The Role of BNP Testing in Heart Failure

Am Fam Physician. 2006 Dec 1;74(11):1893-1900.

Brain natriuretic peptide (BNP) levels are simple and objective measures of cardiac function. These measurements can be used to diagnose heart failure, including diastolic dysfunction, and using them has been shown to save money in the emergency department setting. The high negative predictive value of BNP tests is particularly helpful for ruling out heart failure. Treatment with angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, spironolactone, and diuretics reduces BNP levels, suggesting that BNP testing may have a role in monitoring patients with heart failure. However, patients with treated chronic stable heart failure may have levels in the normal range (i.e., BNP less than 100 pg per mL and N-terminal proBNP less than 125 pg per mL in patients younger than 75 years). Increases in BNP levels may be caused by intrinsic cardiac dysfunction or may be secondary to other causes such as pulmonary or renal diseases (e.g., chronic hypoxia). BNP tests are correlated with other measures of cardiac status such as New York Heart Association classification. BNP level is a strong predictor of risk of death and cardiovascular events in patients previously diagnosed with heart failure or cardiac dysfunction.

Until recently, no simple blood test could detect heart failure or monitor its progression or guide its treatment. With the increasing availability of assays for the measurement of brain natriuretic peptide (BNP), a cardiac hormone, this test may have a role in detecting, monitoring, and perhaps preventing chronic heart failure.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

BNP testing is recommended to detect or rule out heart failure, including diastolic heart failure. The test has a high negative predictive value—a negative result rules out disease more effectively than a positive result rules in disease.

C

24

BNP testing is a useful tool in predicting prognoses in patients with heart failure and appears to be a stronger predictor than some traditional indicators (e.g., left ventricular ejection fraction, ischemic etiology, serum levels, New York Heart Association classification).

C

33

BNP is a predictor of death and cardiovascular events in persons without a previous cardiac dysfunction diagnosis.

C

33

It is premature to use BNP for treatment monitoring in patients with heart failure until further randomized controlled trials are completed.

C

32


BNP = brain natriuretic peptide.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1821 or http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

BNP testing is recommended to detect or rule out heart failure, including diastolic heart failure. The test has a high negative predictive value—a negative result rules out disease more effectively than a positive result rules in disease.

C

24

BNP testing is a useful tool in predicting prognoses in patients with heart failure and appears to be a stronger predictor than some traditional indicators (e.g., left ventricular ejection fraction, ischemic etiology, serum levels, New York Heart Association classification).

C

33

BNP is a predictor of death and cardiovascular events in persons without a previous cardiac dysfunction diagnosis.

C

33

It is premature to use BNP for treatment monitoring in patients with heart failure until further randomized controlled trials are completed.

C

32


BNP = brain natriuretic peptide.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1821 or http://www.aafp.org/afpsort.xml.

Pathophysiology

The heart secretes natriuretic peptides as a homeostatic signal to maintain stable blood pressure and plasma volume and to prevent excess salt and water retention. Atrial natriuretic peptide (ANP) initially was identified in the atrial myocardium of rats.1 BNP subsequently was isolated in porcine brains.2 Natriuretic peptides have several actions: (1) down-regulating the sympathetic nervous system and the renin-angiotensin-aldosterone system, (2) facilitating natriuresis and diuresis through the afferent and efferent hemodynamic mechanisms of the kidney and distal tubules, (3) decreasing peripheral vascular resistance, and (4) increasing smooth muscle relaxation. Natriuretic peptides also may inhibit cardiac growth and hypertrophy, counteracting the mitogenesis that causes ventricular remodeling.35

BNP primarily is secreted by the ventricles in the heart as a response to left ventricular stretching or wall tension.6 It may be a backup hormone that is activated only after a prolonged period of volume overload.7 Cardiac myocytes secrete a BNP precursor that is synthesized into proBNP, which consists of 108 amino acids. After it is secreted into the ventricles, proBNP is cleaved into the biologically active C-terminal portion and the biologically inactive N-terminal (NT-proBNP) portion.

Influences on BNP Levels

Many medications used to treat heart failure (e.g., diuretics such as spironolactone [Aldactone], angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers) reduce natriuretic peptide concentrations.813 Therefore, many patients with chronic stable heart failure will have BNP levels in the normal diagnostic range (i.e., BNP level less than 100 pg per mL [100 ng per L]). However, digoxin and some beta blockers appear to increase natriuretic peptide concentrations.1416 Exercise causes a short-term increase in BNP levels,17 although only small changes (i.e., increase of 0.9 percent in patients without heart failure, 3.8 percent in patients with New York Heart Association [NYHA] class I or II heart failure, and 15 percent in patients with NYHA class III to IV heart failure) are detectable one hour after exercise.18 No circadian variation has been reported when BNP is measured every three hours for 24 hours,19 and there is less hourly variation with BNP than with ANP.20

BNP to Diagnose Heart Failure

There is no agreed-upon first-line test for the diagnosis of heart failure and no simple method of measuring the adequacy of cardiac output in relation to normal levels of activity. Heart failure usually is diagnosed in persons with known heart disease who present with nonspecific symptoms (e.g., breathlessness, ankle swelling) and signs (e.g., basal lung crackles). To confirm clinically suspected heart failure, physicians rely on surrogate measures of cardiac function such as left ventricular ejection fraction. However, it is clear that a large proportion of patients with heart failure, particularly older patients and women, have preserved systolic function (i.e., diastolic heart failure). The best way to diagnose and treat these patients is unclear. BNP increases when cardiac myocytes are strained; therefore, BNP is an effective method for detecting heart failure with or without systolic dysfunction.

Elevated BNP levels also have been associated with renal failure (because of reduced clearance),21 pulmonary embolism, pulmonary hypertension,22,23 and chronic hypoxia.

A systematic review included 20 studies evaluating BNP testing in the diagnosis of heart failure.24 The eight studies that measured BNP against a reference standard of reduced left ventricular ejection fraction (i.e., 40 percent or lower or the equivalent) had a pooled diagnostic odds ratio of 12 (95% confidence interval [CI], 8 to 16).24 This result is consistent with a moderately accurate diagnostic test. The seven studies that measured BNP against clinical criteria (i.e., a consensus view using all other clinical information and often using a panel of two or three cardiologists) had a pooled diagnostic odds ratio of 31 (95% CI, 27 to 35).24 The two studies that measured BNP against echocardiographic criteria for systolic and diastolic heart failure had a pooled diagnostic odds ratio of 38 (95% CI, 6 to 237).24 Therefore, the review showed a greater agreement with a heart failure measure that included diastolic heart failure than one that included systolic heart failure alone (assuming there were no other differences between the studies).24

Results from significant studies of the diagnostic accuracy of BNP and NT-proBNP measurements are shown in Table 1.2529 The largest of these studies enrolled 1,586 patients presenting with dyspnea to seven emergency departments.25 Using a cutoff BNP level of 50 pg per mL (50 ng per L), the positive likelihood ratio was 2.6 (95% CI, 2.3 to 2.8), and the negative likelihood ratio was 0.05 (95% CI, 0.03 to 0.07). This indicates that a low BNP value is highly effective at ruling out heart failure, whereas a value more than 50 pg per mL is only a fair indicator of disease.

TABLE 1

Summary of Studies Evaluating the Diagnostic Accuracy of BNP and NT-ProBNP Measurements in Heart Failure

Study setting Number of patients Cutoff value Reference test Overall probability of heart failure (%) LR+(95% CI)* LR–(95% CI)

BNP

Patients presenting with dyspnea to emergency departments (United States, France, Norway)25

1,586

50 pg per mL (50 ng per L)

Consensus of two cardiologists

47

2.6 (2.34 to 2.79)

0.05 (0.03 to 0.07)

Patients without a previous heart failure diagnosis randomly selected from 21 general practices (United Kingdom)26

1,331

66 pg per mL (66 ng per L)

LVEF of 40 percent or lower

1

1.8 (1.8 to 1.9)

0.0 (0.0 to 0.4)

Patients with suspected heart failure in general practice (United Kingdom)27

106

77 pg per mL (77 ng per L)

Consensus of three cardiologists using ESC criteria

27

6.2 (3.8 to 10.6)

0.04 (0.01 to 0.20)

NT-proBNP

Patients selected from general practices (Denmark)28

672

366 pg per mL (366 ng per L)

LVEF of 40 percent or lower

6

2.3 (1.8 to 2.8)

0.35 (0.19 to 0.59)

General population older than 45 years (United Kingdom)29

307

304 pg per mL (304 ng per L)

Consensus of three cardiologists using ESC criteria

2

3.3 (3.2 to 4.0)

0.0 (0.0 to 0.5)


BNP = brain natriuretic peptide; NT-proBNP = N-terminal pro-brain natriuretic peptide; LR+ = positive likelihood ratio; CI = confidence interval; LR– = negative likelihood ratio; LVEF = left ventricular ejection fraction; ESC = European Society of Cardiologists.

*—Values from 2 to 5 weakly to moderately increase the likelihood of heart failure.

†—Values of 0.1 or less greatly decrease the likelihood of heart failure.

Information from references 25 through 29.

TABLE 1   Summary of Studies Evaluating the Diagnostic Accuracy of BNP and NT-ProBNP Measurements in Heart Failure

View Table

TABLE 1

Summary of Studies Evaluating the Diagnostic Accuracy of BNP and NT-ProBNP Measurements in Heart Failure

Study setting Number of patients Cutoff value Reference test Overall probability of heart failure (%) LR+(95% CI)* LR–(95% CI)

BNP

Patients presenting with dyspnea to emergency departments (United States, France, Norway)25

1,586

50 pg per mL (50 ng per L)

Consensus of two cardiologists

47

2.6 (2.34 to 2.79)

0.05 (0.03 to 0.07)

Patients without a previous heart failure diagnosis randomly selected from 21 general practices (United Kingdom)26

1,331

66 pg per mL (66 ng per L)

LVEF of 40 percent or lower

1

1.8 (1.8 to 1.9)

0.0 (0.0 to 0.4)

Patients with suspected heart failure in general practice (United Kingdom)27

106

77 pg per mL (77 ng per L)

Consensus of three cardiologists using ESC criteria

27

6.2 (3.8 to 10.6)

0.04 (0.01 to 0.20)

NT-proBNP

Patients selected from general practices (Denmark)28

672

366 pg per mL (366 ng per L)

LVEF of 40 percent or lower

6

2.3 (1.8 to 2.8)

0.35 (0.19 to 0.59)

General population older than 45 years (United Kingdom)29

307

304 pg per mL (304 ng per L)

Consensus of three cardiologists using ESC criteria

2

3.3 (3.2 to 4.0)

0.0 (0.0 to 0.5)


BNP = brain natriuretic peptide; NT-proBNP = N-terminal pro-brain natriuretic peptide; LR+ = positive likelihood ratio; CI = confidence interval; LR– = negative likelihood ratio; LVEF = left ventricular ejection fraction; ESC = European Society of Cardiologists.

*—Values from 2 to 5 weakly to moderately increase the likelihood of heart failure.

†—Values of 0.1 or less greatly decrease the likelihood of heart failure.

Information from references 25 through 29.

The number of studies conducted in the primary care setting is approximately equal to the number set in hospitals, and little difference in diagnostic odds ratio has been shown between the two settings. Although the sensitivity and specificity of BNP testing in primary care and hospital settings are similar, interpretation of the test varies between asymptomatic and symptomatic patients and between primary and acute care settings (Table 225,27,29).

TABLE 2

Interpreting BNP Measurements for Heart Failure in Different Clinical Settings

Clinical setting Pretest probability of heart failure (%) Posttest probability of heart failure (%)*
BNP < 50 pg per mL (50 ng per L) BNP 50 to 150 pg per mL (150 ng per L) BNP > 150 pg per mL

Patients presenting in the primary care setting (screening)29

2

0.2

1

9

Patients presenting in the primary care setting who have at least one risk factor for heart failure (e.g., history of myocardial infarction, angina, hypertension, or diabetes)29

7

0.6

4

27

Patients with suspected heart failure in the primary care setting27

27

3

17

65

Patients presenting with dyspnea to the emergency department25

50

7

36

83


BNP = brain natriuretic peptide; LR+ = positive likelihood ratio; LR– = negative likelihood ratio.

*—Based on an assumed LR+ of 5.0 for > 150 pg per mL, LR+ of 0.57 for 50 to 150 pg per mL, and LR– of 0.08 for < 50 pg per mL.

†—Overall prevalence of heart failure.

Information from references 25, 27, and 29.

TABLE 2   Interpreting BNP Measurements for Heart Failure in Different Clinical Settings

View Table

TABLE 2

Interpreting BNP Measurements for Heart Failure in Different Clinical Settings

Clinical setting Pretest probability of heart failure (%) Posttest probability of heart failure (%)*
BNP < 50 pg per mL (50 ng per L) BNP 50 to 150 pg per mL (150 ng per L) BNP > 150 pg per mL

Patients presenting in the primary care setting (screening)29

2

0.2

1

9

Patients presenting in the primary care setting who have at least one risk factor for heart failure (e.g., history of myocardial infarction, angina, hypertension, or diabetes)29

7

0.6

4

27

Patients with suspected heart failure in the primary care setting27

27

3

17

65

Patients presenting with dyspnea to the emergency department25

50

7

36

83


BNP = brain natriuretic peptide; LR+ = positive likelihood ratio; LR– = negative likelihood ratio.

*—Based on an assumed LR+ of 5.0 for > 150 pg per mL, LR+ of 0.57 for 50 to 150 pg per mL, and LR– of 0.08 for < 50 pg per mL.

†—Overall prevalence of heart failure.

Information from references 25, 27, and 29.

The optimal cutoff value for a heart failure diagnosis and whether reference levels should vary with age and sex remain unclear. There is a trade-off, because lowering the cutoff decreases the false-negative rate (i.e., increased sensitivity and fewer missed diagnoses) but increases the false-positive rate (i.e., decreased specificity and more incorrect diagnoses). In addition, the average levels of BNP and NT-proBNP are greater in women than in men and increase with age.19,30 However, these higher levels in women may reflect an increasing prevalence of undetected and possibly asymptomatic cardiac dysfunction in this group.

A trial that included patients presenting with dyspnea to a Swiss emergency department assessed health outcomes and cost of treatment associated with BNP-assisted diagnoses.31 The trial showed that, compared with no BNP test, the test reduced the median length of hospitalization (eight versus 11 days) and the mean total cost of treatment ($5,410 versus $7,264).31 These results are attributable to the test’s ability to rule out heart failure, allowing the physician to initiate treatment for an alternative diagnosis such as chronic obstructive pulmonary disease or pneumonia. According to an updated guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA), BNP measurements can be useful in patients presenting in the urgent care setting when the clinical diagnosis of heart failure is uncertain.32

Determining Prognoses

Nineteen studies showed that elevated BNP levels in patients with heart failure are associated with an increased risk of death or cardiovascular events.33 Pooled results from five studies showed that a BNP increase of 100 pg per mL caused a 35 percent increase in risk of death.33 BNP was the only statistically significant independent predictor of mortality in nine studies, indicating that BNP tests potentially are more useful than traditional predictors of mortality (e.g., age, ischemic etiology, left ventricular ejection fraction, NYHA classification, serum creatinine levels).33

Screening and Prevention

Because BNP tests can predict death and cardiovascular events in patients without a previous heart disease diagnosis, they are being studied as a possible tool for heart failure screening. Although BNP tests may help detect patients at high risk of overt heart failure and may prevent its progression, randomized controlled trials are needed to determine who should be tested and whether or not treating asymptomatic patients is beneficial.

Several studies (some of which excluded persons previously diagnosed with heart failure) have measured the prognostic value of BNP in asymptomatic populations. In the two largest studies, the relative risk of death during the four to five years of follow-up approximately doubled in patients with a BNP value higher than relatively low cutoff levels (17.9 to 23.3 pg per mL [17.9 to 23.3 ng per L]).34,35

Monitoring Patients with Heart Failure

BNP measurement is a potential tool for monitoring treatment response in patients with heart failure because of the test’s ability to diagnose heart failure, predict prognosis, and correlate with more invasive clinical measures (e.g., pulmonary capillary wedge pressure).36 Prognostic studies have shown that BNP levels measured after treatment took effect were more predictive of the risk of death or further cardiovascular events than those initiated at first presentation.37,38

Ideally, randomized trials would offer definitive evidence; however, only two small trials (including 69 and 21 patients) have evaluated BNP-guided treatment.39,40 The first trial showed a nearly twofold decrease in cardiovascular events,39 and the second trial showed a decrease in BNP levels with BNP-guided treatment.40 However, according to the ACC/AHA guideline on the management of heart failure, the value of serial BNP measurements in guiding therapy for patients with heart failure is not well established.32 Larger randomized controlled trials are needed before routine BNP monitoring of heart failure can be recommended.

The Authors

JENNY DOUST, B.M.B.S., FRACGP, is a general practitioner at Inala Primary Care Centre in Brisbane, Australia, and is senior research fellow in clinical epidemiology at the University of Queensland School of Medicine in Brisbane. Dr. Doust received her medical degree from Flinders University School of Medicine and completed a residency at Flinders Medical Centre, Bedford Park, Adelaide, Australia.

RICHARD LEHMAN, B.M.B.C.H., MRCAP, is a general practitioner in Banbury, Oxfordshire, United Kingdom, and is senior research fellow in the Department of Primary Health Care at the University of Oxford, Headington, United Kingdom. Dr. Lehman received a medical degree from the University of Oxford and completed residencies at St. Thomas Hospital and Middlesex Hospital in London.

PAUL GLASZIOU, M.B.B.S., PH.D., FRACGP, is a general practitioner in Oxford, United Kingdom, and is director of the Centre for Evidence-Based Medicine and professor of evidence-based medicine in the Department of Primary Health Care at the University of Oxford. Dr. Glasziou received a medical degree from the University of Queensland School of Medicine and completed a residency at Princess Alexandra Hospital in Woolloongabba, Queensland, Australia.

Address correspondence to Jenny Doust, B.M.B.S., FRACGP, Level 2, Edith Cavell Building, Royal Brisbane Hospital Complex, Herston, QLD 4029, Australia (e-mail: j.doust@sph.uq.edu.au). Reprints are not available from the authors.

Author disclosure: Dr. Glasziou has received an honorarium from Bayer Diagnostics for speaking at a conference.

REFERENCES

1. de Bold AJ, Borenstein HB, Veress AT, Sonnenberg H. A rapid and potent natriuretic response to intravenous injection of atrial myocardial extract in rats. Life Sci. 1981;28:89–94.

2. Sudoh T, Kangawa K, Minamino N, Matsuo H. A new natriuretic peptide in porcine brain. Nature. 1988;332:78–81.

3. Holmes SJ, Espiner EA, Richards AM, Yandle TG, Frampton C. Renal, endocrine, and hemodynamic effects of human brain natriuretic peptide in normal man. J Clin Endocrinol Metab. 1993;76:91–6.

4. Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med. 1998;339:321–8.

5. Yoshimura M, Yasue H, Morita E, Sakaino N, Jougasaki M, Kurose M, et al. Hemodynamic, renal, and hormonal responses to brain natriuretic peptide infusion in patients with congestive heart failure. Circulation. 1991;84:1581–8.

6. Yasue H, Yoshimura M, Sumida H, Kikuta K, Kugiyama K, Jougasaki M, et al. Localization and mechanism of secretion of B-type natriuretic peptide in comparison with those of A-type natriuretic peptide in normal subjects and patients with heart failure. Circulation. 1994;90:195–203.

7. Mair J, Friedl W, Thomas S, Puschendorf B. Natriuretic peptides in assessment of left-ventricular dysfunction. Scand J Clin Lab Invest Suppl. 1999;230:132–42.

8. Inoko M, Fujita M, Nakae I, Tamaki S, Watanuki M, Hashimoto T, et al. Effect of angiotensin-converting enzyme inhibition on sympathetic tone in patients with mild to moderate heart failure. Jpn Circ J. 2001;65:395–8.

9. Latini R, Masson S, Anand I, Judd D, Maggioni AP, Chiang YT, et al., for the Valsartan Heart Failure Trial Investigators. Effects of valsartan on circulating brain natriuretic peptide and norepinephrine in symptomatic chronic heart failure: the Valsartan Heart Failure Trial (Val-HeFT). Circulation. 2002;106:2454–8.

10. Murdoch DR, Byrne J, Morton JJ, McDonagh TA, Robb SD, Clements S, et al. Brain natriuretic peptide is stable in whole blood and can be measured using a simple rapid assay: implications for clinical practice. Heart. 1997;78:594–7.

11. Northridge DB, Newby DE, Rooney E, Norrie J, Dargie HJ. Comparison of the short-term effects of candoxatril, an orally active neutral endopeptidase inhibitor, and frusemide in the treatment of patients with chronic heart failure. Am Heart J. 1999;138(6 pt 1):1149–57.

12. Tsutamoto T, Wada A, Maeda K, Mabuchi N, Hayashi M, Tsutsui T, et al. Effect of spironolactone on plasma brain natriuretic peptide and left ventricular remodeling in patients with congestive heart failure. J Am Coll Cardiol. 2001;37:1228–33.

13. Yoshimura M, Mizuno Y, Nakayama M, Sakamoto T, Sugiyama S, Kawano H, et al. B-type natriuretic peptide as a marker of the effects of enalapril in patients with heart failure. Am J Med. 2002;112:716–20.

14. Tsutamoto T, Wada A, Maeda K, Hisanaga T, Fukai D, Maeda Y, et al. Digitalis increases brain natriuretic peptide in patients with severe congestive heart failure. Am Heart J. 1997;134(5 pt 1):910–6.

15. Effects of metoprolol CR in patients with ischemic and dilated cardiomyopathy: the randomized evaluation of strategies for left ventricular dysfunction pilot study. Circulation. 2000;101:378–84.

16. Yoshizawa A, Yoshikawa T, Nakamura I, Satoh T, Moritani K, Suzuki M, et al. Brain natriuretic peptide response is heterogeneous during beta-blocker therapy for congestive heart failure. J Card Fail. 2004;10:310–5.

17. Kato M, Kinugawa T, Ogino K, Endo A, Osaki S, Igawa O, et al. Augmented response in plasma brain natriuretic peptide to dynamic exercise in patients with left ventricular dysfunction and congestive heart failure. J Intern Med. 2000;248:309–15.

18. McNairy M, Gardetto N, Clopton P, Garcia A, Krishnaswamy P, Kazanegra R, et al. Stability of B-type natriuretic peptide levels during exercise in patients with congestive heart failure: implications for outpatient monitoring with B-type natriuretic peptide. Am Heart J. 2002;143:406–11.

19. Jensen KT, Carstens J, Ivarsen P, Pedersen EB. A new, fast and reliable radioimmunoassay of brain natriuretic peptide in human plasma. Reference values in healthy subjects and in patients with different diseases. Scand J Clin Lab Invest. 1997;57:529–40.

20. Clerico A, Iervasi G, Mariani G. Pathophysiologic relevance of measuring the plasma levels of cardiac natriuretic peptide hormones in humans. Horm Metab Res. 1999;31:487–98.

21. Siebenhofer A, Ng LL, Plank J, Berghold A, Hodl R, Pieber TR. Plasma N-terminal pro-brain natriuretic peptide in type 1 diabetic patients with and without diabetic nephropathy. Diabet Med. 2003;20:535–9.

22. Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191–4.

23. Pruszczyk P, Kostrubiec M, Bochowicz A, Styczynski G, Szulc M, Kurzyna M, et al. N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J. 2003;22:649–53.

24. Doust JA, Glasziou PP, Pietrzak E, Dobson AJ. A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure. Arch Intern Med. 2004;164:1978–84.

25. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al., for the Breathing Not Properly Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161–7.

26. Ng LL, Loke I, Davies JE, Khunti K, Stone M, Abrams KR, et al. Identification of previously undiagnosed left ventricular systolic dysfunction: community screening using natriuretic peptides and electrocardiography. Eur J Heart Fail. 2003;5:775–82.

27. Cowie MR, Struthers AD, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet. 1997;350:1349–53.

28. Groenning BA, Raymond I, Hildebrandt PR, Nilsson JC, Baumann M, Pedersen F. Diagnostic and prognostic evaluation of left ventricular systolic heart failure by plasma N-terminal pro-brain natriuretic peptide concentrations in a large sample of the general population. Heart. 2004;90:297–303.

29. Hobbs FD, Davis RC, Roalfe AK, Hare R, Davies MK, Kenkre JE. Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. BMJ. 2002;324:1498.

30. McCullough PA, Kuncheria J, Mathur VS. Diagnostic and therapeutic utility of B-type natriuretic peptide in patients with renal insufficiency and decompensated heart failure. Rev Cardiovasc Med. 2003;(4 suppl 7):S3–S12.

31. Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med. 2004;350:647–54.

32. Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology, American Heart Association Task force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005;46:E1–82.

33. 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;330:625.

34. McDonagh TA, Cunningham AD, Morrison CE, McMurray JJ, Ford I, Morton JJ, et al. Left ventricular dysfunction, natriuretic peptides, and mortality in an urban population. Heart. 2001;86:21–6.

35. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland T, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med. 2004;350:655–63.

36. Kazanegra R, Cheng V, Garcia A, Krishnaswamy P, Gardetto N, Clopton P, et al. A rapid test for B-type natriuretic peptide correlates with falling wedge pressures in patients treated for decompensated heart failure: a pilot study. J Card Fail. 2001;7:21–9.

37. Anand IS, Fisher LD, Chiang YT, Latini R, Masson S, Maggioni AP, et al., for the Bal-HeFT Investigators. Changes in brain natriuretic peptide and norepinephrine over time and mortality and morbidity in the Valsartan Heart Failure Trial (Val-HeFT). Circulation. 2003;107:1278–83.

38. Wijeysundera HC, Hansen MS, Stanton E, Cropp AS, Hall C, Dhalla NS, et al., for the PRAISE II Investigators. Neurohormones and oxidative stress in nonischemic cardiomyopathy: relationship to survival and the effect of treatment with amlodipine. Am Heart J. 2003;146:291–7.

39. Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000;355:1126–30.

40. Murdoch DR, McDonagh TA, Byrne J, Blue L, Farmer R, Morton JJ, et al. Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy. Am Heart J. 1999;138(6 pt 1):1126–32.


Copyright © 2006 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article