What is the treatment for elevated Brain Natriuretic Peptide (BNP)?

From the Guidelines

Elevated BNP levels should be treated with a focus on addressing the underlying cardiac dysfunction, and in appropriately selected patients with HFpEF, particularly those with elevated BNP levels, use of spironolactone might be considered with close monitoring of potassium and renal function, as suggested by the TOPCAT trial 1. The primary approach to treating elevated BNP levels involves:

• Diuretics like furosemide (20-80mg daily) to reduce fluid overload
• ACE inhibitors such as lisinopril (2.5-40mg daily) or ARBs like losartan (25-100mg daily) to decrease cardiac workload
• Beta-blockers such as metoprolol (12.5-200mg daily) to improve cardiac function For patients with HFpEF, the use of mineralocorticoid receptor antagonists like spironolactone may be considered, with careful monitoring of potassium, renal function, and diuretic dosing to minimize the risk of hyperkalemia and worsening renal function 1. Key considerations for the use of spironolactone in HFpEF patients with elevated BNP levels include:
• Creatinine should be <2.5 mg/dL in men or <2.0 mg/dL in women (or estimated glomerular filtration rate >30 mL/min)
• Potassium should be <5.0 mEq/L
• Close monitoring of potassium, renal function, and diuretic dosing is essential to minimize risks Lifestyle modifications, including sodium restriction (<2g daily), fluid restriction (1.5-2L daily), and regular moderate exercise, are also crucial components of management. BNP levels serve as both a diagnostic marker and a way to monitor treatment effectiveness, with decreasing levels indicating improvement in cardiac function 1.

From the FDA Drug Label

Sacubitril and valsartan tablets reduces NT-proBNP and is expected to improve cardiovascular outcomes. The treatment for elevated BNP (brain natriuretic peptide) is sacubitril and valsartan tablets, which reduce NT-proBNP and are expected to improve cardiovascular outcomes in patients with heart failure.

• The recommended starting dosage for adults is 49 mg/51 mg orally twice daily.
• The target maintenance dose is 97 mg/103mg orally twice daily. 2

From the Research

Elevated BNP Treatment

• Treatment with angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, spironolactone, and diuretics reduces BNP levels, suggesting that BNP testing may have a role in monitoring patients with heart failure 3
• BNP levels are simple and objective measures of cardiac function, and can be used to diagnose heart failure, including diastolic dysfunction 3
• The high negative predictive value of BNP tests is particularly helpful for ruling out heart failure 3
• Increases in BNP levels may be caused by intrinsic cardiac dysfunction or may be secondary to other causes such as pulmonary or renal diseases 3

BNP Levels and Prognosis

• BNP level is a strong predictor of risk of death and cardiovascular events in patients previously diagnosed with heart failure or cardiac dysfunction 3
• Stage A/B patients with high BNP had a similar or worse prognosis than Stage C/D patients with low BNP 4
• Individuals without any history of HF but with BNP >or=100pg/mL are at equal or higher risk than those with a HF history whose BNP is <100pg/mL 4
• Extremely elevated admission BNP is an independent predictor of 6-month all-cause-mortality in patients with acute systolic heart failure 5

Management of Elevated BNP

• Higher doses of ACE inhibitors, angiotensin-2 receptor blockers, and beta-blockers may reduce the risk of HF worsening and hospitalization, but increase the risk of adverse effects 6
• The diagnostic performance of BNP and NT-proBNP as indicators of acute heart failure depends on the clinical setting, and particular caution should be used in the interpretation of elevated BNP and NT-proBNP levels in the intensive care unit 7
• BNP tests are correlated with other measures of cardiac status, such as New York Heart Association classification 3