Quantifying Heart Failure Using Natriuretic Peptides May Help the HEART Teamin Decision-making

Eleni Michou; Gregor Fahrni; Christian Mueller


Eur Heart J. 2019;40(41):3406-3408. 

In This Article

Abstract and Introduction


Apart from individual surgical risk and aspects of technical feasibility, diabetes mellitus and anatomical complexity of coronary artery disease (CAD) quantified by the SYNTAX score (SS) determine the relative benefits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) among patients with left main CAD or multivessel disease.[1,2] Specifically, higher SS (e.g. >22) and the presence of diabetes mellitus favour CABG over PCI as the revascularization modality of choice for the individual patient.

There is increasing evidence that quantifying the presence and extent of cardiac haemodynamic stress and heart failure (HF) by using B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) concentrations could help the HEART team in selecting either PCI or CABG as revascularization modality in patients with left main and/or three-vessel CAD.[3,4] Increased BNP and NT-proBNP concentrations provide incremental prognostic information for adverse outcomes including death, myocardial infarction, and stroke on top of the SS and left ventricular ejection fraction (LVEF). In addition, increased BNP and NT-proBNP concentrations seem to identify patients with particular benefit from revascularization by CABG versus PCI. On the other hand, PCI seems to be the preferred option in patients without HF and correspondingly BNP and NT-proBNP concentrations in the normal range or only mildly elevated (Figure 1).

Figure 1.

Integration of natriuretic peptides in revascularization strategy decision-making in patients with multivessel coronary artery disease.1

These novel insights provided by Zhang et al.[4] in this issue of the European Heart Journal corroborate and extend previous evidence, as well as the current guidelines of the European Society of Cardiology stating that, in patients with chronic HF and LVEF ≤35%, CABG is recommended as the first revascularization strategy choice among those with multivessel disease and acceptable surgical risk.[1,2] Secondary analyses from a randomized trial of PCI vs. CABG in left main CAD and a large prospective cohort of patients with three-vessel CAD document that quantifying HF using BNP or NT-proBNP concentrations could help identify a substantial number of high-risk patients with anatomically less complex disease (SS ≤22), who seem to benefit more from a surgical approach, especially in the long term,[5] and who cannot be identified by anatomical criteria only.