Elsevier

Journal of Critical Care

Volume 33, June 2016, Pages 262-265
Journal of Critical Care

Rapid Communication
A single BNP measurement in acute heart failure does not reflect the degree of congestion,☆☆

https://doi.org/10.1016/j.jcrc.2016.02.023Get rights and content

Abstract

Introduction

Multiple studies found a significant correlation between B-type natriuretic peptide (BNP) level and clinical severity of heart failure (HF). We aim to study the ability of a single BNP measurement to predict the degree of congestion in acute systolic HF.

Methods

Patients enrolled in the ESCAPE trial who were admitted with acute systolic HF were divided into tertiles according to baseline BNP level with comparison of the degree of congestion across tertiles using clinical signs of congestion as well as objective parameters of overload checked by the pulmonary artery catheter.

Results

A total of 251 cases (mean age, 56 years; 75% males) were included in the study after excluding patients with normal (n = 43) or extremely elevated BNP (n = 53) due to the known limited significance of BNP in predicting the degree of congestion in the latter 2 instances. These cases were divided into tertiles as follows: tertile 1, BNP less than or equal to 376 pg/mL; tertile 2, BNP 377 to 792 pg/mL; and tertile 3, BNP greater than or equal to 793 pg/mL. There were significant differences across the BNP tertiles in age (P = .03) and body mass index (P = .003). There were no differences between the 3 BNP tertiles with regard to the presence of rales (P = .533), jugular venous distension (P = .245), positive hepatojugular reflux (P = .224), hepatomegaly (P = .489), ascitis (P = .886), lower extremity edema (P = .068), or S3 gallop (P = .512). With regard to hemodynamic markers of congestion measured via the pulmonary artery catheter, there were no significant differences across the BNP tertiles in the right atrial pressure (P = .148), pulmonary capillary wedge pressure (P = .140), pulmonary artery systolic pressure (P = .155), pulmonary artery diastolic pressure (P = .246), and pulmonary artery mean pressure (P = .607).

Conclusion

Although longitudinal BNP follow-up may be valuable in reflecting the degree of congestion, looking at a single BNP measurement alone is not a good marker to predict the level of congestion and should not be used as a “stand-alone” test for determining aggressiveness of diuresis. Management should be guided by the entirety of physical examination, laboratory values, and hemodynamic parameters when available.

Introduction

Patients hospitalized with heart failure (HF) suffer high mortality and readmission rate despite continued advancements in medical treatment and device therapy [1]. Available data show that the main reason for hospitalization for HF are symptoms of congestion rather than low cardiac output. Grading congestion in acute HF is achieved through a combination of bedside assessment, laboratory markers and central hemodynamic variables of congestion if available. The B-type natriuretic peptide (BNP) is secreted in the cardiac ventricles following volume and pressure overload [2] and has aided in the diagnosis of HF in patients with elevated levels who are presenting with dyspnea. Multiple studies have found a significant correlation between BNP and clinical severity of HF [3]. Nonetheless, we have previously reported that a normal BNP in patients admitted with acute systolic HF has limited diagnostic ability due to similarities in the degree of congestion compared with those with elevated BNP and the fact that it may be a indication of the short BNP half-life of 23 minutes where 2-hours are need to reflect changes due to acute HF [4], [5]. We have also found that an extremely elevated BNP in patients hospitalized with acute systolic HF has an equally limited diagnostic ability when utilizing a single admission measurement to predict the degree of congestion which was comparable in those with or without extremely elevated levels. Herein, we aim to study the ability of a single BNP measurement to reflect the severity of congestion in patients hospitalized with acute systolic HF after excluding these 2 groups of patients with either normal or extremely elevated BNP, due to the known limited significance of BNP in the later two instances.

Section snippets

Methods

This study is a retrospective analysis of a limited access dataset from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) tria which enrolled 433 patients with acute systolic HF managed with clinical assessment plus pulmonary artery catheterization (PAC) versus clinical assessment alone. All patients had New York Heart Association (NYHA) class IV symptoms and a left ventricular ejection fraction (LVEF) < 30% by contrast ventriculography,

Results

A total of 347 patients hospitalized with acute systolic HF had BNP levels checked on admission out of which 43 had normal BNP and 53 had extremely elevated BNP and both groups (n = 96) were excluded from this analysis. The remaining 251 cases (mean age 56 years, 75% males) had a BNP ranging between 100.6 pg/mL and 1676 pg/mL with mean ± SD of 655 ± 421 pg/mL. These cases were divided into tertiles according to BNP level. Tertile 1 comprised 84 cases with BNP ≤ 376 pg/mL, tertile 2 comprised 83

Discussion

We have shown in this retrospective analysis that despite most patients in the ESCAPE trial (87.6%), admitted for HF, had elevated BNP, the absolute value of the BNP level on admission did not appear to match the degree of congestion whether detected clinically or through various hemodynamic parameters measured by the PAC. This analysis was performed after excluding cases with normal or extremely elevated BNP as we have found before that BNP in these two instances have limited value in

Acknowledgement

The ESCAPE trial is conducted and supported by the NHLBI in collaboration with the ESCAPE Study Investigators. This article was prepared using a limited access dataset obtained from the NHLBI and does not necessarily reflect the opinions or views of the ESCAPE trial investigators or the NHLBI.

References (10)

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    Fig. 4 is a summary of variables included in the multivariate model. In a prior analysis, we have demonstrated that looking at a single BNP measurement at one point in time is not a good marker to predict the level of congestion [13] but rather longitudinal follow up is more valuable. Nonetheless, single BNP measurements—on admission and discharge—were previously shown to predict mortality.

  • Longitudinal BNP follow-up as a marker of treatment response in acute heart failure: Relationship with objective markers of decongestion

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    Although a prior study showed that BNP correlated weakly with IVC size in acute HF, the measurements were done at a single time point and thus are unable to evaluate the degree of decongestion in the study population [10]. In fact, we have shown that single time point analysis of BNP did not predict the severity of congestion [3]. The strength of this study is the utilization of objective markers of decongestion: weight loss, reduction of IVC diameter and reduction in PCWP.

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There are no conflicts of interest.

☆☆

No funding has been received for this manuscript.

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