Should BNP and NT-proBNP levels be used in the diagnosis, management, and prognosis of hospitalized/acute heart failure patients?

Bottom line: The summary of evidence provides the driving evidence behind the following class I and class IIb guidelines for the management of heart failure by The American College of Cardiology Foundation (ACCF) and American Heart Association (AHA).
6.3. Biomarkers: Recommendations
B. Hospitalized/Acute
Class I
1. Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. (Level of Evidence: A)
2. Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. (Level of Evidence: A)
Class IIb
1. The usefulness of BNP- or NT-proBNP–guided therapy for acutely decompensated HF is not well established. (Level of Evidence: C)

Summary of evidence:

Guideline: Yancy, Clyde W, et al. “2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.” Circulation 128.16 (2013):e240-e327.

Each guideline is followed by information on the articles that it cites. Though some mention physiological variables, without stating which ones were measured, many articles that are cited to support the guidelines do not specifically mention BNP or NT-proBNP.

6.3. Biomarkers: Recommendations
B. Hospitalized/Acute
Class I
1. Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.[citations 212,245–250] (Level of Evidence: A)
212. Tavazzi, Luigi, et al. “Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial.” Lancet (London, England) 372.9645 (2008):1231-1239.
There is no mention of BNP or NT-proBNP in this article.
245. Abraham, William, et al. “Intrathoracic impedance vs daily weight monitoring for predicting worsening heart failure events: results of the Fluid Accumulation Status Trial (FAST).” Congestive heart failure 17 (2011):51-55.
There is no mention of BNP or NT-proBNP in this article.
246. Abraham, William T, et al. “Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial.” Lancet (London, England) 377.9766 (2011):658-666.
There is no mention of BNP or NT-proBNP in this article.
247. Ritzema, Jay, et al. “Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure.” Circulation 121.9 (2010):1086-1095.
“Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily.” The article provides BNP levels at study enrollment and, for 12-month survivors, values for baseline, 3 months, and 12 months are provided (the p value was not significant for comparisons across all time points). “Patients with adverse outcomes had higher baseline BNP levels and lower resting cardiac output, consistent with more advanced disease.”
248. Bristow, Michael R, et al. “Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure.
“The New England journal of medicine 350.21 (2004):2140-2150. There is no mention of BNP or NT-proBNP in this article.
249. Cleland, John G F, et al. “The effect of cardiac resynchronization on morbidity and mortality in heart failure.” The New England journal of medicine 352.15 (2005):1539-1549.
“Patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony who were receiving standard pharmacologic therapy were randomly assigned to receive medical therapy alone or with cardiac resynchronization. A total of 813 patients were enrolled and followed for a mean of 29.4 months.” Provides data and hazard ratios for patients with NT-BNP levels of <214.5 pg/ml and ≥214.5 pg/ml.
250. Moss, Arthur J, et al. “Cardiac-resynchronization therapy for the prevention of heart-failure events.” The New England journal of medicine 361.14 (2009):1329-1338.
There is no mention of BNP or NT-proBNP in this article.

6.3. Biomarkers: Recommendations
B. Hospitalized/Acute
Class I
2. Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. [citations 248 and 251–258] (Level of Evidence: A)
248. Bristow, Michael R, et al. “Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure.” The New England journal of medicine 350.21 (2004):2140-2150.
There is no mention of BNP or NT-proBNP in this article.
251. Tang, Anthony S L, et al. “Cardiac-resynchronization therapy for mild-to-moderate heart failure.” The New England journal of medicine 363.25 (2010):2385-2395.
There is no mention of BNP or NT-proBNP in this article.
252. Chung, Eugene S, et al. “Results of the Predictors of Response to CRT (PROSPECT) trial.” Circulation 117.20 (2008):2608-2616.
There is no mention of BNP or NT-proBNP in this article.
253. Ellenbogen, Kenneth A, et al. “Primary results from the SmartDelay determined AV optimization: a comparison to other AV delay methods used in cardiac resynchronization therapy (SMART-AV) trial: a randomized trial comparing empirical, echocardiography-guided, and algorithmic atrioventricular delay programming in cardiac resynchronization therapy.” Circulation 122.25 (2010):2660-2668.
There is no mention of BNP or NT-proBNP in this article.
254. Binanay, Cynthia, et al. “Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial.” JAMA: the Journal of the American Medical Association 294.13 (2005):1625-1633.
“The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) was a randomized controlled trial of 433 patients at 26 sites conducted from January 18, 2000, to November 17, 2003. Patients were assigned to receive therapy guided by clinical assessment and a PAC or clinical assessment alone.” The change in BNP levels favored the pulmonary artery catheter (PAC) and clinical assessment group (n=215) versus the clinical assessment only group (n=218).
255. Shah, Monica R, et al. “Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials.” JAMA: the Journal of the American Medical Association 294.13 (2005):1664-1670.
There is no mention of BNP or NT-proBNP in this article.
256. Allen, Larry A, et al. “High mortality without ESCAPE: the registry of heart failure patients receiving pulmonary artery catheters without randomization.” Journal of cardiac failure 14.8 (2008):661-669.
There is no mention of BNP or NT-proBNP in this article.
257. Gray, Alasdair, et al. “Noninvasive ventilation in acute cardiogenic pulmonary edema.” The New England journal of medicine 359.2 (2008):142-151.
There is no mention of BNP or NT-proBNP in this article.
258. Masip, Josep, et al. “Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis.” JAMA: the Journal of the American Medical Association 294.24 (2005):3124-3130.
There is no mention of BNP or NT-proBNP in this article.

6.3. Biomarkers: Recommendations
B. Hospitalized/Acute
Class IIb
1. The usefulness of BNP- or NT-proBNP–guided therapy for acutely decompensated HF is not well established. [citations 259 and 260] (Level of Evidence: C)
259. Kar, Biswajit, et al. “The percutaneous ventricular assist device in severe refractory cardiogenic shock.” Journal of the American College of Cardiology 57.6 (2011):688-696.
There is no mention of BNP or NT-proBNP in this article.
260. Thiele, H, et al. “Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance.” Circulation 104.24 (2001):2917-2922.
There is no mention of BNP or NT-proBNP in this article.

Here are the guideline’s explanations for the classifications and levels of evidence that are used in this blog entry.
Class I: Benefit >>> Risk. Procedure/Treatment SHOULD be performed/administered.
Class IIb: Benefit ≥ Risk. Additional studies with broad objectives needed; additional registry data would be useful. Procedure/Treatment MAY BE CONSIDERED.
Level of Evidence A: Multiple populations evaluated;* data derived from multiple randomized clinical trials or meta-analyses
Level of Evidence C: Very limited populations evaluated;* only consensus opinion of experts, case studies, or standard of care
Class I, Level of Evidence A: Recommmendation that proceducare or treatment is useful/effective; sufficient evidence from multiple randomized trials or meta-analyses
Class IIb, Level of Evidence C: Recommendation’s usefulness/efficacy less well established; only diverging expert opinion, case studies, or standard of care
* Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use

 

Advertisements

About Lisa

I have been a Clinical Informationist (aka Medical Librarian) for Emory University since September 2013. Prior to that, I was a Medical Librarian for Lincoln Memorial University (LMU) from March 2007 to August 2013 and served its DeBusk College of Osteopathic Medicine, Caylor School of Nursing, and allied health programs. From January 2002 - March 2007, I served the Medical Assisting (MA), Occupational Therapy Assistant, Physical Therapy Assistant, Radiologic Technologist, and Nursing programs at South College in Knoxville, Tennessee. I graduated from The University of Tennessee School of Information Sciences with a Master of Science degree in December 2000.
This entry was posted in Diagnosis, EUH, Therapy and tagged . Bookmark the permalink.