Are Serial BNP Measurements Useful in Heart Failure Management?

Natriuretic peptides, including B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), have emerged as powerful markers of cardiovascular risk in patients with heart failure.1 Circulating natriuretic peptide (NP) levels add incremental prognostic value to standard clinical risk stratification algorithms for both ambulatory and hospitalized heart failure patients, with a steady increase in the risk of mortality and recurrent heart failure hospitalization as NT-proBNP levels rise above 1000 pg/mL.2–5 A systematic review of 19 studies of patients with heart failure demonstrated that for every 100-pg/mL rise in BNP concentration, there was a corresponding 35% increase in the relative risk of death.6Response by Januzzi and Troughton on p 516 Beyond the prognostic value of a single NP measurement, changes in NP concentrations over time may help to further stratify risk.2,7 Reductions in NP levels, whether achieved spontaneously or through application of appropriate medical therapy, appear to be associated with improvement in clinical outcomes.8,9 In the Valsartan Heart Failure Trial, subjects with the largest proportional reductions in BNP levels at 4 months after randomization experienced the best outcomes, whereas those with the greatest increase in BNP levels experienced the highest event rates.7 Among patients hospitalized with decompensated heart failure, both predischarge NP levels and the relative change in NP levels during hospital treatment are strong predictors of the risk for death or hospital readmission at 6 months.8,10,11In addition to their association with risk for adverse cardiovascular outcomes, circulating levels of NP appear to vary in relationship to the biology of heart failure progression. NP levels tend to rise during acute heart failure decompensation and to fall with successful treatment in a pattern that mirrors reductions in filling pressure, improvements in left ventricular structure and function, …