B-type natriuretic peptide (BNP & N-terminal pro-BNP) in serum/plasma
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Indications
- evaluation of suspected heart failure*[30]
- sensitive & specific for diagnosis of heart failure in patients with dyspnea[23]
- may reduce hospitalization by distinguishing cardiac from pulmonary dyspnea & directing early therapy[5][23]
- may help to distinguish new-onset ascites due to heart failure vs cirrhosis[29]
- useful in children[13] as well as adults
- serum BNP 40 hours after acute coronary insufficiency may be useful for prognosis
- higher levels of BNP correlate with risk of death at 10 months, repeat MI & congestive heart failure during follow-up
- serial BNP levels after acute coronary syndrome predict risk of death or onset of congestive heart failure.[15]
- admission BNP predicts in-hospital mortality in patients admitted with decompensated heart failure.[20]
- weaning of patients from mechanical ventilation
- assessment of volume status especially in patients with LV systolic dysfunction[27]
* both BNP & NT-proBNP are widely used to aid diagnosis, assess effect of therapy, & predict prognosis in heart failure with reduced ejection fraction; the two have similar predictive values[36]
Contraindications
- routine assessment of chronic heart failure[23]
- serial serum BNP in ambulatory patients to monitor heart failure or to guide therapy[23]
Reference interval
- < 100 pg/mL*
* BNP is mildly increased with chronic renal failure (mean serum creatinine of 4.9* mg/dL) mean serum BNP = 162 vs 28 pg/mL
- mean BNP increases by 20% for each 10 mL/min/1.73m2 reduction in GFR[14] proBNP increases by 20% for each 10 mL/min/1.73m2 reduction in GFR[14]
Patient-specific serum BNP cutoffs suggested[24] (NT-proBNP cutoffs differ, see below)
- 184 pg/mL in patients aged 75
- 150 pg/mL in patients with atrial fibrillation
- 449 pg/mL in patients with creatinine levels of 2 mg/dL
- 25 pg/mL in patients with BMIs >= 35 kg/m2*
* a serum BNP value of < 55 pg/mL rules out acute heart failure in obese patients[23]
Patient-specific serum NT-proBNP cutoffs:[38]
Clinical significance
- BNP* is released by ventricles of the heart when volume or pressure overload occurs
- thus BNP is useful in distinguishing cardiac from pulmonary dyspnea[2][3][5][21]
- low levels rule out cardiogenic shock
- levels are frequently elevated in patients with cardiogenic shock as well as other forms of shock.[7]
- heart failure is unlikely when BNP is < 100 pg/mL, > 70 years < 125 pg/mL & likely when BNP levels are > 500 pg/mL
- at a threshold of < 100 ng/L for heart failure
- sensitivity is 95%,
- specificity is 63%
- positive predictive value (PPV) is 67%,
- negative predictive value (NPV) is 94%[31]
- at a threshold of < 100 ng/L for heart failure
- BNP in top 20% places patient at increased risk of major cardiovascular event & mortality (2-fold).[10][14]
- better predictive value than CRP[10]
- serum pro-BNP < 500 pg/mL with negative predictive value of 97% for adverse outcome associated with pulmonary embolism[4]
- increased N-terminal pro-BNP associated with increased mortality in patients with coronary artery disease
- BNP better than pro-BNP & better than emergency physician for diagnosis of cardiogenic pulmonary edema[11]
- useful for guiding heart failure treatment[19]
- does not improve outcomes when used to guide treatment of heart failure[22]
- serum BNP guided therapy reduces all-cause mortality in patients with chronic heart failure compared with usual clinical care; however, it does not reduce all-cause hospitalization or increase survival free of hospitalization[25]
- serum BNP predicts mortality in patients with or without heart failure[33]
- for serum BNP of 400 pg/mL, 3-year mortality is 21% in patients with heart failure & 19% in those without[33]
*BNP (active peptide) is formed with N-terminal pro-BNP from the prohormone.
Increases
- heart failure*[30]
- pulmonary embolism
- angiotensin receptor neprilysin inhibitor (ARNI) increases serum BNP but decreases serum NT-proBNP[35]
- other[37]
Decreases
- serum BNP levels generally lower in obese patients, even those with heart failure[23]
Methods
- ELISA somewhat better than RIA[16], False negatives 15%[16]
- rapid bedside blood test has been developed & implemented in an emergency department setting[3][5]
Specimen
Notes
- high ANP levels also associated with increased risk[6]
- high level of either peptide also predicts increased risk for heart failure & atrial fibrillation
More general terms
Additional terms
References
- ↑ Journal Watch 21(22):178, 2001 de Lemos JA, Morrow DA, Bentley JH, Omland T, Sabatine MS, McCabe CH, Hall C, Cannon CP, Braunwald E. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med. 2001 Oct 4;345(14):1014-21. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11586953
- ↑ 2.0 2.1 Journal Watch 22(5):35, 2002 Morrison LK, Harrison A, Krishnaswamy P, Kazanegra R, Clopton P, Maisel A. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol. 2002 Jan 16;39(2):202-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11788208
- ↑ 3.0 3.1 3.2 Journal Watch 22(16):126, 2002 Maisel AS et al, N Engl J Med 347:161, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12124404
- ↑ 4.0 4.1 Journal Watch 23(10):79, 2003 Kucher N et al, Circulation 107(Apr 1):1576, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12668488
- ↑ 5.0 5.1 5.2 5.3 Journal Watch 24(5):37,38, 2004 Mueller C et al Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 350:647, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14960741
- ↑ 6.0 6.1 Journal Watch 24(5):38, 2004 Wang TJ et al Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 350:655, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14960742
- ↑ 7.0 7.1 Journal Watch 24(18):143, 2004 Tung RH, Garcia C, Morss AM, Pino RM, Fifer MA, Thompson BT, Lewandrowski K, Lee-Lewandrowski E, Januzzi JL. Utility of B-type natriuretic peptide for the evaluation of intensive care unit shock. Crit Care Med. 2004 Aug;32(8):1643-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15286538
- ↑ Journal Watch 24(20):152, 2004 Takami Y, Horio T, Iwashima Y, Takiuchi S, Kamide K, Yoshihara F, Nakamura S, Nakahama H, Inenaga T, Kangawa K, Kawano Y. Diagnostic and prognostic value of plasma brain natriuretic peptide in non-dialysis-dependent CRF. Am J Kidney Dis. 2004 Sep;44(3):420-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15332214
- ↑ 9.0 9.1 Journal Watch 25(6):47, 2005 Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med. 2005 Feb 17;352(7):666-75. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15716560
- ↑ 10.0 10.1 10.2 Journal Watch 25(9):73, 2005 Kistorp C, Raymond I, Pedersen F, Gustafsson F, Faber J, Hildebrandt P. N-terminal pro-brain natriuretic peptide, C-reactive protein, and urinary albumin levels as predictors of mortality and cardiovascular events in older adults. JAMA. 2005 Apr 6;293(13):1609-16. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15811980
Schillinger M. Cardiovascular risk stratification in older patients: role of brain natriuretic peptide, C-reactive protein, and urinary albumin levels. JAMA. 2005 Apr 6;293(13):1667-9. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15811987 - ↑ 11.0 11.1 Ray P, Arthaud M, Birolleau S, Isnard R, Lefort Y, Boddaert J, Riou B; the EPIDASA Study Group. Comparison of brain natriuretic Peptide and probrain natriuretic Peptide in the diagnosis of cardiogenic pulmonary edema in patients aged 65 and older. J Am Geriatr Soc. 2005 Apr;53(4):643-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15817011
- ↑ Journal Watch 25(10):84, 2005 Doust JA, Pietrzak E, Dobson A, Glasziou P. How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ. 2005 Mar 19;330(7492):625. Review. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15774989 <Internet> http://bmj.bmjjournals.com/cgi/content/full/330/7492/625
- ↑ 13.0 13.1 Journal Watch 25(11):90, 2005 Cohen S, Springer C, Avital A, Perles Z, Rein AJ, Argaman Z, Nir A. Amino-terminal pro-brain-type natriuretic peptide: heart or lung disease in pediatric respiratory distress? Pediatrics. 2005 May;115(5):1347-50. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15867046
- ↑ 14.0 14.1 14.2 14.3 Vickery S, Price CP, John RI, Abbas NA, Webb MC, Kempson ME, Lamb EJ. B-type natriuretic peptide (BNP) and amino-terminal proBNP in patients with CKD: relationship to renal function and left ventricular hypertrophy. Am J Kidney Dis. 2005 Oct;46(4):610-20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16183415
- ↑ 15.0 15.1 Morrow DA, de Lemos JA, Blazing MA, Sabatine MS, Murphy SA, Jarolim P, White HD, Fox KA, Califf RM, Braunwald E; A to Z Investigators. Prognostic value of serial B-type natriuretic peptide testing during follow-up of patients with unstable coronary artery disease. JAMA. 2005 Dec 14;294(22):2866-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16352794
- ↑ 16.0 16.1 16.2 Battaglia M et al, Accuracy of B-type natriuretic peptide tests to exclude congestive heart failure: Systemic review of test accuracy studies. Arch Intern Med 2006; 166:1073 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16717169
Mueller C et al, Cost-effectiveness of B-type natriuretic peptide testing in patients with acute dyspnea. Arch Intern Med 2006; 166:1081 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16717170
Hlatky M and Heidenreich P, The value BNP testing. Arch Intern Med 2006; 166:1063 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16717166 - ↑ 17.0 17.1 Bibbins-Domingo K, Gupta R, Na B, Wu AH, Schiller NB, Whooley MA. N-terminal fragment of the prohormone brain-type natriuretic peptide (NT-proBNP), cardiovascular events, and mortality in patients with stable coronary heart disease. JAMA. 2007 Jan 10;297(2):169-76. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17213400
Konstam MA. Natriuretic peptides and cardiovascular events: more than a stretch. JAMA. 2007 Jan 10;297(2):212-4. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17213406 - ↑ Heart Protection Collaborative Group: N-terminal pro-B-type natriuretic peptide, vascular disease risk, and cholesterol reduction among 20,536 patients in the MRC/BHF Heart Protection Study. J Am Coll Cardiol 2007, 43:311 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17239712
- ↑ 19.0 19.1 Jourdain P et al, Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: The STARS-BNP multicenter study. J Am Coll Cardiol 2007, 49:1733 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17448376
- ↑ 20.0 20.1 Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M; ADHERE Scientific Advisory Committee and Investigators. Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure. J Am Coll Cardiol. 2007 May 15;49(19):1943-50. Epub 2007 Apr 30. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17498579
- ↑ 21.0 21.1 Green SM, Martinez-Rumayor A, Gregory SA, Baggish AL, O'Donoghue ML, Green JA, Lewandrowski KB, Januzzi JL Jr. Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea. Arch Intern Med. 2008 Apr 14;168(7):741-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18413557
- ↑ 22.0 22.1 Pfisterer M 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 2009 Jan 28; 301:383. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19176440
- ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 24.0 24.1 Rogers RK et al Usefulness of adjusting for clinical covariates to improve the ability of B-type natriuretic peptide to distinguish cardiac from noncardiac dyspnea. Am J Cardiol 2009 Sep 1; 104:689. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19699346
- ↑ 25.0 25.1 Porapakkham P et al B-Type Natriuretic Peptide-Guided Heart Failure Therapy Arch Intern Med. 2010;170(6):507-514 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20308637 <Internet> http://archinte.ama-assn.org/cgi/content/abstract/170/6/507
- ↑ B-Type Natriuretic Peptide Laboratory Test Directory ARUP: http://www.aruplab.com/guides/ug/tests/0030191.jsp
- ↑ 27.0 27.1 Dessap AM et al. Natriuretic peptide-driven fluid management during ventilator weaning: A randomized controlled trial. Am J Respir Crit Care Med 2012 Dec 15; 186:1256 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22997204
- ↑ Mehra MR, Uber PA, Park MH et al Obesity and suppressed B-type natriuretic peptide levels in heart failure. J Am Coll Cardiol. 2004 May 5;43(9):1590-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15120816
- ↑ 29.0 29.1 Farias AQ et al. Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: A diagnostic accuracy study. Hepatology 2014 Mar; 59:1043 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23907731 <Internet> http://onlinelibrary.wiley.com/doi/10.1002/hep.26643/abstract
- ↑ 30.0 30.1 30.2 Palazzuoli A, Gallotta M, Quatrini I, Nuti R. Natriuretic peptides (BNP and NT-proBNP): measurement and relevance in heart failure. Vasc Health Risk Manag. 2010 Jun 1;6:411-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20539843
- ↑ 31.0 31.1 Roberts E et al. The diagnostic accuracy of the natriuretic peptides in heart failure: Systematic review and diagnostic meta-analysis in the acute care setting. BMJ 2015 Mar 4; 350:h910 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25740799
- ↑ Mahadavan G, Nguyen TH, Horowitz JD. Brain natriuretic peptide: a biomarker for all cardiac disease? Curr Opin Cardiol. 2014 Mar;29(2):160-6. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24406448
- ↑ 33.0 33.1 33.2 York MK, Gupta DK, Reynolds CF et al B-Type Natriuretic Peptide Levels and Mortality in Patients With and Without Heart Failure. J Am Coll Cardiol. Volume 71, Issue 19, May 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29747827 <Internet> http://www.onlinejacc.org/content/71/19/2079
Vodovar N, Logeart D Similar BNP and Mortality Association in Patients With and Without Heart Failure. Any Increase Matters. J Am Coll Cardiol. Volume 71, Issue 19, May 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29747828 <Internet> http://www.onlinejacc.org/content/71/19/2089 - ↑ Daniels LB, Clopton P, Bhalla V et al How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure. Results from the Breathing Not Properly Multinational Study. Am Heart J. 2006 May;151(5):999-1005. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16644321
- ↑ 35.0 35.1 Velazquez EJ, Morrow DA, DeVore AD et al. PIONEER-HF Investigators Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med 2018 Nov 11. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30415601 https://www.nejm.org/doi/10.1056/NEJMoa1812851
- ↑ 36.0 36.1 Rorth R et al. Comparison of BNP and NT-proBNP in patients with heart failure and reduced ejection fraction. Circ Heart Fail 2020 Feb; 13:e006541 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32065760 https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.119.006541
- ↑ 37.0 37.1 Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
- ↑ 38.0 38.1 NEJM Knowledge+ Complex Medical Care
Hill SA, Booth RA, Santaguida PL et al Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence. Heart Fail Rev. 2014 Aug;19(4):421-38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24957908 Review.
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B-type natriuretic peptide (BNP & N-terminal pro-BNP) in serum/plasma patient information