit the degradation of NP by inhibiting neprilysin. Neprilysin is particularly responsible for the degradation of BNP. Since the inhibition of neprilysin leads to an increase in BNP levels, one could wrongly assume that the treatment is ineffective. It is important to point out that it is NT-proBNP levels that matter under ARNI treatment, not BNP. Because NT-proBNP remains stable as it is not a neprilysin substrate, it can be used as a progression parameter for therapy."

What consequences could this observation have for the future use of biomarkers (BNP, NT-proBNP) and how well are colleagues in private practice already informed about this?

Dr S Henne: "Even though the data on this new drug combination is really very good, one will still be cautious at first, especially in the practice situation, with regard to dealing with side effects such as potential angioedema and wait for the experience from the clinics. What we do have available, however, is the optimal monitoring of the course of therapy by means of NT-proBNP values, which can also be carried out by any GP. However, the different effects of ARNI on BNP or NT-proBNP are not yet widely known - not even by many cardiologists in private practice. Since new drugs are realised faster than laboratory markers, it is elementary important to educate about the differences so that the correct follow-up can be implemented quickly: Rethinking is needed here, and rethinking is usually harder than learning something completely new!"

Thank you very much for the interview, Dr Henne!