Dr Dong-Hyuk Cho

Cardiologist/Assistant Professor Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Korea

Home > Education & CME > Clinical Cases from Korea: Value of NT-proBNP in Cardiomyopathy

Clinical Cases from Korea: Value of NT-proBNP in Cardiomyopathy

13 October 2021

Review the clinical case details and select the most probable diagnosis below. More information on the diagnosis and expert opinion can be seen by clicking on the “Click to review the answer” button.

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Destabilized HF-I
Destabilized HF-II

58-year old woman

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-2.png" alt="" />

Key signs and symptoms

Exertional dyspnea (NYHA IIII, progressed for 1 month). Orthopnea (+)

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-3.png" alt="" />

Medical History

HTN (-) DM (-)
No history of Medications (-)

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-4.png" alt="" />

Clinical examination

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

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-5.png" alt="" />

Laboratory test results

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

TTE and MRI images

LVEF 25%

Mid-wall LGE in CMR
suggestive of Myocardial
Fibrosis

CAG

No Obstructive
Coronary Artery
Disease observed

CSR

Cardiomegaly

ECG

Sinus Tachycardia

	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

Therapy with ARNI/Ivabradine

Click to reveal the answer

Diagnosis

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

Dilated cardiomyopathy, idiopathic.

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

Dilated cardiomyopathy was diagnosed based on dilated LV chamber and diffuse hypokinesis of LV on TTEand mid-wall LGE uptake on CMR.

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

NT-proBNP level was still elevated at the first OPD after GDMT during 2 weeks.

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

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-2.png" alt="" />

Key signs and symptoms

NYHA IV dyspnea and PND (progressed for 1 month)

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-3.png" alt="" />

Medical History

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)

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-4.png" alt="" />

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

<img decoding="async" class="img-1" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-5.png" alt="" />

Laboratory test results

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

CXR

Multiple Pulmonary
consolidation, Left
pleural effusion.

before

After dobutamine infusion
and volume controls with diuretics,
pulmonary congestion has been
much improved.

TTE

LVEF 20%
and akinetic apex

	At Admission	1^stsup> OPD (2W)	2^nd 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

Click to reveal the answer

Diagnosis

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

Ischemic cardiomyopathy.

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

Ischemic cardiomyopathy was diagnosed based on previous MI history and akinetic apex and reduced LVEF on TTE.

<img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" alt="" data-src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://dianews.roche.com/rs/106-RRW-330/images/CTL-ProfCho-Case-Study-Oct-Asset-13.png" alt="" />

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.

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)

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