How often should BNP (Brain Natriuretic Peptide) or pro-BNP (pro-Brain Natriuretic Peptide) levels be checked in patients hospitalized for heart failure?

BNP/NT-proBNP Monitoring in Hospitalized Heart Failure Patients

For patients hospitalized with heart failure, BNP or NT-proBNP should be measured at admission and again prior to discharge to assess treatment response and risk stratify patients for post-discharge outcomes. 1

Recommended Monitoring Schedule:

1. Initial measurement: At admission (baseline)
2. Follow-up measurement: Prior to discharge
3. Optional intermediate measurements: At 24-48 hours after admission if clinical uncertainty persists about treatment response

Rationale for This Schedule:

• Admission measurement:

  • Establishes baseline severity
  • Confirms heart failure diagnosis when clinical uncertainty exists
  • Provides initial risk stratification 1

• Discharge measurement:

  • Predischarge BNP/NT-proBNP is a stronger predictor of outcomes than admission levels
  • Helps identify patients at high risk for readmission or mortality
  • Patients with >30% reduction from baseline have better outcomes 1, 2

Interpretation of Results:

BNP Values:

• Heart failure unlikely: <100 ng/L
• Grey zone: 100-500 ng/L
• Heart failure likely: >500 ng/L 1

NT-proBNP Values:

• Heart failure unlikely: <300 ng/L
• Heart failure likely based on age:
  • <50 years: >450 ng/L
  • 50-75 years: >900 ng/L

  • 75 years: >1800 ng/L 1, 3

Risk Stratification Based on Response:

1. High Risk: Patients whose BNP/NT-proBNP remains elevated or decreases by <30% from admission to discharge have significantly higher risk of death or readmission 2, 4

2. Moderate Risk: Patients with initially high BNP/NT-proBNP that decreases by >30% but remains above target thresholds 2

3. Lower Risk: Patients whose discharge BNP is <300 pg/mL and who achieve >46% reduction from baseline have the best prognosis 4

Clinical Application:

• A reduction of BNP >46% at discharge compared to admission levels, coupled with an absolute value <300 pg/mL, is associated with significantly better outcomes 4

• For NT-proBNP, a predischarge value >137 ng/L portends poor prognosis, while reductions >30% from baseline are associated with better outcomes 1

• Serial measurements during hospitalization help identify patients who need more aggressive management before discharge 1

Important Considerations:

• BNP/NT-proBNP levels are affected by age, renal function, obesity, and atrial fibrillation 1

• For patients with significant renal failure (eGFR <60 mL/min/1.73 m²) or BMI >35 kg/m², different decision limits should be used 1

• Failure to achieve significant BNP/NT-proBNP reduction despite treatment should prompt consideration of more aggressive therapy or longer hospitalization 2

• More frequent monitoring (e.g., daily) has not been shown to provide additional clinical benefit and is not recommended as standard practice

Bottom Line:

The evidence strongly supports measuring BNP/NT-proBNP at admission and discharge, with the discharge value and percent change from baseline providing the most valuable prognostic information. Additional measurements at 24-48 hours may be considered in select cases but are not routinely necessary.