Dr Jin-Oh Choi
Cardiologist/ Professor, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea

Clinical Cases from Korea: High NT-proBNP levels useful in differential diagnosis of HF

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58-year old man

Key signs and symptoms

Dyspnea with limited exertion

Medical History

Diagnosed as dilated cardiomyopathy 10 years ago.
8 years ago ICD was implanted and his symptoms improved with GDMT.
Recently aggravated dyspnea on exertion with persistently low LVEF.

Clinical examination

BP 94/60 mmHg
Heart rate 86/min
S3 (+)
JVP elevated

Laboratory test results

E’ Na 138 mmol/L
K 4.0 mmol/L
BUN 13.9 mg/dL
Cr 0.7 mg/dL
Hb 16.6 g/dL
NT-proBNP 3120 pg/mL

TTE and MRI images

Echo CG LVEF of 17% severe global hypokinesia, mild to moderate MR


Normal Coronary angiogram with ICD lead in place


Chest PA view shows cardiomegaly,
pulmonary congestion, ICD in situ


ECG showing Normal sinus rhythm, Bi-atrial enlargement, RBBB, VPC
NT-proBNP in advanced heart failure due to dilated cardiomyopathy

What is the management of this case ?



He was diagnosed as having advanced heart failure due to dilated cardiomyopathy and his medication of ACE inhibitor was replaced by Sacubitril/Valsartan 100 mg bid and Ivabradine was added.


After adjustment of medications his NT-proBNP level was reduced to the level of 1443 pg/mL with slight improvement of symptoms.


However, after 18 months of management his symptom re-aggravated with persistent elevation of NT-proBNP up to 3592 pg/mL. There was no evidence of arrhythmia, infection, anemia, or thyroid dysfunction.


He also denied any other aggravating factors such as high salt diet, skipped medication, or medicines such as NSAID. This was second admission due to aggravation of HF since 6 months before.


Now he is referred to the advanced HF clinic if he is eligible to HF surgery such as LVAD and/or heart transplantation.

Author’s opinion

  • As up-to-date guideline-directed medical treatment could not improve his symptom and his NT-proBNP level is persistently high above 3000 pg/mL, he can be a candidate for surgical treatment of HF such as LVAD and/or heart transplantation.

  • He would undergo evaluation such as right heart catheterization and exercise test measuring peak oxygen consumption rate. The tests would confirm if he is eligible for LVAD surgery or heart transplantation.

  1. Domingo A. Pascual-Figal. et al, European Hear Journal, Volume 29, Issue 8, April 2008, Pages 1011-1018

61-year old woman

Key signs and symptoms

Recent aggravation of DOE with exertional chest pain

Medical History

1 year ago dyspnea on exertion fc 2
Recently aggravated as NYHA III with exertional chest pain
Mild concentric LVH
Normal LV function
Normal RV function
Diagnosed for subglottic cancer previously but currently no evidence of recurrence
Suggested for further evaluation

Clinical examination

BP 91/63 mmHg
Heart rate 63/min
Pretibial pitting edema (+/+)

Laboratory test results

Hb 14.7 g/dL
E’ Na 143 mmol/L
K 3.9 mmol/L
BUN 16 mg/dL
Cr 1.19 mg/dL
NT-proBNP 4430 pg/mL
TnI 0.059 ng/mL
Serum Free Kappa light chain 474 mg/L
Serum Free Lambda light chain 6.18 mg/L

Bone Marrow biopsy

Normocellular Marrow with Proliferation of Monoclonal Plasma Cells and Deposition of Amyloid

Plasma Cell Myeloma (Plasma cells: 15~20%)

Primary Amyloidosis with Amyloid Deposition in Bone Marrow


Chest PA shows cardiomegaly, no significant finding


Normal Coronary angiogram with elevated LVEDP of 18 mmHg


Normal LVEF of 63%
LVH with high E/e’ of 28
(normal < 15)


ECG showing Normal sinus rhythm, non-specific ST-T change
NT-proBNP in cardiac infiltrative disease

What is the diagnosis of this case?



In case of HFpEF, if patient has very high NT-proBNP level, normal kidney function and sinus rhythm, think about cardiac amyloid.


This patient was diagnosed as having primary cardiac amyloidosis was confirmed by cardiac biopsy together with bone marrow examination.

Author’s opinion

  • Echocardiogram gives a hint of amyloid if read by an experienced person, but the initial diagnosis did not include amyloidosis.

  • Level of NT-proBNP, its level of > 3000 pg/mL in the case with normal EF, sinus rhythm and no significant renal dysfunction, one should think about cardiac amyloid. 1

  • And in the case of normal coronary angiogram for typical angina chest pain, it is recommended to measure LVEDP.

  • Elevated LVEDP, very high NT-proBNP, mildly elevated cardiac troponin, without evidence of renal failure could be a clue to the diagnosis of cardiac amyloidosis with normal coronary angiogram.

  • This patient was diagnosed as having primary cardiac amyloidosis was confirmed by cardiac biopsy together with bone marrow examination and was treated with chemotherapy for plasma cell dyscrasia.

  1. G. Merlini et al, Leukemia (2016) 30, 1979–1986

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