From the Guidelines
B-type Natriuretic Peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are essential biomarkers used to diagnose, risk-stratify, and guide treatment in heart failure patients, with BNP levels above 100 pg/mL or NT-proBNP levels above 300 pg/mL suggesting heart failure. These peptides are released from ventricular myocardium in response to increased wall stress and volume overload, making them valuable indicators of cardiac dysfunction 1. In clinical practice, they help clinicians distinguish between cardiac and non-cardiac causes of dyspnea in emergency settings, with higher levels correlating with greater heart failure severity.
Key Points
- BNP and NT-proBNP are useful in supporting clinical decision making in the diagnosis of heart failure, especially when there is clinical uncertainty 1.
- Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic heart failure 1.
- BNP- or NT-proBNP–guided therapy can be useful to achieve optimal dosing of medical therapy in select clinically euvolemic outpatients in structured management programs 1.
- Serial measurements can guide medication adjustments, with treatment intensification recommended when levels remain elevated despite standard therapy.
Clinical Utility
The physiological basis for their utility lies in their production: pre-proBNP is cleaved into BNP (the active hormone that promotes diuresis and vasodilation) and NT-proBNP (the inactive fragment with a longer half-life) 1. While these biomarkers are valuable tools, they should be interpreted alongside clinical assessment and imaging studies for optimal heart failure management. The most recent and highest quality study recommends using BNP and NT-proBNP levels to guide treatment and risk-stratify patients with heart failure 1.
Limitations
However, the usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalizations or mortality in patients with heart failure has not been established 1. Additionally, many patients taking optimal doses of medications continue to show markedly elevated levels of BNP, and some patients demonstrate BNP levels within the normal range despite advanced HF 1.
Recommendations
In summary, BNP and NT-proBNP are essential biomarkers in the management of heart failure, and their measurement should be used to support clinical decision making, establish prognosis, and guide treatment. While they have limitations, their utility in clinical practice is well established, and they should be interpreted alongside clinical assessment and imaging studies for optimal heart failure management 1.
From the Research
Role of BNP and NT-proBNP in Managing Heart Failure
- B-type natriuretic peptide (BNP) and N-terminal pro b-type natriuretic peptide (NT-proBNP) are biomarkers used in the diagnosis and management of heart failure 2, 3, 4.
- These peptides are produced by the heart ventricles in response to increased mechanical load and wall stretch, and they play a crucial role in protecting the heart from adverse consequences of overload 2.
- BNP and NT-proBNP can be used to assess the severity of ventricular dysfunction and heart failure, and as prognostic predictors, regardless of the primary cause of the condition 2, 3.
Diagnostic Value of BNP and NT-proBNP
- BNP and NT-proBNP have excellent negative predictive value with regard to left ventricular dysfunction and heart failure, making them useful as a rule-out test for heart failure 2, 5, 6.
- A BNP level of 80 pg/mL is useful in diagnosing heart failure in symptomatic patients without a history of heart failure 3.
- However, BNP and NT-proBNP are nonspecific biomarkers of cardiac dysfunction, and specific diagnostic tools, such as echocardiography, are required to define the actual abnormality 2.
Prognostic Value of BNP and NT-proBNP
- BNP and NT-proBNP are independent predictors of mortality and other cardiac composite endpoints in patients with risk of coronary artery disease, diagnosed coronary artery disease, and diagnosed heart failure 6.
- Elevated levels of BNP and NT-proBNP are associated with increased risk of recurring myocardial infarction, heart failure, and death 2.
Therapeutic Monitoring Value of BNP and NT-proBNP
- BNP and NT-proBNP can be used to guide the therapy of heart failure and left ventricular dysfunction 2, 3.
- However, the relationship between BNP and NT-proBNP levels and outcome is limited and not consistent, and there is insufficient evidence to demonstrate that BNP and NT-proBNP levels show change in response to therapies to manage stable chronic heart failure patients 6.