Natriuretic peptides in acute chest pain and acute coronary syndrome: from pathophysiology to clinical and prognostic applications Nadia Aspromonte a , Stefania A. Di Fusco a , Roberto Latini b , Dinna N. Cruz c , Serge Masson b , Marco Tubaro a and Alberto Palazzuoli d Background Plasma levels of natriuretic peptides (NPs) appear to have an important prognostic value in many clinical settings including coronary artery disease and provide additional information about cardiovascular risk. Content The aim of this study was to review the literature on the role of NPs in the prognosis and management of patients with acute chest pain and acute coronary syndrome (ACS). Several trials have assessed the prognostic value of NPs as biomarkers of myocardial injury for risk stratification in patients with acute chest pain and ACS. The additional prognostic information on measurement of NP levels is independent of that provided by cardiac troponin and the various clinical and ECG features and traditional risk markers available at hospital admission. Conclusion Although measurement of the level of NPs is not recommended as a diagnostic tool in ACS management, their concentrations seem to distinguish patients at a higher risk not only for heart failure but also for ACS. NPs are a good risk marker for ACS, in addition to troponins, but have not yet been proved suitable for guiding therapy. Coron Artery Dis 24:33–39  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. Coronary Artery Disease 2013, 24:33–39 Keywords: acute coronary syndrome, guided therapy, natriuretic peptides, prognosis a Cardiovascular Department, San Filippo Neri Hospital, Rome, b Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri, Milan, c Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, and d Department of Internal Medicine and Metabolic Diseases, Cardiology Section, University of Siena, Siena, Italy Correspondence to Nadia Aspromonte, MD, FESC, FACC, via B. Cerretti 18, 00167 Rome, Italy Tel: +39 347 797 7895; fax: +39 06 33062489; e-mail: naspromonte @yahoo.it Received 19 June 2012 Accepted 4 October 2012 Introduction In the last few years, clinical and experimental research has shown novel biomarkers of cardiac function to be important tools for clinical management. These biomarkers evaluated under several conditions, such as inflammation, wall stress, tissue necrosis, and platelet activation, have improved our understanding of the mechanisms underlying the complex- ity of cardiac disease. Acute coronary syndrome (ACS) are heterogeneous disorders ranging from unstable angina without evidence of myocardial injury to acute myocardial infarction (AMI) with or without ST elevation, in which there is significant myocardial cell necrosis. ACS thus encompass a wide range of events with different clinical presentations and prognoses. Risk assessment is currently based on clinical history, physical examination, and electrocardiographic findings. Prognosis is related to plaque-type lesion and the extent of coronary atherosclerosis, the presence of irreversible myocyte injury, and the hemodynamic consequences of the ischemic event; however, it is still not accurate. Laboratory assessment could help physicians identify patients at a higher risk. Together with traditional necrosis markers, we now have markers of hemodynamic inflammatory and vascular damage. In this context, natriuretic peptides (NPs) could be important to stratify the outcome better in ACS patients [1,2]. This paper reviews the literature addressing the role of NPs in the prognosis and management of patients with acute chest pain and ACS. Pathophysiology of the natriuretic peptide system The endocrine function of the heart was first suspected in 1956 when granules similar to those in endocrine glands were found in atrial cells [3]. Since then, growing evidence has indicated a crucial role of cardiac hormones in the regulation of cardiovascular homeostasis. Cardiac hormones are a family of mediators called NPs, with similar structural conformation, characterized by a peptide ring with a cysteine bridge. NPs include atrial NP (ANP), secreted mainly by atrial myocytes; brain NP (BNP), so called because it was first isolated from porcine brain, synthesized mainly by the ventricular myocardium; C-type NP (CNP), expressed mainly in endothelial cells; and dendroaspis NP (DNP), identified in mammalian plasma. The synthesis and secretion of these NPs are regulated differently in atrial and ventricular myocytes. Mature ANPs are cleaved and secreted mainly in response to increased transmural pressure or stretch as a consequence of volume expansion. Other stimuli that induce ANP release include vasopressin, endothelin, angiotensin II, several cytokines, and ischemia per se [4–6]. Diagnostic methods 33 0954-6928  c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MCA.0b013e32835b6741 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.