Does a patient with chest pressure and elevated B-type natriuretic peptide (BNP) level of 548 require hospital admission?

Hospital Admission for Patient with Chest Pressure and Elevated BNP

A patient with chest pressure and elevated BNP of 548 pg/mL with normal troponin should be admitted to the hospital for further evaluation and management of suspected heart failure.

Clinical Assessment of the Presentation

This patient presents with two key findings:

• Chest pressure (suggesting possible cardiac origin)
• Elevated BNP of 548 pg/mL (significantly above the diagnostic threshold of 100 pg/mL)
• Normal troponin (ruling out acute myocardial injury)

Significance of Elevated BNP

BNP is a cardiac neurohormone released upon ventricular myocyte stretch. According to the ACC/AHA guidelines:

• BNP levels >100 pg/mL are highly suggestive of heart failure 1
• A BNP of 548 pg/mL is substantially elevated and associated with increased mortality risk
• In the GUSTO-IV trial, patients with BNP in the highest quartile had a one-year mortality rate of 19.2% 1

Decision Algorithm for Admission

1. Elevated BNP >500 pg/mL with symptoms: Strongly indicates need for admission

   • BNP of 548 pg/mL falls into a range associated with significant cardiac dysfunction
   • Chest pressure suggests possible cardiac etiology requiring further evaluation

2. Normal troponin: While ruling out acute myocardial injury, it doesn't exclude:

   • Heart failure with preserved ejection fraction
   • Heart failure with reduced ejection fraction
   • Other cardiac pathology requiring inpatient management

3. Clinical profile assessment:

   • This patient likely falls into the "volume overload" profile described in the ACC/AHA guidelines 1
   • Requires inpatient diuresis and medication adjustment

Management Considerations

The 2009 ACC/AHA Heart Failure Guidelines specifically state:

• "In general, patients should not be discharged from the hospital until a stable and effective diuretic regimen is established, and ideally, not until euvolemia is achieved" 1
• "Patients who are sent home before these goals are reached are at high risk of recurrence of fluid retention and early readmission" 1

Inpatient Management Should Include:

• Echocardiogram to assess cardiac function and structure
• Serial BNP measurements to track response to therapy
• Careful diuresis with loop diuretics
• Initiation or adjustment of guideline-directed medical therapy
• Monitoring for electrolyte abnormalities and renal function

Important Caveats and Pitfalls

1. Not all elevated BNP indicates heart failure:

   • Age, renal dysfunction, and atrial fibrillation can elevate BNP 2
   • However, a level of 548 pg/mL is unlikely to be explained by these factors alone

2. Normal troponin doesn't rule out cardiac pathology:

   • Heart failure can occur without myocardial injury
   • Serial troponin measurements may be warranted

3. Discharge planning:

   • Should not occur until euvolemia is achieved
   • Requires establishment of stable diuretic regimen
   • Early follow-up (within 72 hours) should be arranged 1

4. Potential for rapid decompensation:

   • Patients with heart failure can deteriorate quickly
   • Outpatient management of new or significantly decompensated heart failure carries substantial risk

Conclusion

Based on the clinical presentation of chest pressure with significantly elevated BNP of 548 pg/mL, this patient requires hospital admission for further evaluation and management, even with normal troponin. The risk of adverse outcomes is too high to manage this condition in the outpatient setting initially.