Clinical Cases from Korea: Value of NT-proBNP in Cardiomyopathy
13 October 2021
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58-year old woman
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Key signs and symptoms
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Exertional dyspnea (NYHA IIII, progressed for 1 month). Orthopnea (+) |
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Medical History
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HTN (-) DM (-)
No history of Medications (-) |
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Clinical examination
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Acutely ill looking
BMI–21.8
BP 135/85 mmHg
Vital signs
Temperature 36.2°C
Heart rate 120/min regular
RR 22/min
No murmur or extracardiac sound
No crackles
G2 pitting edema in lower extremities
Other physical findings were NC |
|
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Laboratory test results
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CBC 14.0 g/dL
WBC 8580/mcL
Platelets 344,000/mcL
Electrolytes:
Sodium 142 mmol/L
Potassium 3.7 mmol/L
Chloride 104 mmol/L
BUN/Cr 17.4/0.81 mg/dL
AST/ALT 41/40 IU/L
NT-proBNP 3490 pg/mL |
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TTE and MRI images
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| LVEF 25% |
Mid-wall LGE in CMR
suggestive of Myocardial
Fibrosis |
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CAG
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No Obstructive
Coronary Artery
Disease observed |
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| |
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CSR
|
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Cardiomegaly |
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| |
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ECG
|
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| Sinus Tachycardia |
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At Admission |
1st OPD
(2W) |
2st OPD
(4W) |
3rd OPD
(8W) |
4th OPD
(16W) |
Vital Signs BP
(mm/Hg)/HR/min |
135/85-120 |
137/84-103 |
119/77-73 |
113/72-75 |
125/75-70 |
| |
ELectrolyte-Na/K(mmol/L)
BUN/Cr(mg/dL) |
142-3.7
17.4/0.81 |
139-4.3
17.0/0.82 |
138-4.5
16.7/0.70 |
138-4.6
13.7/0.65 |
139-4.8
19.2/0.95 |
| |
| Stmptoms |
NYHA III |
NYHA II |
NYHA II |
NYHA I
Dizziness |
NYHA I |
| |
| Medications |
Perindropil 4 mg
Carvedilol 3.125 mg bid
Furosemide 20 mg bid
Spironolactone 12.5 mg bid |
Perindropil cut
Entresto 50 mg bid
Ivabradine 5 mg bid |
Entresto 100 mg bid
Furosemide 20 mg qd
Spironolactone 12.5 mg qd |
Entresto 50 mg bid |
No change |
| |
| |
Acute decompensated
HFrEF Therapy with
neurohormonal blocker |
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Therapy with ARNI/Ivabradine |
Diagnosis
| |
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Dilated cardiomyopathy, idiopathic.
|
|
| |
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Dilated cardiomyopathy was diagnosed based on dilated LV chamber and diffuse hypokinesis of LV on TTEand mid-wall LGE uptake on CMR.
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NT-proBNP level was still elevated at the first OPD after GDMT during 2 weeks.
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Author’s opinion
Serial monitoring for change in NT-proBNP levels offers superior prognostic information to clinical assessment among outpatients with recent destabilized HF (especially at the first OPD).1 NT-proBNP is not a substrate of neprilysin inhibition, and it is useful to evaluate the clinical response in patients using ARNI.
- Domingo A. Pascual-Figal. et al, European Heart Journal, Volume 29, Issue 8, April 2008, Pages 1011–1018
59-year old man
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Key signs and symptoms
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NYHA IV dyspnea and PND (progressed for 1 month) |
|
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Medical History
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HTN (-) DM (-)
History of admission last year due to AMI (pLAD)
Has been on Aspirin 100 mg, Clopidogrel 75 mg, Rosuvastatin 10 mg
NYHA II-III dyspnea and worsened to NYHA IV (unable to lay flat) |
|
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Clinical examination
|
Acutely ill looking
BMI–18.5
BP 88/66 mmHg
Vital Signs
Temperature 36.2°C
Heart rate 104/min regular
RR 22/min
Jugular vein engorgement
No murmur or extracardiac sound
Crackles in mid to lower lung
G1 pitting edema in lower extremities
Other physical findings were NC |
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Laboratory test results
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CBC 15.9 g/dL
WBC 5170/mcL
Platelets 302,000/mcL
Electrolytes: Na/K/Cl 137/5.3/101 mmol/L
BUN/Cr 29.7/1.22 mg/dL
AST/ALT 45/24 IU/L
CRP < 0.40 mg/dL
NT-proBNP 4010 pg/mL |
|
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CXR
|
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Multiple Pulmonary
consolidation, Left
pleural effusion. |
|
|
| before |
After dobutamine infusion
and volume controls with diuretics,
pulmonary congestion has been
much improved. |
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TTE
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LVEF 20%
and akinetic apex |
|
| |
At Admission |
1stsup> OPD
(2W) |
2nd OPD
(4W) |
3 rd OPD
(8W) |
4 th OPD
(16W) |
Vital Signs BP
(mm/Hg)/HR/min |
93/67-95 |
95/63-92 |
92/67-65 |
92/55-62 |
93/59-65 |
| |
ELectrolyte-Na/K(mmol/L)
BUN/Cr(mg/dL) |
142-3.4
11.4-0.70 |
143-4.1
16.2-0.80 |
138-4.5
21.2-0.94 |
143-4.2
17.9-1.14 |
137-4.4
23.3-1.23 |
| |
| Stmptoms |
NYHA III |
NYHA II |
NYHA II |
NYHA I |
NYHA I |
| |
| Medications |
Bisoprolol 1.25 mg qd
Furosemide 20 mg bid
Spironolactone 12.5 mg qd |
Bisoprolol 1.25 mg qd
Furosemide 20 mg bid
Spironolactone 12.5 mg qd |
Candesartan 2 mg
Bisoprolol 1.25 mg qd
Ivabradine 5 mg bid
Furosemide 20 mg qd
Spironolactone 12.5 mg qd |
Candesartan 4 mg
Bisoprolol 1.25 mg qd
Ivabradine 5 mg bid
Furosemide 20 mg qd
Spironolactone 12.5 mg qd |
Candesartan 4 mg
Bisoprolol 1.25 mg qd
Ivabradine 5 mg bid
Furosemide 20 mg qd
Spironolactone 12.5 mg qd |
| |
Diagnosis
| |
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Ischemic cardiomyopathy.
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Ischemic cardiomyopathy was diagnosed based on previous MI history and akinetic apex and reduced LVEF on TTE.
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In such cachexic patients (BMI–18), up-titration of HF medications needs reliable biomarkers because these fragile patients usually show marginal blood pressure and heart rate.
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Author’s opinion
Although BP & HR were marginal in the patients with ICM, GDMT has been finely adjusted according to the NT-proBNP level. NT-proBNP level might be used to serve as a tool to “guide” application of GDMT, triggering more aggressive therapy titration in those with persistently elevated concentrations.1
- Current Heart Failure Reports volume 15, pages 37–43 (2018)
