What is the management approach for a patient with severely elevated pro-brain natriuretic peptide (proBNP) levels indicating severe heart failure?

From the Guidelines

Management of a patient with a proBNP level of 23,000 requires immediate and comprehensive intervention to reduce morbidity, mortality, and improve quality of life. The patient's severely elevated proBNP level indicates severe heart failure, and initial management should focus on stabilization with intravenous diuretics such as furosemide 40-80mg IV to reduce fluid overload, along with oxygen therapy to maintain saturation above 92% 1. For acute decompensated heart failure, inotropic support with dobutamine (2.5-10 mcg/kg/min) or milrinone (0.375-0.75 mcg/kg/min) may be necessary. Long-term management includes guideline-directed medical therapy with:

• ACE inhibitors (e.g., lisinopril 10-40mg daily)
• Beta-blockers (e.g., carvedilol 3.125-25mg twice daily)
• Mineralocorticoid receptor antagonists (e.g., spironolactone 25-50mg daily)
• SGLT2 inhibitors (e.g., empagliflozin 10mg daily) Device therapy should be considered, including implantable cardioverter-defibrillators for patients with ejection fraction ≤35% and cardiac resynchronization therapy for those with QRS duration >150ms 1. Lifestyle modifications are essential, including:
• Sodium restriction (<2g/day)
• Fluid restriction (<2L/day)
• Daily weight monitoring
• Regular physical activity as tolerated These interventions target the neurohormonal activation and hemodynamic abnormalities that characterize heart failure, reducing symptoms, preventing disease progression, and improving survival 1. Regular monitoring of renal function, electrolytes, and clinical status is crucial for optimizing therapy. It is also important to note that serial measurement of serum potassium concentration is necessary, as hypokalemia is a common adverse effect of treatment with diuretics and may cause fatal arrhythmias and increase the risk of digitalis toxicity 1. Additionally, the use of BNP measurements to guide the titration of drug doses has not been shown conclusively to improve outcomes more effectively than achievement of the target doses of drugs shown in clinical trials to prolong life 1. However, recent literature has illustrated that reduction in blood natriuretic peptide levels over time may be directly associated with corresponding reductions in long-term clinical events 1. Therefore, serial blood BNP or NT-proBNP concentrations may be used to track changes in risk profiles and clinical status among patients with heart failure in selected situations where additional risk stratification is required 1.

From the FDA Drug Label

The efficacy of sacubitril and valsartan was evaluated in a multinational, randomized, double-blind trial PARADIGM-HF comparing sacubitril and valsartan (n = 4,187) and enalapril (n = 4,212) in patients with heart failure. Sacubitril and valsartan also improved overall survival (HR 0.84; 95% CI [0.76,0.93], p = 0.0009)

For a patient with severely elevated pro-brain natriuretic peptide (proBNP) levels indicating severe heart failure, the management approach may include the use of sacubitril and valsartan, as it has been shown to improve overall survival and reduce the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure.

• The treatment effect reflected a reduction in both cardiovascular death and heart failure hospitalization.
• Sacubitril and valsartan may be considered as a treatment option for patients with severe heart failure, including those with elevated proBNP levels. 2

From the Research

Management Approach for Severe Heart Failure

• The management approach for a patient with severely elevated pro-brain natriuretic peptide (proBNP) levels, such as 23,000, indicating severe heart failure, involves a comprehensive treatment plan to reduce symptoms, slow disease progression, and improve quality of life 3.
• Elevated NT-proBNP levels are associated with increased left ventricular filling pressure during exercise, despite preserved systolic function, and can be useful for the detection of diastolic dysfunction in patients with exertional dyspnea 4.
• A study found that adults with NT-proBNP ≥450 pg/mL had significantly higher risks of all-cause death, cardiovascular mortality, incident total cardiovascular disease, atherosclerotic cardiovascular disease, and heart failure, compared with individuals with NT-proBNP <125 pg/mL 5.

Diagnostic Utility of NT-proBNP

• NT-proBNP levels can be a useful adjunct in the diagnosis of hypertensive heart disease, particularly in the assessment of diastolic dysfunction and left ventricular hypertrophy 6.
• The prognostic utility of NT-proBNP in the setting of hypertension has been characterized in the general US adult population, and elevated NT-proBNP is associated with an increased risk of mortality, compared to low levels of NT-proBNP 7.

Treatment and Prognosis

• The elevated cardiovascular risk in persons with high NT-proBNP and no history of cardiovascular disease is similar to, or higher than, the risk conferred by a history of cardiovascular disease, suggesting that it might be appropriate to manage adults with NT-proBNP ≥450 pg/mL as if they had a history of clinical cardiovascular disease 5.
• Measurement of NT-proBNP may have potential for clinical use to optimize hypertension treatment, and can provide additional prognostic information within and across categories of blood pressure 7.