Physicians' Academy for Cardiovascular Education

Use of BNP to guide prognosis in heart failure

Literature - van Veldhuisen DJ, Linssen GC, Jaarsma T, et al. - J Am Coll Cardiol. 2013;61:1498-506.

B-type natriuretic peptide and prognosis in heart failure patients with preserved and reduced ejection fraction.

van Veldhuisen DJ, Linssen GC, Jaarsma T, et al.
J Am Coll Cardiol. 2013;61:1498-506. doi: 10.1016/j.jacc.2012.12.044.


Heart failure with preserved ejection fraction (HFPEF) is a large medical and epidemiological problem [1–5]. Mortality in HFPEF patients is roughly similar to that in HF patients with a reduced left ventricular ejection fraction (LVEF) [3,4]. Although survival has improved over the last 10 to 20 years in HF patients with reduced LVEF, this was not observed in HFPEF patients.  Although a recent meta-analysis showed that medical treatment may improve exercise capacity [6], none of the treatments was convincingly shown to improve outcome, and therefore none of these drugs has received a
recommendation for HFPEF in current HF guidelines [1,5,7]. The presence of HF in patients with HFPEF can be defined by using natriuretic peptides: B-type natriuretic peptide (BNP); or N-terminal pro–B-type natriuretic peptide (NT-proBNP). These biomarkers have been proven to be of value in the management of HF patients with reduced LVEF. These natriuretic peptides may also be used in HFPEF, both for diagnostic and for prognostic purposes [8–11].
The aim of this study was to study the prognostic value of B-type natriuretic peptide (BNP) in patients with heart failure with preserved ejection fraction (HFPEF), in comparison to that in patients with reduced left ventricular (LV) EF (≤40%). This was an 18-month prospective cohort analysis of patients (n = 615) with New York Heart Association (NYHA) functional class II-IV heart failure participating in the COACH (Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure) trial. COACH was a randomized trial to evaluate the effect of two levels of a disease management program versus usual care. In this trial, patients were randomized before discharge at the end of a hospitalization for HF. A single BNP measurement was taken at this time. The primary outcome was a composite of hospitalization for HF or all-cause mortality.

Main results

  • BNP levels were significantly higher in patients with reduced LVEF than in those with HFPEF (p < 0.001).
  • Among patients with an LVEF >50% (n = 74), the mean BNP level was 256 pg/ml (112-598 pg/ml), compared to 534 pg/ml (275-1130 pg/ml) in those with an LVEF ≤20%.
  • BNP was a strong predictor for outcome, both in the whole population, as well as in the two subgroups of patients with LVEF ≤40% and in those with LVEF >40%.


BNP levels in patients with HFPEF are lower than in those with reduced LVEF, but are still predictive of prognosis. These findings may have important implications in the management of HFPEF patients in everyday clinical practice and in the design of trials in HFPEF.

Editorial comment [12]

While limited by a small size (especially in the subset of patients with an LVEF ≤40%, which the authors defined as PEF), the current analysis indicates that the prognosis in patients with HFPEF is similar as in those with reduced LVEF, for a given BNP level. Although future research is needed and there are still no proven therapies for the growing problem of HFPEF, this analysis would at least suggest that BNP can be used to guide prognosis in everyday clinical practice and in conduct of clinical trials, irrespective of LVEF.


1. McMurray JJV, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Eur J Heart Fail 2012;14:803– 69.
2. Kindermann M, Reil JC, Pieske B, et al. Heart failure with normal left ventricular ejection fraction: what is the
evidence? Trends Cardiovasc Med 2008;18:280 –92.
3. Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved
ejection fraction. N Engl J Med 2006;355:251–9.
4. Bhatia RS, Tu JV, Lee DS, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006;355:260 –9.
5. Paulus WJ, Van Ballegoij JJ. Treatment of heart failure with normal ejection fraction: an inconvenient truth. J Am Coll Cardiol 2010;55:526–37.
6. Holland DJ, Kumbhani DJ, Ahmed SH, Marwick TH. Effects of treatment on exercise tolerance, cardiac function, and mortality in heart failure with preserved ejection fraction: a meta-analysis. J Am Coll Cardiol 2011;57:1676–86
7. Krum H, Abraham WT. Heart failure. Lancet 2009;373:941–55.
8. Daniels LB, Maisel AS. Natriuretic peptides. J Am Coll Cardiol 2007;50:2357– 68.
9. Januzzi JL, Jr., Rehman SU, Mohammed AA, et al. Use of aminoterminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular dysfunction. J Am Coll Cardiol 2011;58:1881–9.
10. Parekh N, Maisel AS. Utility of B-natriuretic peptide in the evaluation of left ventricular diastolic function and diastolic heart failure. Curr Opin Cardiol 2009;24:155– 60.
11. Komajda M, Carson PE, Hetzel S, et al. Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). Circ Heart Fail 2011;4:27–35
12. Januzzi JL Jr. Natriuretic peptides, ejection fraction, and prognosis: parsing the phenotypes of heart failure.
J Am Coll Cardiol. 2013;61:1507-9.

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