Consensus document by the HFA of the ESC
Proposed algorithm for screening at the risk for HF8
Asymptomatic subjects with conditions predisposing to HF
(e.g., hypertension or diabetes)
Natriuretic peptides, including NT-proBNP, are produced within cardiomyocytes in response to stress, and are released after clinical triggers.1
| Diagnosis of HF | In-hospital management of HF | Disease monitoring of chronic HF | |||
|---|---|---|---|---|---|
| Acute HF | Chronic HF | At admission | At discharge | ||
| Patient profile and setting | Patients presenting dyspnea in the ED | Patients presenting dyspnea in ambulatory setting | Acute hospitalized HF patients | Patients with chronic HF in outpatient setting |
|
| Clinical utility | To rule out AHF in patients with lower levels and rule in AHF in patients with higher levels |
To provide incremental value to clinical judgement when the cause is unclear |
To establish prognosis and identification of patients with greater risk of adverse outcomes |
To aid discharge planning and optimization of GDMT to avoid early readmission |
To monitor patients’ condition to improve outcomes |
| ACC/AHA 20227 | Recommended (Class 1) | Recommended (Class 1) |
Can be useful (Class 2a) |
Recommended (Class 1) |
|
| ESC 20218 | Recommended (Class I) | Recommended (Class I) | Recommended (Class I) | Recommended (Class I) | N/A |
| Diagnosis of HF | ||
|---|---|---|
| Acute HF | Chronic HF | |
| Patient profile and setting |
Patients presenting dyspnea in the ED |
Patients presenting dyspnea in ambulatory setting |
| Clinical utility |
To rule out AHF in patients with lower levels and rule in AHF in patients with higher levels |
To provide incremental value to clinical judgement when the cause is unclear |
| ACC/AHA 20227 | Recommended (Class 1) | |
| ESC 20218 | Recommended (Class I) | Recommended (Class I) |
| In-hospital management of HF |
||
|---|---|---|
| At admission | At discharge | |
| Patient profile and setting |
Acute hospitalized HF patients |
|
| Clinical utility | To establish prognosis and identification of patients with greater risk of adverse outcomes |
To aid discharge planning and optimization of GDMT to avoid earlyreadmission |
| ACC/AHA 20227 | Recommended (Class 1) |
Can be useful (Class 2a) |
| ESC 20218 | Recommended (Class I) | Recommended (Class I) |
| Disease monitoring of chronic HF |
|
|---|---|
| Patient profile and setting |
Patients with chronic HF in outpatient setting |
| Clinical utility | To monitor patients’ condition to improve outcomes |
| ACC/AHA 20227 | Recommended (Class 1) |
| ESC 20218 | N/A |
Roche NT-proBNP
<125pg/mL HF unlikely,
consider other diagnoses
Roche NT-proBNP
Roche NT-proBNP
>125pg/mL
HF likely,
perform
echocardiography to
confirm the diagnosis
of HF
Roche NT-proBNP
Roche NT-proBNP
<125pg/mL HF unlikely,
consider other diagnoses
Roche NT-proBNP
>125pg/mL
HF likely,
perform
echocardiography to
confirm the diagnosis
of HF
Roche NT-proBNP
< 300pg/mL
Search for other symptoms
Roche NT-proBNP
>300pg/mL but under
“rule-in” cut-offs
Diagnosis by imaging
Roche NT-proBNP
>450pg/mL if <50 years
>900pg/mL if 50–75 years
>1,800pg/mL if >75 years
*Results in the grey zone have to be interpreted in the clinical context as other causes beyond HF can lead to elevation of natriuretic peptides.23
A single value of NT-proBNP >5,000pg/mL in HF patients predicts a greater risk of mortality and poor outcomes16
The reduction of NT-proBNP levels ≥30% between admission and discharge predicts better clinical outcomes16
Risk stratification in dyspneic patients to ED
Adapted from Januzzi JL, et al. 2006.
Kaplan–Meier curves for all-cause mortality and composite endpoint at 180 days according to the dichotomized NT-proBNP percentage reduction during hospitalization
Adapted from Salah K, et al. 2014.
A baseline value of NT-proBNP is needed for a new HF patient in cltinic.16 Rechecking NT-proBNP after adequate treatment is suggested16
For patients whose NT-proBNP level remain ≥1,000pg/mL after treatment, the medication for HF should be optimized, comorbidities and other reasons should be investigated16
Risk of primary endpoint if NT-proBNP value of 1,000pg/mL achieved or not achieved 1 month after randomization18
Adapted from Zile MR, et al. 2016.
Patients who achieved a NT-proBNP level of ≤1,000pg/mL in 1 month was associated with around 50% better CV outcomes at the 3-year follow-up 18
• Primary endpoint: the first occurrence of CV death or HF hospitalization
Effects on the risk of primary endpoint if NT-proBNP changed from baseline to 1 month after randomization*18
*Levels of NT-proBNP were measured at baseline and at 1 month **HH means that the NT-proBNP levels were both >1,000pg/mL at baseline and 1 month
HR and 95% CI for each category with HH serving as a reference18
Adapted from Zile MR, et al. 2016.
There are differences in assay design (reagent antibody and methodology) and calibration method22
Not all NT-proBNP assays are the same and the result obtained from different assays are not transferable 21
Are you interested in finding out more about Roche NT-proBNP?
Please leave your contact details.
Our Roche respresentative
will contact you
as soon as possible.
Abbreviations: ACC: American College of Cardiology; AHA: American Heart Association; AHF: Acute heart failure; APAC: Asia-Pacific; ARNi: Angiotensin receptor-neprilysin inhibitor; CI: Confidence interval; CV: Cardiovascular; CVD: Cardiovascular disease; ED: Emergency department; ESC: European Society of Cardiology; GDMT: Guideline-directed medical therapy; HF: Heart failure; HFA: Heart Failure Association; HFrEF: Heart failure with reduced ejection fraction; HH: High-high; HL: High-low; HR: Hazard ratio; LH: Low-high; LL: Low-low; NT-proBNP: N terminal pro B type natriuretic peptide; N/A: Not available; NYHA: New York Heart Association; T2DM: Type 2 diabetes mellitus
References:
MAP-2023-JUL-001
NT-proBNP vs. HbA1c1
| Endpoint | NT-proBNP | HbA1c | ||
|---|---|---|---|---|
| HR (CI) | p value | HR (CI) | p value | |
| All-cause mortality |
1.0010 (1.0005–1.0014) |
<0.001 | 1.0028 (0.7415–1.3562) |
N.S. |
| CV- hospitalization |
1.0006 (1.0003-1.0009) |
<0.001 | 1.1393 (0.9538-1.3609) |
N.S. |
| HIGHLY predictive at baseline and follow-up |
NO predictive value |
|||
Adapted from Neuhold S, et al. 2011.
NT-proBNP vs. Albuminuria2
Clinical trials have shown that NT-proBNP cut-off of 125pg/mL has good
discrimination ability in selected T2DM patients with history or at high risk for CV events.4,5
CANVAS Study4
Substantial overlap was observed at NT-proBNP levels >125pg/mL in patients with and without history of HF
Higher risk of CV events observed in patients with NT-proBNP ≥125pg/mL
MACE
HFH
HFH/CV death
DECLARE-TIMI 58 Study5
Substantially higher event rates of CV/HFH observed in patients with NT-proBNP levels ≤125pg/mL
A sharp increase in NT-proBNP levels can be detected as early as 6 months
before HF hospitalization, regardless of previous history of HF.6
2022 AHA/ACC/HFSA Guideline
In the patient at risk of developing HF, BNP or NT-proBNP-based screening followed by team-based care, a CV specialist, can be useful to prevent the development of LV dysfunction or new-onset HF.7
Proposed algorithm for screening at the risk for HF8
Asymptomatic subjects with conditions predisposing to HF
(e.g., hypertension or diabetes)
Are you interested in finding out more about Roche NT-proBNP?
Please leave your contact details.
Our Roche respresentative
will contact you
as soon as possible.
Abbreviations: AHA/ACC/HFSA: American Heart Association/American College of Cardiology/Heart Failure Society of America; BNP: B type natriuretic peptide; CI: Confidence interval; CV: Cardiovascular; CVD: Cardiovascular disease; DM: Diabetes mellitus; ESC: European College of Cardiology; HbA1c: Hemoglobin A1c; HF: Heart failure; HFA: Heart Failure Association; HFH: Heart failure hospitalization; HR: Hazard ratio; hs: High sensitivity; LV: Left ventricular; MACE: Major adverse cardiac events; N.S.: Not significant; NP: natriuretic peptide; NT-proBNP: N terminal pro B type natriuretic peptide; TTE: Transthoracic echocardiogram; T2DM: Type 2 diabetes mellitus; URL: Upper reference limit.
References:
MAP-2023-JUL-001