A repeat NT-proBNP result would be recommended before discharge as natriuretic peptides have prognostic value in heart failure.
For hospitalized patients, NT-proBNP should be checked at least twice at admission and before discharge.
A single value of >5000 pg/mL predicts a greater risk of mortality and poorer outcomes.
Change of NT-proBNP provides useful information for determining the optimal treatment at discharge.
Based on the admission value of >5000 pg/mL and the lack of reduction before discharge, this patient would be at high risk for mortality and heart failure rehospitalization. It impacted on the switch from enalapril to Sacubitril/Valsartan to optimize the medical therapy.
Conclusion
Patients who attained a significant reduction (>30%) in NT-proBNP between admission and discharge had a lower subsequent rate of cardiovascular death or heart failure hospitalization.
Author’s opinion:
Although the level of NT-proBNP and the change of NT-proBNP should not be used as the only criterion to determine admission and discharge of heart failure patients, NT-proBNP provides additional information to clinical evaluation in support of clinical decision on admission, triage, discharge and optimizing treatment.
References:
MR Ziles, BL Claggett, MF Prescott, et al. Prognostic Implications of Changes in N-Terminal Pro-B-type Natriuretic Peptide in Patients With Heart Failure. J Am Coll Cardiol 2016; 68: 2425-2436. CSP Lam, YH Li, A Bayes-Genis, et al. The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure. J Chin Med Assoc 2019; 82(6):447-451.
45-year old man
Key signs and symptoms
New referral to the heart failure clinic , NYHA class 2 , LVEF 35%
Medical history
Hypertension for the last 10 years
Chronic heart failure for the last 2 years
Acute myocardial infarction 7 years ago
Clinical examination
BP 110/70 mmHg
Heart rate 68/min
No evidence of fluid overload
Potassium 4.0 mmol/L
Creatinine 130 Umol/L
LDL 1.9 mmol/L
BMI-23
Medications
Sacubitril/Valsartan 200 mg bid
Carvedilol 25 mg bid
Spironolactone 25 mg od
Loop diuretic
Aspirin 100 mg od
Atorvastatin 40 mg on
A baseline value of NT-proBNP is needed for a new heart failure patient in clinic.
NT-proBNP is a continuous variable and an one time measurement is not sufficient. The higher the value, the worse the prognosis.
After adequate treatment, the NT-proBNP level should be rechecked. If NT-proBNP level is still higher than 1000 pg/mL after 1 month, it predicts a higher risk for mortality and heart failure readmission.
After optimization of the medical therapy, co-morbidities and other reasons should be investigated if the NT-proBNP level is still higher than 1000 pg/mL.
This patient had dapagliflozin added to his medications to optimize the medical therapy as the continuous monitoring of the NT-proBNP showed a level persistently above 1000 pg/mL.
Conclusion
NT-proBNP values higher than 1000 pg/mL in heart failure patients indicates an increased risk of death or hospitalization.
Author’s opinion:
NT-proBNP values higher than 1000 pg/mL in heart failure patients indicates an increased risk of death or hospitalization.
References:
MR Ziles, BL Claggett, MF Prescott, et al. Prognostic Implications of Changes in N-Terminal Pro-B-type Natriuretic Peptide in Patients With Heart Failure. J Am Coll Cardiol 2016; 68: 2425-2436.
CSP Lam, YH Li, A Bayes-Genis, et al. The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure. J Chin Med Assoc 2019; 82(6):447-451.
65-year old man
Key signs and symptoms
Follow up in general cardiology clinic NYHA class 1, LVEF 38%
Medical history
Hypertension for the last 15 years
Dyslipidaemia for the last 15 years
Coronary artery bypass surgery 10 years ago
Clinical examination
BP 115/70 mmHg
Heart rate 65/min
No evidence of fluid overload
Potassium 3.8 mmol/L
Creatinine 80 Umol/L
LDL 1.8 mmol/L
BMI-19
Medications
Sacubitril/Valsartan 100 mg bid
Bisorprolol 10 mg od
Spironolactone 25 mg od
Aspirin 100 mg od
Rosuvastatin 10 mg od
NT-proBNP should be measured for all patients in the first visit to the clinic.
During follow up, NT-proBNP should be measured when necessary depending on the severity of heart failure, change in the treatment or to optimize treatment, and local follow up practice.
In heart failure patients without symptom, NT-proBNP level >1000 pg/mL predicts poor outcome. This group of patients should be referred to heart failure specialists and the treatment should be optimized.
In heart failure patients treated with angiotensin receptor neprilysin inhibitor, NT-proBNP is the preferred natriuretic peptides biomarker.
Due to the elevated NT-proBNP, the patient was referred to the heart failure specialist and the Sacubitril/Valsartan was up titrated to 200 mg bid with a repeat NT-proBNP in 30 days showing a reduction to 850 pg/mL (< 1000 pg/mL).
Conclusion
In stable heart failure patients, NT-proBNP values less than 1000 pg/mL indicates better prognosis.
Author’s opinion:
NT-proBNP is a useful tool to help with the clinical evaluation and treatment of stable heart failure patients as the symptoms may be masked. Optimization of treatment to aim for a NT-proBNP level of less than 1000 pg/mL will reduce the subsequent risk for mortality and hospitalization.
References:
MR Ziles, BL Claggett, MF Prescott, et al. Prognostic Implications of Changes in N-Terminal Pro-B-type Natriuretic Peptide in Patients With Heart Failure. J Am Coll Cardiol 2016; 68: 2425-2436. CSP Lam, YH Li, A Bayes-Genis, et al. The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure. J Chin Med Assoc 2019; 82(6):447-451.
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