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Heart Failure

Diagnosis, Definition, and Risk Stratification




February 2013

Diagnosis of Heart Failure

To diagnose heart failure, a cardiologist will discuss the patient’s medical history and risk factors, perform a thorough physical examination, and may also recommend other tests, including:

  • Blood tests
  • Chest X-ray
  • Coronary catheterization (angiogram)
  • Echocardiogram
  • Electrocardiogram (ECG)
  • Magnetic resonance imaging (MRI)
  • Myocardial biopsy
  • Right heart catheterization
  • Stress tests
  • Radionuclide ventriculography or Multiple-gated Acquisition Scanning (MUGA)

Natriuretic Peptides: BNP and NT-proBNP

Natriuretic peptides, including the biologically active B-type natriuretic peptide (BNP) and the inactive amino-terminal fragment (NT-proBNP), are important diagnostic tools for assessment of patients who present acutely with dyspnea. BNP and NT-proBNP are biomarkers that reflect the physiological response to left ventricular filling pressure and wall stress; they are also responsible for lowering the concentrations of angiotensin II and aldosterone. It is hypothesized that is it through this mechanism that reduction in procollagen deposition and myocardial fibrosis occurs. Natriuretic peptide concentrations generally correlate well with the New York Heart Association (NYHA) heart failure classification system, which is based upon the severity of the patient’s symptoms.

Natriuretic peptides are also powerful independent prognostic predictors in patients with acute coronary syndrome (ACS), stable coronary artery disease (CAD), heart failure, and chronic stable angina. Furthermore, they have demonstrated additional utility for detection of clinical and subclinical cardiac dysfunction.

Clinical Cutpoints for BNP and NT-proBNP1-9

 
BNP
NT-proBNP
Acute Diagnosis of Heart Failure    
Heart Failure Unlikely <100 pg/mL <300 pg/mL
Heart Failure Possible 100-400 pg/mL 300-450 pg/mL (<50 years)
300-900 pg/mL (50-75 years)
Heart Failure Likely >400 pg/mL
>200 pg/mL (renal failure)
>170 pg/mL (BMI <25 kg/m2)
>110 pg/mL (BMI 25-35 kg/m2)
>54 pg/mL (BMI > or =35 kg/m2)
>450 pg/mL (<50 years)
>900 pg/mL (50-75 years)
>1,800 pg/mL (>75 years)
>1,200 pg/mL (renal failure)
Screening or Prognosis    
Increased cardiovascular disease risk   >125 pg/mL
Structural or functional
cardiac dysfunction
  >450 pg/mL

 

References

  1. Maisel AS, Krishnaswamy P, Nowak RM, et al: Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161–167
  2. McCullough PA, Nowak RM, McCord J, et al: B-type natriuretic peptide and clinical judgement in emergency diagnosis of heart failure. Analysis from Breathing Not Properly (BNP) Multinational Study. Circulation 2002;106:416–422
  3. McCullough PA, Duc P, Omland T, et al: B-type natriuretic peptide and renal function in the diagnosis of heart failure: An Analysis from the breathing not properly multinational study. Am J Kidney Dis 2003;41:571–575
  4. Januzzi JL, Camargo CA, Anwaruddin S, et al: The N-terminal pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005;95:948–954
  5. Wang TJ, Larson MG, Levy D, et al: Impact of obesity on plasma natriuretic peptide levels. Circulation 2004;109:594–600
  6. Krauser DG, Lloyd-Jones DM, Chae CU, et al: Effect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: A proBNP Investigation of dyspnea in the emergency department (PRIDE) substudy. Am Heart J 2005;149:744–750
  7. Kistorp C, Raymond I, Pedersen F, et al: 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 April 6;293(13):1609-1616
  8. De SJ, De BD, Cuypers S et al: Plasma N-terminal pro-brain natriuretic peptide concentration predicts coronary events in men at work: a report from the BELSTRESS study. Eur Heart J 2005 December;26(24):2644-2649
  9. Galasko GI, Lahiri A, Barnes SC, et al: What is the normal range for N-terminal pro-brain natriuretic peptide? How well does this normal range screen for cardiovascular disease? Eur Heart J 2005 November;26(21):2269-2276

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