Clinical Utility of BNP Testing in Heart Failure

1
Clinical Utility of BNP Testing in Heart
Failure

• Adam Werne, MD
• Cardiology Fellow
• St. Vincent Hospital

2
Heart Failure Pathophysiology

• Baig MK, Mahon N, McKenna WJ, et al. The
  pathophysiology of advanced heart failure.
  American Heart Journal 135 S216-30, 1998.

3
Diagnosis of Heart Failure

• The cardinal manifestations of heart failure are
  dyspnea, fatigue, and fluid retention leading to
  exercise intolerance, pulmonary congestion, and
  peripheral edema.
• Risk of developing heart failure strongly
  correlates with increasing age.
• The diagnosis of heart failure remains a clinical
  one based primarily on signs and symptoms derived
  from a thorough history and physical examination.
• Elevated jugular venous pressure is the most
  specific finding.
• Response to diuretic therapy can help confirm the
  diagnosis in difficult cases.
• Echocardiography is the single most useful
  diagnostic test in the evaluation of patients
  with heart failure.

• Jessup M, Abraham WT, Casey DE, et al. 2009
  Focused Update ACCF/AHA guidelines for the
  diagnosis and management of heart failure in
  adults. Journal of the American College of
  Cardiology 53 1343-82, 2009.

4
Natriuretic Peptides

• Brain natriuretic peptide (BNP) is a hormone
  initially identified in the brain but released
  primarily from the ventricles of the heart in
  response to myocardial cell stretch from
  increased volume, filling pressures, and wall
  tension.

• Cleavage of the prohormone proBNP produces the
  biologically active 32 amino acid BNP as well as
  the inert N-terminal pro-BNP, both of which can
  be measured by commercially available assays.

• Maisel A, Mueller C, Adams K Jr, et al. State
  of the art using natriuretic peptide levels in
  clinical practice. European Journal of Heart
  Failure 10 824-39, 2008.

5
Physiologic effects of BNP include diuresis,
afterload reduction, and neuro-hormonal
modulation.

• Baig MK, Mahon N, McKenna WJ, et al. The
  pathophysiology of advanced heart failure.
  American Heart Journal 135 S216-30, 1998.

6
Elevated BNP levels are associated with
LV dysfunction by echocardiography.
416
30
LV Function by Echocardiography

• Krishnaswamy P, Lubien E, Clopton P, et al.
  Utility of B-natriuretic peptide levels in
  identifying patients with left ventricular
  systolic or diastolic dysfunction. American
  Journal of Medicine 111 274-9, 2001.

7
BNP levels are increased in both systolic and
diastolic dysfunction of the left ventricle.
Echocardiographic Findings

• Krishnaswamy P, Lubien E, Clopton P, et al.
  Utility of B-natriuretic peptide levels in
  identifying patients with left ventricular
  systolic or diastolic dysfunction. American
  Journal of Medicine 111 274-9, 2001.

8
Elevated BNP levels suggest a diagnosis of
heart failure in dyspnea of uncertain etiology.
675
110
346
No HF (N 770)
Dyspnea due to HF(N 744)
Noncardiac dyspnea in pts w/ LV dysfx (N72)

• Maisel AS, Krishnaswamy P, Nowak RM, et al.
  Rapid measurement of B-type natriuretic peptide
  in the emergency diagnosis of heart failure. New
  England Journal of Medicine 347 161-7, 2002.

9
BNP levels increase incrementally with worsening
heart failure symptoms.

• Maisel AS, Krishnaswamy P, Nowak RM, et al.
  Rapid measurement of B-type natriuretic peptide
  in the emergency diagnosis of heart failure. New
  England Journal of Medicine 347 161-7, 2002.

10
BNP levels less than 100 are very sensitive for
excluding heart failure as a cause of dyspnea.
Sensitivity 90 Specificity 76

• Maisel AS, Krishnaswamy P, Nowak RM, et al.
  Rapid measurement of B-type natriuretic peptide
  in the emergency diagnosis of heart failure. New
  England Journal of Medicine 347 161-7, 2002.

11
BNP levels should be interpreted in the context
of a patients clinical characteristics.

• Strunk A, Bhalla V, Clopton P, et al. Impact of
  the history of congestive heart failure on the
  utility of B-type natriuretic peptide in the
  emergency diagnosis of heart failure results
  from the breathing not properly multinational
  study. Am J Med 119 69e.1 11, 2006.

12
BNP levels vary with age, gender, weight, and
comorbid conditions.

• Increased BNP
• Advanced age
• Male gender
• Renal failure
• Atrial fibrillation
• Coronary artery disease
• Pulmonary HTN

• Decreased BNP
• Young age
• Female gender
• Obesity

• Tang WHW, Girod JP, Lee MJ, et al . Plasma
  B-type natriuretic peptide levels in ambulatory
  patients with established chronic symptomatic
  systolic heart failure. Circulation 108 2964-6,
  2003.

13
BNP levels correlate with mortality
in patients with heart failure.

• Anand IS, Fisher LD, Chiang YT, et al. Changes
  in brain natriuretic peptide and norepinephrine
  over time and mortality and morbidity in the
  valsartan heart failure trial (Val-HeFT).
  Circulation 1071278-83, 2003.

14
Data are mixed regarding the efficacy of using
BNP levels to guide heart failure therapy.

• Jourdain P, Jondeau G, Funck F, et al. Plasma
  brain natriuretic peptide-guided therapy to
  improve outcome in heart failure the STARS-BNP
  multicenter study. Journal of the American
  College of Cardiology 49 1733-9, 2007.
• Pfisterer M, Buser P, Rickli H, et al.
  BNP-guided vs symptom-guided heart failure
  therapy the trial of intensified vs standard
  medical therapy in elderly patients With
  congestive heart failure (TIME-CHF) randomized
  trial. JAMA 301 383-92, 2009.

15
Conclusions

• Elevated BNP levels are associated with left
  ventricular dysfunction by echocardiography (both
  systolic and diastolic).
• BNP levels can help confirm or exclude a clinical
  diagnosis of heart failure in patients with
  dyspnea of uncertain etiology.
• Levels less than 100 have good negative
  predictive value.
• Levels greater than 500 have good positive
  predictive value.
• Values are affected by age, gender, weight, and
  comorbidities.
• BNP should be assessed in all patients suspected
  of having heart failure when the diagnosis is not
  certain (inpatient or outpatient).
• BNP levels have prognostic significance in
  patients with heart failure.
• Titration of heart failure therapy based on BNP
  level is not routinely recommended at this time.

16
References

• Anand IS, Fisher LD, Chiang YT, et al. Changes
  in brain natriuretic peptide and norepinephrine
  over time and mortality and morbidity in the
  valsartan heart failure trial (Val-HeFT).
  Circulation 1071278-83, 2003.
• Baig MK, Mahon N, McKenna WJ, et al. The
  pathophysiology of advanced heart failure.
  American Heart Journal 135 S216-30, 1998.
• Jessup M, Abraham WT, Casey DE, et al. 2009
  Focused Update ACCF/AHA guidelines for the
  diagnosis and management of heart failure in
  adults. Journal of the American College of
  Cardiology 53 1343-82, 2009.
• Jourdain P, Jondeau G, Funck F, et al. Plasma
  brain natriuretic peptide-guided therapy to
  improve outcome in heart failure the STARS-BNP
  multicenter study. Journal of the American
  College of Cardiology 49 1733-9, 2007.
• Krishnaswamy P, Lubien E, Clopton P, et al.
  Utility of B-natriuretic peptide levels in
  identifying patients with left ventricular
  systolic or diastolic dysfunction. American
  Journal of Medicine 111 274-9, 2001.
• Maisel AS, Krishnaswamy P, Nowak RM, et al.
  Rapid measurement of B-type natriuretic peptide
  in the emergency diagnosis of heart failure. New
  England Journal of Medicine 347 161-7, 2002.
• Maisel A, Mueller C, Adams K Jr, et al. State of
  the art using natriuretic peptide levels in
  clinical practice. European Journal of Heart
  Failure 10 824-39, 2008.
• Pfisterer M, Buser P, Rickli H, et al.
  BNP-guided vs symptom-guided heart failure
  therapy the trial of intensified vs standard
  medical therapy in elderly patients With
  congestive heart failure (TIME-CHF) randomized
  trial. JAMA 301 383-92, 2009.
• Strunk A, Bhalla V, Clopton P, et al. Impact of
  the history of congestive heart failure on the
  utility of B-type natriuretic peptide in the
  emergency diagnosis of heart failure results
  from the breathing not properly multinational
  study. American Journal of Medicine 119 69e.1
  11, 2006.
• Tang WHW, Girod JP, Lee MJ, et al . Plasma
  B-type natriuretic peptide levels in ambulatory
  patients with established chronic symptomatic
  systolic heart failure. Circulation 108 2964-6,
  2003.