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B-type natriuretic peptide (BNP & N-terminal pro-BNP) in serum/plasma

Indications: 1) evaluation of suspected heart failure* [30] a) sensitive & specific for diagnosis of heart failure in patients with dyspnea [23] b) may reduce hospitalization by distinguishing cardiac from pulmonary dyspnea & directing early therapy [5,23] c) may help to distinguish new-onset ascites due to heart failure vs cirrhosis [29] 2) useful in children [13] as well as adults 3) serum BNP 40 hours after acute coronary insufficiency may be useful for prognosis a) higher levels of BNP correlate with risk of death at 10 months, repeat MI & congestive heart failure during follow-up b) serial BNP levels after acute coronary syndrome predict risk of death or onset of congestive heart failure. [15] 4) admission BNP predicts in-hospital mortality in patients admitted with decompensated heart failure. [20] 5) 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] - < 50 years: > 450 pg/mL - 50-75 years: > 900 pg/mL - > 75 years: > 1800 pg/mL 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] - 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 a) hazard ratio 2.4 for those in highest 25% vs lowest 25% [9,17] b) may identify subset of patients with benefit from statin - BNP better than pro-BNP & better than emergency physician for diagnosis of cardiogenic pulmonary edema [11] - best cut-off values: - BNP: > 250 pg/mL - pro-BNP: > 1500 pg/mL - 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: 1) heart failure* [30] a) cardiogenic pulmonary edema b) cardiomyopathy 1] dilated cardiomyopathy 2] restrictive cardiomyopathy 2) pulmonary embolism 3) angiotensin receptor neprilysin inhibitor (ARNI) increases serum BNP but decreases serum NT-proBNP [35] 4) other [37] - renal failure - atrial fibrillation - valvular heart disease - pericardial disease - acute coronary syndrome - anemia - obstructive sleep apnea - pulmonary hypertension - hypertension - hepatic cirrhosis - female - older age 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: lavender top Notes: - high ANP levels also associated with increased risk [6] - high level of either peptide also predicts increased risk for heart failure & atrial fibrillation

Related

basic (brain) natriuretic peptide (BNP, B-type)

General

B-type natriuretic peptide (BNP & N-terminal pro-BNP) in serum/plasma/blood

References

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  24. 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: 19699346
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  26. B-Type Natriuretic Peptide Laboratory Test Directory ARUP: 30191
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