Dr Byung-Su Yoo
Cardiologist/ Professor, Division of Cardiology, Wonju College of Medicine, Yonsei University, Korea

Clinical Cases from Korea: Serial NT-proBNP measurement and Heart Failure prognosis


45-year old woman

Key signs and symptoms

Acute Dyspnea (NYHA IV) for 4 days
Dyspnea/Orthopnea (+/+)
Cough/Sputum (-/-)

Medical History

No Diabetes Mellitus
No Pulmonary Tuberculosis
No Hepatitis
Hypertension with medication (Amlodipine 5 mg) for 10 years

Clinical examination

Dyspnea on exertion/Paroxysmal nocturnal dyspnea (+/+)
Palpitation/headache/sweating (+/+/+)
Rapid Heart Beat without murmur
Crackles in both lung fields
Pedal edema (++/++)



Cardiomegaly with pulmonary
congestion on both sides



EF=25% with delayed enhancement
(Late Gadolinium Enhancement-LGE)
in mid-wall by MRI

CT angiogram


No significant narrowing of coronary
on CT angiogram

Serial NT-proBNP level and medication

  At Admission 1st Visit 2st Visit 3rd Visit 4th Visit
Medications acertil 4 mg
dilatrend 3.125 mg bid
furix 40 mg bid
aldactone 25 mg qd
procoralan 5 mg bid
entresto 50 mg bid 50 mg bid 100 mg bid 50 mg bid

NT-proBNP is a good biomarker in OPD post-discharge during early follow up and drug adjustment period.

At admission
NT-proBNP 8900 pg/mL

After discharge 2 weeks (1st OPD visit)
NT-proBNP 2300 pg/mL

OPD 4 month
NT-proBNP 210 pg/mL

Dr Yoo Clinical Case - 3

What time period after therapy adjustment in Patients with Recent HF Destabilization can help predict prognosis?



De-novo HF


HF with reduced EF


R/o idiopathic DCMP (Non-ischemic dilated cardiomyopathy)

Author’s opinion

  • The changes in NT-proBNP levels during follow-up do correlate with changes in clinical status for patients with HF destabilization, relative changes in NT-proBNP levels are better predictors of future clinical events.

  • In PIONEER-HF trial, the initiation of sacubitril–valsartan therapy after hemodynamic stabilization led to a greater reduction in the NT-proBNP concentration than enalapril therapy, a difference that was evident by the first week.1

  • Predischarge NT-proBNP levels or short-term change (in percentage terms) in NT-proBNP levels at 1-2 weeks is a strong predictor of clinical events.

  • In addition, NT-proBNP monitoring added independent prognostic information to clinical scoring in patients with destabilized HF. 

  • Therefore, Serial monitoring for per cent change in NT-proBNP concentrations offers superior prognostic information to clinical assessment among outpatients with recent destabilized HF.

  1. Eric J. Velazquez et al, N Engl J Med 2019; 380:539-548

62-year old woman

Key signs and symptoms

Acute severe chest pain for 10 days
Acute dyspnea (NYHA IV) for 3 days
No other specific signs and symptoms

Medical History

Diabetes with oral medication (Diabex 500 mg, Sitagliptin 100 mg) for 10 years
Smoking 40 pack years
Elevated CK-MB and Troponin levels

Clinical examination

BP 118/68 mmHg
RR 92/min



Chest X-Ray showed pleural
effusion and pulmonary congestion


ECG shows no evidence of myocardial infarction

Coronary Angiogram

Coronary angiography shows significant narrowing on dRCA and dLCX



MRI: LGE (+)
EF: 35%
LVEDD: 5.2cm

MRI showed larger amount LGE
which means infarcted myocardium

Serial NT-proBNP level and medication

  At Admission 1st day 2nd day At discharge
(5 days)
30 days 180 days 365 days
(*< 3.7 ng/mL)
18.40 1.60 0.63 0.53 0.58 0.22
Troponin I
(< 0.046 ng/mL)
2.648 1.649 0.271 0.211 0.012 < 0.015

Initial NT-proBNP level was 7800, patient continued to experience dyspnea and chest pain. Serial measurement showed reduced levels.

Dr Yoo Clinical Case - 4

Which of the following is the serial NT-proBNP level status of the patient with the best prognosis?

Author’s opinion

  • Natriuretic peptides (NPs) are important predictors of outcomes in patients with acute myocardial infarction (AMI) but can change over time.1

  • Changes in the NT-proBNP levels over time are associated with concurrent changes in the EF or ventricular volumes and the clinical symptoms, suggesting that these natriuretic peptides may potentially serve as useful surrogate markers for patients with progressive remodeling after AMI.2

  • In addition, a persistently elevated NT-proBNP assessed 1 month after discharge was associated with a higher risk of mortality in patient with AMI.

  • Post discharge or early period risk stratification using NT-proBNP has the potential to identify higher risk patients after AMI.

  1. Tom Hendriks et al The International Journal of Cardiovascular Imaging volume 33, pages 1415–1423 (2017).
  2. Jens C. Nilsson MDa Am Heart J. Volume 143, Issue 4, April 2002, pages 696-702

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