Serum Brain Natriuretic Peptide (BNP)

Indications

Prevention of Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])

Recommendations (2017 Focused Update of 2013 ACCF/AHA Guideline for the Management of Heart Failure) (Circulation, 2017) [MEDLINE]

  • For Patients at Risk of Developing Heart Failure, BNP-Based Screening Followed by Team-Based Care, Including a Cardiovascular Specialist Optimizing Guideline-Directed Management and Therapy, Can Be Useful to Prevent the Development of Left Ventricular Dysfunction (Systolic or Diastolic) or New-Onset Heart Failure (Class of Recommendation II1, Level of Evidence B-R
    • Data Suggest that BNP Screening and Early Intervention May Prevent Heart Failure

Diagnosis of Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])

Clinical Efficacy-Systolic Dysfunction

  • xxx

Clinical Efficacy-Diastolic Dysfunction

  • Severity of Diastolic Dysfunction is Correlated with Both BNP and NT Pro-BNP Levels (J Amer Coll Cardiol, 2003) [MEDLINE] and (NEJM, 2007) [MEDLINE]

Recommendations (2017 Focused Update of 2013 ACCF/AHA Guideline for the Management of Heart Failure) (Circulation, 2017) [MEDLINE]

  • Acute Heart Failure
    • In Patients Presenting with Dyspnea, Measurement of BNP (or NT-ProBNP) is Useful to Support or Exclude a Diagnosis of Heart Failure (Class of Recommendation I, Level of Evidence A)
    • Measurement of Baseline BNP/NT-ProBNP and/or Cardiac Troponin on Admission to the Hospital is Useful to Establish a Prognosis in Acutely Decompensated Heart Failure (Class of Recommendation I, Level of Evidence A)
    • During a Heart Failure Hospitalization, a Predischarge BNP/NT-ProBNP Can Be Useful to Establish a Post-Discharge Prognosis (Class of Recommendation IIa, Level of Evidence B-NR)
  • Chronic Heart Failure
    • Measurement of BNP/NT-ProBNP is Useful for Establishing Prognosis or Disease Severity in Chronic Heart Failure (Class of Recommendation I, Level of Evidence A)
    • In Patients with Chronic Heart Failure, Measurement of Other Clinically Available Tests, Such as Biomarkers of Myocardial Injury or Fibrosis (Soluble ST2 Receptor, Galectin-3, High-Sensitivity Cardiac Troponin, etc) in Addition to BNP/NT-ProBNP May Be Considered for Additive Risk Stratification (Class of Recommendation II1, Level of Evidence B-NR)
      • A Combination of Biomarkers May Prove to Be More Useful than Single Biomarkers

Prediction of Perioperative Complications Rates

Clinical Efficacy

  • Preoperative BNP >385 pg/mL Predicted the Postoperative Complication Rate and 1-Year Mortality Rate After Cardiac Surgery ( J Am Coll Cardiol, 2004) [MEDLINE]
    • Postperatively, Elevated BNP Levels and Elevated Change to Peak BNP Level were Associated with Prolonged Hospital Stay and 1-Year Mortality Rate

Prediction of Ventilator Weaning

Clinical Efficacy

  • Baseline Plasma BNP Level Before the First Weaning Attempt is Higher in Patients with Subsequent Weaning Failure and Correlates with Weaning Duration (Intensive Care Med, 2006) [MEDLINE]

Risk Stratification of Patients with Acute Pulmonary Embolism (PE) (see xxxx, [[xxxx]])

Clinical Efficacy

  • xxxx

Technique

  • Leuchte 2006 Paper: BNP >33 has a 87% sens for dx of pulmonary hypertension in idiopathic pulmonary fibrosis

Effect of Age

  • BNP Increases with Age (Eur J Heart Fail, 2008)[MEDLINE]: unclear why
    • Age <50 y/o: NT Pro BNP cutoff point = 450 pg/mL
    • Age 50-75 y/o: NT Pro BNP cutoff point = 900 pg/mL
    • Age >75 y/o: NT Pro BNP cutoff point = 1800 pg/mL

Effect of Sex

  • Males Have Lower BNP Levels than Females: unclear why

Effect of Renal Function

  • Values are Highly Variable with CrCl <60 mL/min and Cutpoints May Need to Be Adjusted: for this reason, BNP testing is not recommended in patients on hemodialysis
    • Mechanisms of BNP Elevation in the Setting of Renal Disease
      • Decreased Renal Clearance
      • Abnormal Counter-Regulatory Response Between the Heart and Kidney

Obesity (see Obesity, [[Obesity]])

  • Obese Patients Have Lower BNP Levels than Non-Obese Patients (with a Linear Inverse Relationship Between BMI and BNP): unclear why

Effect of Disease States

  • Cardiogenic Shock Increases BNP Levels
  • Sepsis Increases BNP Levels (see Sepsis, [[Sepsis]])
    • BNP Does Not Appear to Reliably Predict the Pulmonary Capillary Wedge Pressure (PCWP) in ICU Patients (Especially in Patients with Shock) (Crit Care Med 2004) [MEDLINE] and (J Am Coll Cardiol, 2005) [MEDLINE]

References

  • Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Amer Coll Cardiol Jun 4 2003;41(11):2010–7 [MEDLINE]
  • Brain natriuretic peptide: a marker of myocardial dysfunction and prognosis during severe sepsis. Crit Care Med 2004;32:660–5 [MEDLINE]
  • Utility of B-type natriuretic peptide in predicting postoperative complications and outcomes in patients undergoing heart surgery. J Am Coll Cardiol 2004;43:1873–9 [MEDLINE]
  • Utility of B-type natriuretic peptide for the evaluation of intensive care unit shock. Crit Care Med 2004;32:1643–7 [MEDLINE]
  • Relationship between B-type natriuretic peptides and pulmonary capillary wedge pressure in the intensive care unit. J Am Coll Cardiol 2005;45:1667–71 [MEDLINE]
  • B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med 2006;32:1529–36 [MEDLINE]
  • Prognosis in heart failure with a normal ejection fraction. N Engl J Med Aug 23 2007;357(8):829–30 [MEDLINE]
  • State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail. 2008 Sep;10(9):824-39. doi: 10.1016/j.ejheart.2008.07.014. Epub 2008 Aug 29 [MEDLINE]
  • 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15;128(16):e240-327. doi: 10.1161/CIR.0b013e31829e8776. Epub 2013 Jun 5 [MEDLINE]
  • The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Heart Transplantation Report–2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant. 2015 Oct;34(10):1244-54. doi: 10.1016/j.healun.2015.08.003. Epub 2015 Aug 28 [MEDLINE]
  • 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017 Aug 8;136(6):e137-e161. doi: 10.1161/CIR.0000000000000509. Epub 2017 Apr 28 [MEDLINE]