Heart failure – what the general physician needs to know
Editor – The summary paper from the British Society for Heart Failure 7th meeting highlights some important aspects for the general physician with respect to heart failure management.1 With respect to diagnosis, however, I would make one comment regarding the use of brain natriuretic peptide (BNP) and NT-proBNP in ruling out heart failure. While it is agreed that natriuretic peptide measurement is very helpful in ruling this out in the majority patients, it is important to bear in mind that in obese patients BNP and NT-proBNP levels are significantly reduced by mechanisms yet to be fully explained.2 This raises questions about the utility of BNP and NT-proBNP in obese patients in heart failure; further studies are warranted here.
In the meantime, in obese patients where there remains a high clinical suspicion of heart failure, it is recommended that echocardiography is undertaken where the BNP or NT-proBNP level is normal, accepting the fact that echocardiographic views may be suboptimal in the context of an increased body mass index (BMI). Indeed, I have encountered several such cases of echocardiographic proven left ventricular systolic dysfunction in obese patients presenting with acute symptoms of heart failure and with normal NT-proBNP levels. Interestingly, our trust protocol suggests proceeding to echocardiography if clinically heart failure is still strongly suspected after a normal NT-proBNP level and the observations above would appear to support that approach. In an ever-increasing epidemic of increasing BMI in patients due to a variety of factors, it is likely this situation may become more frequent.
- © 2016 Royal College of Physicians
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