Living with heart failure can be challenging. Take Paul, he's 68 years old.
Acute heart failure
Paul is at home with his daughter, Anne, one day when, suddenly, he has an acute shortness of breath.
These symptoms can be as painful and stressful as chest pain in heart attack.
In a panic and fearing for her father’s life, Paul’s daughter calls for an ambulance.
Thankfully, the ambulance comes quickly and takes Paul to the closest hospital’s emergency department.
The emergency physician, Rachel, reassures Paul that she will find out what is happening and help him and his family through this traumatic time.
Rachel will asess heart failure probability before proceeding to further investigations, through Paul's clinical history, a physical examination and an electrocardiogram.1
Rachel is looking for a comprehensive picture to make a decision on what the next steps for Paul's care should be:
One element of the initial assessment is abnormal, that's why Rachel performs a NT-proBNP test in order to confirm the high likeliness of acute heart failure or to exclude it.2
NT-proBNP < 300 pg/mL
Heart failure is unlikely. 1,2
The 2016 ESC Heart Failure Guidelines say, if NT-proBNP is lower than 300 pg/mL, heart failure is unlikely and echocardiography is not required.1 Another diagnosis needs to be considered.
NT-proBNP ≥ 300 pg/mL
Heart failure is likely. 2
The 2016 ESC Heart Failure Guidelines say, results equal or higher than 300 pg/mL, means that the patient needs further investigation to confirm the diagnosis of heart failure.1
The interpretation of the results depends on various factors, including the age of the patient.2
NT-proBNP has age-specific cutoffs to improve the accuracy of the diagnosis.2
Paul’s result is high at 6,293 pg/mL.
Therefore, Rachel does an echocardiography1 to confirm the diagnosis: Paul has acute heart failure.
Paul needs to be transferred to the cardiology department, where the appropriate treatment is started.
Rajiv, the cardiologist, recommends that he will have to stay 5 - 10 days3 in the hospital until his status is more stable.
After 10 days, Paul is responding well to the treatment and is nearly ready to go home. To be sure that Paul is OK to be discharged, Rajiv performs another NT-proBNP test to see how well Paul's condition has stabilized.
Paul's result is 2,909 pg/mL, which is a decrease of more than 30% compared to the admission results, and reflect a low risk for future cardiovascular adverse events. 4-6
As Paul has significantly improved, from now on he will be managed by a multidisciplinary team, including a nurse, general practitioner, cardiologist and other specialists who monitor Paul's clinical status and NT-proBNP.1
As Paul has significantly improved, from now on he will be managed by a multidisciplinary team, including a nurse, general practitioner, cardiologist and other specialists who monitor Paul's clinical status and NT-proBNP.1
Monitoring NT-proBNP in out-patient setting provides an objective indication of Paul's disease status beyond symptoms which may not always be a reliable guide. 1,7
Increasing NT-proBNP levels indicate that the patient's condition is worsening and that the risk of hospitalization or mortality is rising.1,7-9
Decreasing NT-proBNP levels indicate that the patient's condition is improving. 1,8,9
Paul's result is 900 pg/mL and decreased in comparison to his results at the previous visit.
Changes in NT-proBNP levels strongly predict outcomes regardless of therapy. 1,7-10
Paul's NT-proBNP levels are decreasing and he shows no worsening symptoms of heart failure. His condition is improving 1,7-10 and he can get back to living his life.
Clinical assessment, plus NT-proBNP testing, helps physicians to make better decisions in heart failure management at every stage of care.
Paul has been feeling unwell for some time and complains about a range of symptoms like . . .
It's frustrating for Paul, as even simple tasks become more challenging, so he visits his general practitioner, John. From Paul's assessment, John can see a number of possible diagnosis, but thinks about heart failure.
John will assess heart failure probability before proceeding to further investigations, through Paul's clinical history, a physical examination and if possible through an electrocardiogram.1
John is looking for a comprehensive picture to make a decision on what the next steps for Paul's care should be:
One element of the initial assessment is abnormal, that's why John performs a NT-proBNP test in order to identify if the patient needs further investigation to confirm the diagnosis of heart failure.1
NT-proBNP < 125 pg/mL
Heart failure is unlikely.1
NT-proBNP ≥ 125 pg/mL
Echocardiography required1
Paul's result is high at 1,087 pg/mL. Therefore, an echocardiography¹ will be done to confirm the diagnosis: Paul has chronic heart failure.
At first he feels anxious but he is reassured by his treatment and regular check-ups, where John monitors his clinical status and NT-proBNP.
Monitoring NT-proBNP is out-patient setting provides an objective indication of Paul's disease status beyond symptoms, which may not be a reliable guide.1,7
Increasing NT-proBNP levels indicate that the patient's condition is worsening and that the risk of hospitalization or mortality is rising.1,7-9
Decreasing NT-proBNP levels indicate that the patient's condition is improving. 1,8,9
Paul's result is 469 pg/mL and decreased in comparison to his results at the previous visit.
Changes in NT-proBNP levels strongly predict outcomes regardless of therapy. 1,7-10
Paul's NT-proBNP levels are decreasing and he shows no worsening symptoms of heart failure. His condition is improving 1,7-10 and he can get back to living his life.
Clinical assessment, plus NT-proBNP testing, helps physicians to make better decisions in heart failure management at every stage of care.
Chronic heart failure
References
Ponikowski et al. (2016). Eur Heart J. 37(27), 2129-200
Januzzi et al. (2006). Eur Heart J. 27, 330-337
Cowie et al. (2014). ESC Heart Fail. 1(2):110-145
Salah et al. (2014). Heart. 100(2):115-125
Stienen et al. (2015). J Card Fail. 21(11):930-934
Stienen et al. (2015). Eur J Heart Fail. 17(9):936-944
Pellicori et al. (2017). Eur J Heart Fail. 19, 768–778
Zile et al. (2016). J Am Coll Cardiol. 68(22):2425-2436
Januzzi, J.L. Jr. (2016) Clin Chem. 62(5):663-5
McKie and Burnett (2016). J Am Coll Cardiol. 68(22):2437-2439