Rapid CommunicationA single BNP measurement in acute heart failure does not reflect the degree of congestion☆,☆☆
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.
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Cited by (19)
Role of prehospital point-of-care N-terminal pro-brain natriuretic peptide in acute life-threatening cardiovascular disease
2022, International Journal of CardiologyCitation Excerpt :However, the evidence is not so clear regarding their use in AHF; there are numerous studies corroborating the usefulness of NP in the prognosis of the acute appearance of this pathology, either individually [19,20] or as part of multiparametric scales [21], although several recent prognostic scales do not include these biomarkers [22,23]. Moreover, evidence exists discouraging the use of single NPs measurements in the prognostic evaluation of AHF [24]. The results of our study favour this latter line of evidence, as POCT NT-proBNP has not shown good predictive ability when used in isolation so it seems that this biomarker should be combined with other clinical and analytical data within risk scales in order to be used reliably to predict outcome in AHF.
Natriuretic peptide B plasma concentration increases in the first 12 h of pulmonary edema recovery
2018, European Journal of Internal MedicineCitation Excerpt :Patients with the most difficult-to-treat edema, as assessed by the time needed to reduce dyspnea, showed a non-statistically significant higher BNP level at admission but a higher level at 8 and 12 h. Unexpectedly, BNP further increased up to 12 h after emergency admission in all study groups, regardless of the time course of dyspnea resolution. It is totally unknown, but intriguing to speculate, whether the amount of BNP increase has a prognostic power [21,22]. Studies on this aspect are in our opinion needed.
Acute systolic heart failure with normal admission BNP: clinical features and outcomes
2017, International Journal of CardiologyDischarge BNP is a stronger predictor of 6-month mortality in acute heart failure compared with baseline BNP and admission-to-discharge percentage BNP reduction
2016, International Journal of CardiologyCitation Excerpt :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
2016, International Journal of CardiologyCitation Excerpt :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.