Elsevier

Heart & Lung

Volume 37, Issue 4, July–August 2008, Pages 275-285
Heart & Lung

Issue in cardiovascular nursing
Diagnostic and prognostic impact of brain natriuretic peptide in cardiac and noncardiac diseases

https://doi.org/10.1016/j.hrtlng.2007.05.010Get rights and content

Objective

Cardiac secretion of brain natriuretic peptide (BNP) increases with the progression of congestive heart failure (CHF). The plasma measurement of BNP emerged recently as a useful, cost-effective biomarker for the diagnosis and prognosis of CHF.

Methods

BNP assay is useful for evaluating patients with acute dyspnea, because a low level can help rule out CHF in primary care settings and reduce the demand for echocardiography. Equally, BNP level can be particularly useful in recognizing heart failure in a patient with acute dyspnea and a history of chronic obstructive pulmonary disease.

Results

However, although the clinical use of BNP as a biomarker in CHF is increasing, the specificity of BNP in CHF is not strong, suggesting that other mechanisms beyond simple ventricular stretch stimulate BNP release. Multiple disorders in the intensive care unit, apart from CHF, cause elevated BNP levels, including cardiovascular disease states such as ischemia, arrhythmias, cardiac hypertrophy, and coronary endothelial dysfunction, as well as disorders of no cardiac origin, such as sepsis, septic shock, and acute respiratory distress syndrome. Moreover, the impact of increased BNP in patients with sepsis is not clear. The relationship between BNP and both left ventricular ejection fraction and left-sided filling pressures is weak, and data on the prognostic impact of high BNP levels in patients with sepsis are conflicting.

Conclusion

Nevertheless, this review highlights the potential benefits of BNP in the recognition and management of heart failure, and defines the gray zones of BNP levels; it also identifies conditions influencing BNP levels in relation to a certain heart failure and describes conditions of no cardiac origin with increased BNP.

Section snippets

Biosynthesis and Physiology of Brain Natriuretic Peptide

BNP is a 32-amino acid hormone that was named so because it was initially detected in porcine brain.7, 8 Subsequent studies found that BNP is constitutively released from ventricular myocyte as a preprohormone of 134 amino acids, which are cleaved into a pro-BNP hormone (108 amino acids). On being stimulated into secretion, it is further cleaved into a 76-amino acid N-terminal fragment (NT-proBNP) and a 32-amino acid hormone (BNP).9, 10 Elevated mechanical ventricular load and probably

Action

Numerous studies found that the biological actions of BNP affect kidney, vascular vessels, endocrine, and heart. The earliest finding of BNP biological action was the increase of glomerular filtration rate, renal plasma flow, urine flow rate, and inhibiting distal sodium reabsorption, causing natriuresis and diuresis.10, 17, 18 BNP can inhibit cardiac sympathetic nervous system activity by reducing norepinephrine level at a low dose, and the renin-angiotensin-aldosterone system by suppressing

Diagnosis of Acute Left-Sided Heart Failure

Cardiorespiratory dysfunction is usually manifested with severe dyspnea, but the relative contributions of the cardiac and respiratory components can vary enormously. Correct assessment of the cardiac contribution to dyspnea carries important implications for prognosis and management. Therefore, it is imperative to be able distinguish CHF efficiently from other diseases producing similar clinical sequelae.8, 40

A plasma BNP cutoff value of 100 pg/mL is a widely cited threshold with high

Brain Natriuretic Peptide in Cardiovascular Diseases Other Than Left-Sided Heart Failure

Plasma BNP has been reported to be of potential use in a number of other clinical settings antedating or associated with heart failure. Therefore, plasma BNP may perform better when used to screen for a wide array of cardiovascular disorders (Table I).8

BNP has a recognized role in the counteractive response to ischemia. In patients with chronic stable angina, the BNP level was correlated with the size of the ischemic area.62, 63 In patients with unstable angina, the BNP level was higher than

Brain Natriuretic Peptide in Prognosis and Management of Chronic Heart Failure

There is prognostic value of BNP and NT-proBNP. Patients with higher values on admission and/or discharge to hospital generally do worse. Those with marked reductions during treatment do better.37, 58, 89

Current research90 suggests that a BNP level greater than 480 pg/mL may predict higher 6-month mortality and rehospitalization rates for patients with CHF. An elevated BNP level 48 hours after myocardial infarction seems to be a strong predictor of death or the reoccurrence of heart failure

Brain Natriuretic Peptide in Sepsis

BNP elevation in patients with sepsis can be considerably high, even though a cardiac disorder is not obvious. A small retrospective analysis revealed that BNP levels in patients with sepsis and preserved systolic left ventricular function can be as high as that in patients admitted to the hospital with CHF because of severely impaired systolic left ventricular function. In this study, six of eight patients with sepsis (more of them with septic shock) presented a BNP level of greater than 1.000

Brain Natriuretic Peptide in Other Noncardiovascular Critical Diseases

Liver cirrhosis may be associated with mildly elevated BNP and NT-proBNP levels, probably as the result of cirrhotic cardiomyopathy.106, 107

Brain disorders or brain injury affect BNP levels in the critical care settings: Plasma NT-proBNP levels are elevated in acute stroke and predict poststroke mortality.108 Release of BNP from the brain,109 or more probably from the heart,110 in subarachnoid hemorrhage is associated with more brain edema,111 cerebral vasospasm,112 and poorer outcome,113 and

Brain Natriuretic Peptide in Various Populations

Despite diseases with high plasma BNP levels there are physiologic factors associated with increased values. These factors include increasing age, female sex, and impaired renal function (Table I).117, 118

The increase of BNP levels seen with advancing age is to be expected on the basis of a physiologic decline in cardiac function.119 Consistent with the increase associated with female gender, hormone replacement causes an elevation of BNP.120 Exercise has little effect on BNP,121 but BNP

Conclusions

The plasma BNP test can be used in high-risk populations, such as those presenting to the hospital with dyspnea. In the setting of acute dyspnea, a BNP level of less than 100 pg/mL makes the diagnosis of CHF unlikely, whereas BNP levels of greater than 400 pg/mL44, 129 or greater than 500 pg/mL11, 43 are associated with a high probability of CHF. The intermediate range (BNP, 100-400 pg/mL or 500 pg/mL) is a gray zone, in which several conditions including stable left ventricular dysfunction and

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