1. Biomarkers are measurable indicators of biological processes that can help diagnose, monitor, and guide treatment of heart failure. 2. Natriuretic peptides like BNP and NT-proBNP are useful biomarkers for diagnosing and risk-stratifying acute heart failure. Their levels are also impacted by factors like age, kidney function, and medications. 3. Biomarker-guided heart failure management that incorporates serial biomarker testing may help identify vulnerability, assess risk, and guide therapy in both event-driven and goal-directed approaches.

1. Biomarkers In Heart Failure Heart Failure Teleconference ● June 25, 2011

6. Biomarker Discovery De Couto et al, Nat Rev Cardiol 2010

7. Natriuretic Peptide Testing in Acute Heart Failure Januzzi et al, AJC 2006 Maisel et al N Engl J Med 2002 Biosite BNP (pg/ml) Roche NT-proBNP Negative Predictive Value >90%

9. Incremental Benefit with Natriuretic Peptide Testing in Acute Heart Failure Muller et al, N Engl J Med 2003 Moe et al, Circulation 2007 IMPROVE-CHF BASEL Biosite BNP (pg/ml) Roche NT-proBNP (pg/ml)

10. Incremental Benefit with Natriuretic Peptide Testing in Acute Heart Failure Muller et al, N Engl J Med 2003 Moe et al, Circulation 2007 IMPROVE-CHF BASEL Biosite BNP (pg/ml) Roche NT-proBNP (pg/ml) HFSA 2010 Guideline Recommendation 4.6: It is recommended that BNP or NT-proBNP levels be assessed in all patients suspected of having HF, especially when the diagnosis is not certain. (Strength of Evidence = A)

11. Risk Stratification: BNP in Acute Heart Failure Logeart et al, J Am Coll Cardiol 2004 Biosite BNP (pg/ml)

12. Risk Stratification: Concordance with Clinical Status Morrow et al, JAMA 2005 Bayer ADVIA BNP (in pg/ml) High BNP at Month 4 Low BNP at Month 4

16. Risk Stratification: Multimarker Strategy (Serial) Miller et al, Circulation 2007 Shionogi BNP (pg/ml)

17. Natriuretic Peptide-Guided Therapy: BATTLE-SCARRED Richards et al, JACC 2009

18. Natriuretic Peptide-Guided Therapy: PROTECT Januzzi et al , AHA Late-Breaking Clinical Trial (2010)

20. Monitoring Progression Towards Heart Failure Adapted from Jessup et al, Circulation 2009; and Aamer et al, Circulation 2007

21. Screening: Echocardiographic Abnormalities (Olmsted County) McKie et al, Hypertension 2006 Roche NT-proBNP (pg/ml)

22. Screening: Echocardiographic Abnormalities (Olmsted County) McKie et al, Hypertension 2006 Roche NT-proBNP (pg/ml) HFSA 2010 Guideline Recommendation 4.3: Routine determination of plasma B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) concentration as part of a screening evaluation for structural heart disease in asymptomatic patients is not recommended . (Strength of Evidence = B)

23. Prognostic Value of “Screening” Natriuretic Peptides McKie et al, Hypertension 2006 Lowest third <13.4 pg/mL Middle third 13.4–39.7 pg/mL Highest third >39.7 pg/mL Lowest third <36.7 pg/mL Middle third 36.7-109.0 pg/mL Highest third >109.0 pg/mL

25. Linking Biomarkers to Therapy Hare et al, J Am Coll Cardiol 2008 Liggett et al, Nature Med 2008