Can brain natriuretic peptide be used to guide the management of patients with heart failure and a preserved ejection fraction? The wrong way to identify new treatments for a nonexistent disease.

Physicians make the diagnosis of heart failure when patients present with exercise intolerance that is limited by dyspnea, fatigue, or both and that can be attributed to an identifiable abnormality of cardiac function. Patients with exertional symptoms attributable to severe primary valvular disease respond symptomatically and prognostically to surgical valve repair or replacement. Patients with exertional dyspnea attributable to left ventricular systolic dysfunction exhibit fluid retention and neurohormonal activation and respond both symptomatically and prognostically to the administration of diuretics, inhibitors of the renin-angiotensin system, -blockers, and aldosterone antagonists. Although circulating levels of brain natriuretic peptide (BNP) can be measured in these 2 groups of patients, there is no reliable or persuasive evidence that such measurement provides a useful guide to the selection of patients to be treated, the medical or surgical interventions to be prescribed, or the timing of surgery or the doses of drugs to be achieved.1