Clinical Cases from Korea: Serial NT-proBNP measurement and Heart Failure prognosis - Cardio ThinkLab

De Novo heart failure with
reduced ejection fraction
Acute heart failure After AMI

45-year old woman

Key signs and symptoms

Acute Dyspnea (NYHA IV) for 4 days
Dyspnea/Orthopnea (+/+)
Cough/Sputum (-/-)

Medical History

No Diabetes Mellitus
No Pulmonary Tuberculosis
No Hepatitis
Hypertension with medication (Amlodipine 5 mg) for 10 years

Clinical examination

Dyspnea on exertion/Paroxysmal nocturnal dyspnea (+/+)
Palpitation/headache/sweating (+/+/+)
Rapid Heart Beat without murmur
Crackles in both lung fields
Pedal edema (++/++)

CXR

Cardiomegaly with pulmonary
congestion on both sides

MRI

EF=25% with delayed enhancement
(Late Gadolinium Enhancement-LGE)
in mid-wall by MRI

CT angiogram

No significant narrowing of coronary
on CT angiogram

Serial NT-proBNP level and medication

	At Admission	1st Visit	2st Visit	3rd Visit	4th Visit

Symptoms	NYHA II	NYHA III	–	–	NYHA I

Medications	acertil 4 mg dilatrend 3.125 mg bid furix 40 mg bid aldactone 25 mg qd procoralan 5 mg bid	entresto 50 mg bid	50 mg bid	100 mg bid	50 mg bid

NT-proBNP is a good biomarker in OPD post-discharge during early follow up and drug adjustment period.

At admission
NYHA IV
NT-proBNP 8900 pg/mL

After discharge 2 weeks (1st OPD visit)
NYHA III
NT-proBNP 2300 pg/mL

OPD 4 month
NYHA II
NT-proBNP 210 pg/mL

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Diagnosis

De-novo HF

HF with reduced EF

R/o idiopathic DCMP (Non-ischemic dilated cardiomyopathy)

Author’s opinion

The changes in NT-proBNP levels during follow-up do correlate with changes in clinical status for patients with HF destabilization, relative changes in NT-proBNP levels are better predictors of future clinical events.
In PIONEER-HF trial, the initiation of sacubitril–valsartan therapy after hemodynamic stabilization led to a greater reduction in the NT-proBNP concentration than enalapril therapy, a difference that was evident by the first week.¹
Predischarge NT-proBNP levels or short-term change (in percentage terms) in NT-proBNP levels at 1-2 weeks is a strong predictor of clinical events.
In addition, NT-proBNP monitoring added independent prognostic information to clinical scoring in patients with destabilized HF.
Therefore, Serial monitoring for per cent change in NT-proBNP concentrations offers superior prognostic information to clinical assessment among outpatients with recent destabilized HF.

Eric J. Velazquez et al, N Engl J Med 2019; 380:539-548

62-year old woman

Key signs and symptoms

Acute severe chest pain for 10 days
Acute dyspnea (NYHA IV) for 3 days
No other specific signs and symptoms

Medical History

Diabetes with oral medication (Diabex 500 mg, Sitagliptin 100 mg) for 10 years
Smoking 40 pack years
Elevated CK-MB and Troponin levels

Clinical examination

BP 118/68 mmHg
RR 92/min

CXR

Chest X-Ray showed pleural
effusion and pulmonary congestion

ECG

ECG shows no evidence of myocardial infarction

Coronary Angiogram

Coronary angiography shows significant narrowing on dRCA and dLCX

MRI


MRI: LGE (+) EF: 35% LVEDD: 5.2cm MRI showed larger amount LGE which means infarcted myocardium

Serial NT-proBNP level and medication

	At Admission	1st day	2nd day	At discharge (5 days)	30 days	180 days	365 days

CK MB (*< 3.7 ng/mL)	18.40	1.60	0.63	0.53	0.58	0.22	–

Troponin I (< 0.046 ng/mL)	2.648	1.649	0.271	0.211	0.012	< 0.015	–

Initial NT-proBNP level was 7800, patient continued to experience dyspnea and chest pain. Serial measurement showed reduced levels.

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Author’s opinion

Natriuretic peptides (NPs) are important predictors of outcomes in patients with acute myocardial infarction (AMI) but can change over time.¹
Changes in the NT-proBNP levels over time are associated with concurrent changes in the EF or ventricular volumes and the clinical symptoms, suggesting that these natriuretic peptides may potentially serve as useful surrogate markers for patients with progressive remodeling after AMI.²
In addition, a persistently elevated NT-proBNP assessed 1 month after discharge was associated with a higher risk of mortality in patient with AMI.
Post discharge or early period risk stratification using NT-proBNP has the potential to identify higher risk patients after AMI.

Tom Hendriks et al The International Journal of Cardiovascular Imaging volume 33, pages 1415–1423 (2017).
Jens C. Nilsson MDa Am Heart J. Volume 143, Issue 4, April 2002, pages 696-702