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2008 China-Western 2008 China-Western
BNP ConsensusBNP Consensus Alan Maisel MD, FACC, ACPAlan Maisel MD, FACC, ACP
Professor of Medicine, Professor of Medicine, University of California, San Diego University of California, San Diego
Director Coronary Care Unit and Heart Director Coronary Care Unit and Heart Failure Program,Failure Program,
San Diego Veterans HospitalSan Diego Veterans Hospital
2008 China-Western BNP ConsensusIntroductions
International meeting:International meeting: • China 15, USA 2, Greece 1 and Switzerland 1China 15, USA 2, Greece 1 and Switzerland 1
Interdisciplinary experts:Interdisciplinary experts:• Cardiology 9, Nephrology 2, Emergency Medicine 5, Laboratory Cardiology 9, Nephrology 2, Emergency Medicine 5, Laboratory
Medicine 2 and Gerontology 1Medicine 2 and Gerontology 1
Scientific Organizers:Scientific Organizers: • Chinese College of Cardiovascular Physician Chinese College of Cardiovascular Physician • Chinese Laboratory Medicine Doctor Association Chinese Laboratory Medicine Doctor Association • Chinese Medical Doctor Association-Evidence-Based Medicine Chinese Medical Doctor Association-Evidence-Based Medicine
Committee Committee • University of California at San Diego University of California at San Diego
Aim of the Meeting
• To review the latest key literature on B-type natriuretic peptide (BNP) measurements and utilization in clinical application?
• To discuss in the following topics: BNP guidelines adherence BNP for dyspnea patients (CHF & AHF) BNP and Cardio-Renal Syndrome Point-of-care-testing (POCT) with BNP Economic & Operational Benefits and make consensus statement?• To revise 2004 BNP consensus
Medical Board for the Consensus
ChairmanChairman Co-chairmanCo-chairman
Prof. Hu Dayi Prof. Hu Dayi China China
Prof. Alan Maisel Prof. Alan Maisel U.S.A U.S.A
Board of the Consensus Prof. Chen Nan Prof. Chen Nan
Shanghai Ruijin hospital Shanghai Ruijin hospital Department of NephrologyDepartment of Nephrology
Prof. Cong YulongProf. Cong Yulong General Hospital of the Chinese People'sGeneral Hospital of the Chinese People's Liberation Army Liberation Army Clinical laboratoryClinical laboratory
Prof. Huang JunProf. Huang Jun People’s Hospital of Jiangsu province People’s Hospital of Jiangsu province Department of CardiologyDepartment of Cardiology
Prof. Gui Ming Prof. Gui Ming People’s Hospital of Jiangsu province People’s Hospital of Jiangsu province Department of CardiologyDepartment of Cardiology
Prof. Liao Xiaoxing Prof. Liao Xiaoxing First affiliated hospital, Sun yat-sen First affiliated hospital, Sun yat-sen
university university Emergency DepartmentEmergency Department
Prof. Liu Meilin Prof. Liu Meilin First Hospital of Peking University First Hospital of Peking University Department of Gerontology Department of Gerontology
Prof. Liu MeiyanProf. Liu Meiyan People’s Hospital of Peking University People’s Hospital of Peking University Department of CardiologyDepartment of Cardiology
Mr. Ning TianhaiMr. Ning Tianhai Shanghai Ruijin hospitalShanghai Ruijin hospital Editorial Department Editorial Department
Prof. Qi WenhangProf. Qi Wenhang Shanghai Ruijin hospital Shanghai Ruijin hospital Department of CardiologyDepartment of Cardiology
Ms. Shi Hong Ms. Shi Hong Chinese Journal of Laboratory Chinese Journal of Laboratory
Editorial DepartmentEditorial Department
Prof. Sun Yihong Prof. Sun Yihong People’s Hospital of Peking People’s Hospital of Peking
University University Department of Cardiology Department of Cardiology
Prof. Yan Shengkai Prof. Yan Shengkai China-Japan Friendship Hospital China-Japan Friendship Hospital
Clinical laboratoryClinical laboratory
Prof. Yang Yuejin Prof. Yang Yuejin Beijing FuWai Hospital Beijing FuWai Hospital Department of CardiologyDepartment of Cardiology
Prof. Zhang Jian Prof. Zhang Jian Beijing FuWai Hospital Beijing FuWai Hospital Department of CardiologyDepartment of Cardiology
Prof. Zhang Wen Prof. Zhang Wen Shanghai Ruijin Hospital Shanghai Ruijin Hospital Department of NephrologyDepartment of Nephrology
Prof. Zhu Jihong Prof. Zhu Jihong People’s Hospital of Peking People’s Hospital of Peking
University University Emergency DepartmentEmergency Department
Prevalence of CHF in China Adult Population
Urban Rural P Urban Rural P 1.1% 0.8% 0.0541.1% 0.8% 0.054
North South PNorth South P 1.4% 0.5% < 0.011.4% 0.5% < 0.01
Female Male PFemale Male P 1.0% 0.7% < 0.051.0% 0.7% < 0.05
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Prevalence of Chronic Heart Failure in China
Sample data were collected from 10 provinces
Male n=7,518 Female n=8,000
Pre
vale
nce
(%
)
P<0.05
Age (Years)
P<0.05
35-44 45-54 55-64 65-74 sum
0
0.3
0.6
0.9
1.2
1.5
0.7
1.0
0.3
0.5 0.6
1.3 1.3 1.41.1
1.5
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Duration of HF in Hospital MortalityDuration of HF in Hospital Mortality
39.6
46.2
74.2
6.28.2 10.0
54.2
45.5
16.2
0
15
30
45
55
60
1980 1990 2000
<5 years 5-10 years > 10 years
75
Percent (%)
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Age of Hospitalized Heart Failure Patients
67.8
63.863.1
0
55
60
65
70
75
1980
P<0.05
Age (year)
4 years
20001990
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Mortality In Hospitalized HF Patients
%
Mortality
1980 1990 2000
15.4
12.3
6.2
0
5
10
15
20
25
1980 20001990
Percent (%)
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Cardiovascular Mortality vs. HF Mortality
Heart failure mortality
Whole cardiac mortality
3.0
6.0
%
GU Dongfeng et al. Chin J Cardiol. 2003;31:3-6
Long term survival of HF in China
±º‰£®‘¬£©
100806040200
___
1. 0
.8
.6
.4
.2
0. 0
Time (month)
Su
rviv
al
Chin J Cardiol, 2002; 30: 450-454
N=92, follow-up 47 months (37-71)
Etiology of Heart FailureEtiology of Heart Failure
Framingham† - SOLVD*Framingham† - SOLVD*
Total African-American White
Hypertension 77% 32% 4%Hypertension 77% 32% 4%CAD 39%–50% 36% 73%CAD 39%–50% 36% 73%Rheumatic/Valvular 2%–20% 11% 10%Rheumatic/Valvular 2%–20% 11% 10%Idiopathic 5%–15% 13% 12%Idiopathic 5%–15% 13% 12%
†Framingham Heart Study.
*Bourassa et al. J Am Coll Cardiol. 1993;22:14A-19A.
Changes of Etiology of Hospitalized HF Patients In China
Data were taken from 42 hospitals in different city in China
Rheumatic valvular heart disease
N=10,714
CAD HTN others
36.8 33.8
45.6
8.010.4
12.9
34.4 34.3
18.6 18.7 18.920.5
05
101520253035404550 1980 1990 2000
Chin J Cardiol, 2002; 30: 450-454
Etiology of Hospitalized Patients With HF
CAD
45.6% RHD
18.6%HT
12.9%
Others
20.5%
CAD: Coronary Artery Disease; HT: Hypertension; RVHD: Rheumatic valvular heart disease; Others including congenital heart disease, non-rheumatic valvular heart disease, cardiomyopathy, etc.
Year 2000
Utilization of BNP TestAn important diagnostic tool for HF
U.S.A — Over 80% U.S.A — Over 80% hospitalshospitals
Europe — Over 50% Europe — Over 50% hospital hospital
China — Over 10% China — Over 10% hospitals, which is 400 total hospitals, which is 400 total
BNP: Quantitative Marker of Heart Failure
LV Systolic Dysfunction+
LV Diastolic Dysfunction+
Valvular Dysfunction+
RV Dysfunction
Increasednatriuresis
Suppression ofrenin-angiotensin
and endothelin
ANP BNP =
CNPVolume Pressure
Decreasedperipheral vascular
resistance (decreased blood pressure)
Iwanaga Y et al. JACC. 2006;47:742-8.
The Cardiovascular Disease Continuum
Adapted from Dzau V et al. Am Heart J.1991;121:1244-63.
Risk Factors:Obesity,
Insulin Resistance
Endothelial Dysfunction
Vascular Disease (Atherosclerosis)
Pathological Remodeling
(LVH)
Heart Attack (Myocardial Dysfunction)
Left Ventricular Enlargement
Heart Failure
DEATH
EndothelialDysfunction
MaladaptiveRemodeling
BNP
BNP
BNP
BNP BNP
BNP
BNP
BNP = 0
Age (years)
BN
P (
pg
/mL
)
20 40 60 80
20
100
Normal
Stage C & D
Stage B
Stage A
BNP by Staged HF Classification
Daniels LB & Maisel AS. Heart Failure Clin. 2006;2(3):299-309.
The Short of Breath Pie
Heart Failure
BNP in Dyspnea Secondary to CHF or COPD
N=56 N=94
Dao, Q., Maisel, A. et al. J. American College of Cardiology, Vol 37, No. 2, 2001
86 +/- 39
138 +/- 1076
0
200
400
600
800
1000
1200
BN
P p
g/m
L
COPD CHF
Cause of Dyspnea
Consensus Statement
• BNP accurately differentiates BNP accurately differentiates respiratory and cardiac etiologies respiratory and cardiac etiologies of dyspneaof dyspnea
Frequency HistogramClinical Probability of CHF
(Blinded to BNP)
Pretest Probability of CHF
Nu
mb
er
of
Ca
ses
Adapted with permission from McCullough P et al. Circulation. 2002;106:416−422.
0
50
100
150
200
250
300
350
0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
Significant Indecision Exists 43%
Maisel AS et al. N Engl J Med. 2002;347:161-167.
Specificity, Sensitivity, & Accuracy of BNP Cutoff Value
1.0
0.8
0.6
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.01-Specificity
Sen
siti
vity
• Final Diagnosis
HF
• Final Diagnosis NOT HF
•BNP 100 pg/mL“Test positive”
• 673 • 227
• BNP <100 pg/mL
“Test negative”
• 71Sensitivity
=90%
• 615Specificity
=73%
• Positivepredictive value=75
• Negative predictive value=90%
BNP=50 pg/mL BNP=80 pg/mL
BNP=100 pg/mL
BNP=150 pg/mL
BNP=125 pg/mL
Optimal cut-off point determined @ 100 pg/mL
Clarification of Diagnosis & BNP
Clarification of Diagnosis & BNP
Ind
ec
isio
n
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Clinical Evaluation
Clinical Evaluation and BNP
BNP reduces clinical indecision by 74%
43%
11%
*P <0.0001
ROC Accuracy Improvement with BNP
Consensus Statement
• The knowledge of BNP levels significantly The knowledge of BNP levels significantly improves ED physician diagnostic improves ED physician diagnostic accuracyaccuracy
End PointEnd Point
Routine Routine AssessmentAssessment
(n=227)(n=227)
Routine Routine AssessmentAssessment
+ BNP (n=225)+ BNP (n=225) PP Value Value
Time to treatment Time to treatment (minutes, median, interquartile range)(minutes, median, interquartile range)
90 90 (20-205)(20-205)
63 63 (16-153)(16-153)
0.030.03
Time to discharge Time to discharge (days, median, interquartile range)(days, median, interquartile range)
11.0 11.0 (5.0-18.0)(5.0-18.0)
8.0 8.0 (1.0-16.0)(1.0-16.0)
0.0010.001
Hospitalization (%)Hospitalization (%) 8585 7575 0.0080.008
Intensive-care unit admission (%)Intensive-care unit admission (%) 2424 1515 0.010.01
Total treatment cost Total treatment cost (S. median, 95% confidence intervals)(S. median, 95% confidence intervals)
7264 7264 (6301-8227)(6301-8227)
5410 5410 (4516-6304)(4516-6304)
0.0060.006
In-hospital mortality (%)In-hospital mortality (%) 99 66 0.210.21
30-d mortality (%)30-d mortality (%) 1212 1010 0.450.45
Results of the BNP for Acute Shortness of Breath Evaluation (BASEL) Study
Mueller C et al. N Engl J Med 2004;350:647-54.
BNP Consensus Algorithm
Silver M., Maisel AS et al. BNP Consensus Panel 2004 (Heart Failure 2004; (suppl. 3) S3-S14)Revision, BNP Working Group, April 2007, Eur Heart Journal
Patients presenting with Dyspnea
Physical examination,Chest x-ray,
ECG, BNP Level
BNP<100pg/mL
HF very improbable (2%)
BNP 100-400 pg/mL
Clinical suspicion of HFOr past History of HF
HF probable (75%)
BNP >400 pg/mL
HF very Probable (95%)
Risk Stratification
BNP Predicting Clinical Events
Maisel A, et al. Annals of Emergency Medicine 2001 (in press)
0 20 40 60 80 100 120 140 160 1800%
5%
10%
15%
20%
25%
30%
35%
40%
45%
BNP < 230 pg/ml
BNP 230-480 pg/ml
BNP > 480 pg/ml
Death or Heart Failure Hospitalization
Days
Admission BNP and In-Hospital Mortality in ADHF Distribution of BNP Values
(pg/mL)
48,629 (63%) out of 77,467 pt episodes had BNP assessment at initial evaluation.Only 3.3% of patients in ADHERE with initial BNP < 100 pg/mL
Fonarow et al, JACC 2007 in press
pg/mL
Consensus Statement
BNP provides strong prognostic data in BNP provides strong prognostic data in the EDthe ED
Low BNP levels (< 200 pg/mL) are associated Low BNP levels (< 200 pg/mL) are associated with a very low rate of subsequent adverse with a very low rate of subsequent adverse eventsevents
Very high BNP levels (> 1,700 pg/mL) are Very high BNP levels (> 1,700 pg/mL) are associated with very high acute mortalityassociated with very high acute mortality
IN ACS--Time
Is Myocardium!
So we strive to
shorten door to
balloon time
So in Acute
Decompensated
Heart Failure,
why don’t we strive
to improve door to
Diuretic time!!
Sunday in the ED
Is speed important?
This is you
Delayed BNP Equals Delayed Treatment
0
1
2
3
4
5
6
7
8
<1.05 1.05-2.22 2.23-4.9 >4.9
<449
449-864
865-1738
>1738
Tim
e to
BN
P
Treatment Time
Maisel, Peacock, Fonarow, Jesse et al JACC 2008
BNP Levels with Diuretic Time
50
55
60
65
70
75
80
85
90
<1.05 1.05-2.22 2.23-4.98 >4.98
<449
450-864
865-1738
>1738
% R
ales
Time to diuretic
Maisel, Peacock, Fonarow, Jesse et al JACC 2008
ED Time (hrs) vs. Quartiles of Diuretic time & BNP level
4
5
6
7
8
<1.05 1.05-2.22 2.23-4.98 >4.98
<449
450-864
865-1738
>1738
Treatment Time
ED Time
Mo
rtal
ity
(%)
Time to IV Diuretic (hours)iB
NP Lev
els
(pg/m
L)
Mortality and Diuretics
Consensus Statement
• Early knowledge of the BNP leads Early knowledge of the BNP leads to decreased hospital length of to decreased hospital length of staystay
BNP Levels with either Systolic or Diastolic Dysfunction
J Am Coll Cardiol 2003;410(11):2010-17.
1000
500300200
100
503020
10
5
BN
P (
pg
/mL
)
Non CHF Diastolic Systolic n=844 n=165 n=287
Median=34 pg/mL
Median=821 pg/mL
Median=413 pg/mL
BNP Levels in Patients with Diastolic Dysfunction
0
100
200
300
400
500
BN
P (
pg
/mL
)
Normal ImpairedRelaxation
Pseudonormal Restrictive
P < 0.001
33 ± 3
203 ± 30
294 ± 82
402 ± 66
Lubien and Maisel, Circulation. 2002; 105:595-601
Consensus Statement Diastolic Dysfunction
• In patients presenting with acute CHF with preserved-In patients presenting with acute CHF with preserved-LV function, BNP levels are always high although LV function, BNP levels are always high although usually not as high as patients with systolic usually not as high as patients with systolic dysfunction (800 pg/mL vs. 400 pg/mL)dysfunction (800 pg/mL vs. 400 pg/mL)
• BNP levels cannot be used to differentiate systolic BNP levels cannot be used to differentiate systolic from diastolic dysfunction in the emergency from diastolic dysfunction in the emergency departmentdepartment
• In the outpatient setting-very few people have In the outpatient setting-very few people have diastolic dysfunction with BNP levels under 20-40 diastolic dysfunction with BNP levels under 20-40 pg/mL.pg/mL.
Changes in BNP and PAW* Levels During 24 Hours of Treatment
Maisel, A. et al. J Cardiac Failure, Vol. 7, No. 1, 2001
N = 15 (responders)
PA
W (
mm
Hg
)
Hours
BN
P (p
g/m
l)
15171921232527293133
baseline 4 8 12 16 20 24600
700
800
900
1000
1100
1200
1300
PAWBNP
*Pulmonary artery wedge
250500
800
1750
500
1000
1500
2000
2500
I II III IV
Dry ( NYHA Euvolemic state)
In Volume Overloaded Patients: BNP level = baseline BNP (dry) plus change due to increased volume (wet)
BN
P le
vel (
pg/m
l)
NYHA Class - Euvolemic (Dry) BNP
250500
800
1325 12501000
1200
1750
500
1000
1500
2000
2500
I II III IV
Wet (Change due to volume overload)
Predischarge BNP for Identifying Patients at High Risk of Re-Admission After
Decompensated HF
Logeart D. et al. J Am Coll Cardiol. 2004 Feb 18;43(4):635-41
Follow-up (days)
Hazard ratiosof 2nd and 3rd
versus 1st BNP range
Dea
th o
r re
adm
issi
on (
%)
100
75
50
25
0
0 30 60 90 120 150 180
Predischarge BNP >700ng/ln =41, events =38
Predischarge BNP 350 - 700ng/ln =50, events =30
Predischarge BNP <350ng/ln =111, events =18
p <0.0001
p <0.0001
15.2
5.1
1
Consensus Statement In-patient monitoring
• BNP levels above baseline usually means volume overload
• With a half-life of 20 minutes, BNP levels from volume overloaded heart failure patients drop quickly
• Patients whose BNP level do not drop in the hospital have a poor prognosis
• The lower the BNP levels are at the time of discharge, the less likely the patient will be readmitted over the short term
Consensus StatementAchievement of Optimal BNP Levels
• One must determine wet versus optivolemic BNP level
• If BNP levels don’t fall after one day of treatment, one should consider more aggressive therapy.
• While a drop in BNP level is important it is not the magnitude of the drop as much as it is the final BNP level that relates to optivolemic status and prognosis.
• At least two BNP levels should be measured during hospitalization: admission, 24 hours after treatment started, and at discharge.
BNP Utilization in the Out-patient Setting
• Decompensation- Variability
• Driving Outpatient Therapy
• BNP as a Surrogate
• Screening
Reference Change Values for BNP and NT-BNP
O’Hanlon R et al. J Card Fail. 2007. Feb;13(1):50-5.
RCV %
0
20
40
60
80
100
120
140
Wu Bruin O'Hanlon Schou
BNP
NT-BNP
Reasons for Variability
• Relevant variables such as renal function, age Relevant variables such as renal function, age and gender did not influence variabilityand gender did not influence variability
• Variability likely not ( all ) random; reflects Variability likely not ( all ) random; reflects changes in the complex regulatory changes in the complex regulatory environment environment of BNPof BNP
–HemodynamicHemodynamic
–StructuralStructural
–NeuroendocrineNeuroendocrine
–RenalRenal
Weight Change ROC
Lewin J. Eur J Heart Fail. 2005 Oct;7(6):953-7.
AUC: 0.65/0.63
0.00 0.25 0.50 0.75 1.00
0.25
0.50
0.75
1.00
0.00
1-Specificity
Se
ns
itiv
ity
Source of the Curve
Reference Line
Percent
Absolute
Correlation Between ∆ in BNP and Weight
R=0.002
P=0.983 (NS)
Weight Change
BN
P C
han
ge
-3 -2 -1 0 1 2 3 4 5
4000
3000
2000
1000
0
-1000
-2000
-3000
Lewin J. Eur J Heart Fail. 2005 Oct;7(6):953-7.
Algorithms for BNP Outpatient Management
TELEMEDICINE
Draw BNP
Patient Reports Weight Gain
3-5 lbs
Edema or Increased SOB No Symptomatic Changes
Adjust Diuretic
>50% From Baseline
<25% From Baseline
25-50% From Baseline
Clinical DecisionConsider Other Work-up
Adjust Diuretic Over Phone
Algorithms for BNP Outpatient Management
>50% From Baseline
<25% From Baseline
25-50% From Baseline
Wt Gain3-5 lbs
Adjust Diuretic
Patient Arrives With Worsening Symptoms
Wt Gain3-5 lbs
Clinical Decision
Clinical Decision
Adjust Diuretic
Other Work-up
Yes Yes NoNo
OUTPATIENT CLINIC
What is “Biomarker Guided Therapy?”
• A A treatment strategytreatment strategy that that integratesintegrates measurement of a biomarker of biologic measurement of a biomarker of biologic response (or lack or response) into response (or lack or response) into treatment decisionstreatment decisions
Odds Ratio (95% Confidence Interval)0.43 (0.183, 1.02); p=0.055
Troughton
STARS-BNP
STARBRITE
Combined (random effects)
0.01 0.1 1.0 10.0 100.
BNP Monitoring Trials – Mortality
FAVORS BNP STRATEGY FAVORS CLINICAL STRATEGY
Perspective
−70
−60
−50
−40
−30
−20
−10
0
10
Ch
ang
e in
BN
P (
pg
/mL
) n=137 n=148 n=1850 n=51 n=50 n=340 n=343
ALOFT3 months
A-HeFT6 months
Val-HeFT4 months
RALES3 months
−12
−61
−34
+2n=1890
− 6
−15
−8
−39
Placebo AliskirenValsartan
Spironolactone Hydralazine-isosorbide dinitrate
Baseline BNPconcentration(pg/mL)
p=0.016
p<0.0001
p=0.02
p=0.05
291 181 ~70 ~300
Out-patient Monitoring Impact of BNP StrategiesOut-patient Monitoring Impact of BNP Strategies
• BNP-oriented strategies reduced heart failure related hospitalizations and mortality.
• Use of BNP oriented strategies could help clinicians optimize medical therapy in patients with or without beta blockers.
• In CHF, BNP-oriented strategies are based on BNP target value (100- 300 pg/ml) rather than on BNP variation due to heterogeneity of basal BNP value. These threshold values are only indicative due to low number of randomized studies.
• BNP-oriented strategies are safe and don’t lead to hemodynamic or renal deterioration.
Consensus Statement
Potential Biomarker Targets in ACS
Inflammation
Plaque Rupture
Thrombosis
Neurohormone Activation
hs-CRP, Ox LDLMCP-1, MPO, IL18
PAI-1, sCD40LvWF, D dimer
BNP, NEEndothelial Activation
sICAM, pSelectin
Arrhythmias
IschemiaNecrosis
MMP’s, PAPPsCD40L, PIGF
cTnT, cTnI, Myo, CK-MB, FABP
IMA, uFFA
The Prognostic value of BNP in ACS (preliminary results)
Med
ian o
f BN
PM
edian
of B
NP
50005000
40004000
30003000
20002000
10001000
Death (n=14Death (n=14) ) No deathNo death (n=313(n=313))
•ACS patients ACS patients （（ N=327N=327 ）） with or without ST with or without ST elevation between elevation between Nov,2006 and Dec,2007,in Nov,2006 and Dec,2007,in PUPHPUPH
•BNP by Triage BNP Test (Biosite, Inc., San Diego, CA)
In-hospital mortality 4.28%In-hospital mortality 4.28%
4,487pg/ml4,487pg/ml
1,434pg/ml1,434pg/ml
Data not publishedData not published
• A high BNP level in a troponin negative patient may herald a subsequent troponin elevation.
• In the patient with atypical chest pain, no ECG changes, and no troponin elevation, the addition of a BNP level less than 100 pg/mL signifies a patient who is especially low-risk.
• A high BNP in the setting of ACS and NSTEMI is a significant predictor of death, even in troponin negative patients. This provides physicians with opportunity to provide more aggressive treatment to these patients.
• High or rising BNP levels in patients presenting with ACS my herald the imminent onset of acute HF.
BNP with Chest Pain Presentation Additional Value to Necrosis Biomarkers
Consensus Statement
BNP and Guidelines
• As with every new diagnostic As with every new diagnostic or treatment modality, or treatment modality, guidelines often lag behind guidelines often lag behind state-of-the-art practicestate-of-the-art practice
• It is very encouraging to see It is very encouraging to see that after only several years that after only several years of introduction into clinical practice,of introduction into clinical practice,the use of BNP is alreadythe use of BNP is alreadyrecommended by all recommended by all major guidelinesmajor guidelines
Suspected Acute Heart Failure
Assess Symptoms and Signs
Heart Disease?
ECG / BNP/ X-ray?
Normal
Evaluate function by
Echocardiography / other imaging
Normal
Abnormal
Abnormal
Heart Failure, assess by
Echocardiography Selected tests
(angio, hemodynamic
monitoring, PAC)
Characterize type and severity
Consider other diagnosis
European Heart J. 2005;26:385-6.
Ten Key Messages for Physicians
• BNP is a quantitative marker of heart failure.
• BNP is highly accurate in the diagnosis of heart
failure.
• BNP may help risk stratify patients in the ED with
regard to admission or discharge.
• BNP testing improves patient management and
reduces total treatment costs.
• BNP testing has costs savings out to 6 months.
Ten Key Messages for Physicians
• BNP is the most powerful predictor of outcome heart failure.
• BNP levels may be helpful in assessing safety for discharge from the hospital
• BNP- guided therapy appears to improve outcome in chronic heart failure.
• BNP levels, along with symptoms and weight gain are the best way to ascertain clinical decompensation.
• BNP is the most powerful predictor of death in acute coronary syndrome.
China-Western Consensus Group
2007 European-North American BNP Consensus
THANK YOU !THANK YOU !
