Natriuretic peptide B plasma concentration increases in the first 12 h of pulmonary edema recovery

Published:March 17, 2018DOI:


      • Single BNP value is used for distinguishing cardiac and non-cardiac acute dyspnea.
      • BNP changes during acute cardiogenic pulmonary edema recovery is unknown.
      • In 50 chronic HF patients BNP increased up to 12 h after admission.
      • The quantitative mean of BNP in acute cardiogenic pulmonary edema is questionable.
      • Single BNP determination in acute hemodynamic impairment setting could be not sufficient.



      According to guidelines, single determination of B-type Natriuretic peptide (BNP) should be used for distinguishing between cardiac and non-cardiac acute dyspnea at the emergency room. BNP measurement is also recommended before hospital discharge in patients hospitalized for heart failure to assess prognosis and to evaluate treatment efficacy.
      In acute cardiogenic pulmonary edema, BNP is measured using a single BNP determination, but the temporal behavior of BNP during pulmonary edema recovery is unknown.


      Fifty chronic low ejection fraction (<40%) heart failure patients (age 77 ± 9 years, 17 M-33F) admitted for acute pulmonary edema were studied. Patients were grouped according to 50% dyspnea recovery time into 3 groups: ≤30 min (n = 14), 30 to 60 min (n = 19), and > 60 min (n = 17). BNP was measured at arrival and 4, 8, 12 and 24 h afterwards.


      At arrival, BNP was elevated in all patients without significant difference among groups. In the entire population, BNP median and interquartile range value were 791 (528–1327) pg/ml, 785(559–1299) pg/ml, 1014(761–1573) pg/ml, 1049(784–1412) pg/ml, 805(497–1271) pg/ml at arrival and 4, 8, 12 and 24 h afterwards, respectively, showing higher values at 8 and 12 h. This peculiar temporal behavior of BNP was shared by all study groups. Patients with the longest edema resolution showed the highest BNP level 8 and 12 h after admission.


      In acute pulmonary edema, BNP increased up to 12 h after emergency admission regardless of dyspnea recovery time, making BNP quantitative meaning in the acute phase of pulmonary edema uncertain.


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        • Ponikowski P.
        • Voors A.A.
        • Anker S.D.
        • et al.
        ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
        Eur Heart J. 2016; 37: 2129-2200
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
        Circulation. 2013; 128: e240-327
        • Mueller C.
        • Scholer A.
        • Laule-Kilian K.
        • et al.
        Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea.
        N Engl J Med. 2004; 350: 647-654
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.
        J Am Coll Cardiol. 2017; 70: 776-803
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.
        Circulation. 2016; 134: e282-93
        • Jourdain P.
        • Jondeau G.
        • Funck F.
        • et al.
        Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP multicenter study.
        J Am Coll Cardiol. 2007; 49: 1733-1739
        • Troughton R.W.
        • Frampton C.M.
        • Brunner-La Rocca H.P.
        • et al.
        Effect of B-type natriuretic peptide-guided treatment of chronic heart failure on total mortality and hospitalization: an individual patient meta-analysis.
        Eur Heart J. 2014; 35: 1559-1567
        • Heidenreich P.A.
        • Albert N.M.
        • Allen L.A.
        • et al.
        Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.
        Circ Heart Fail. 2013; 6: 606-619
        • Savarese G.
        • Trimarco B.
        • Dellegrottaglie S.
        • et al.
        Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials.
        PLoS One. 2013; 8e58287
        • Bettencourt P.
        • Azevedo A.
        • Pimenta J.
        • Frioes F.
        • Ferreira S.
        • Ferreira A.
        N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients.
        Circulation. 2004; 110: 2168-2174
        • Kociol R.D.
        • Horton J.R.
        • Fonarow G.C.
        • et al.
        Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from organized program to initiate lifesaving treatment in hospitalized patients with heart failure (OPTIMIZE-HF) linked to Medicare claims.
        Circ Heart Fail. 2011; 4: 628-636
        • Feldman A.M.
        • Mann D.L.
        • She L.
        • et al.
        Prognostic significance of biomarkers in predicting outcome in patients with coronary artery disease and left ventricular dysfunction: results of the biomarker substudy of the surgical treatment for ischemic heart failure trials.
        Circ Heart Fail. 2013; 6: 461-472
        • Lourenco P.
        • Ribeiro A.
        • Pintalhao M.
        • Silva S.
        • Bettencourt P.
        Predictors of six-month mortality in BNP-matched acute heart failure patients.
        Am J Cardiol. 2015; 116: 744-748
        • McQuade C.N.
        • Mizus M.
        • Wald J.W.
        • Goldberg L.
        • Jessup M.
        • Umscheid C.A.
        Brain-type natriuretic peptide and amino-terminal pro-brain-type natriuretic peptide discharge thresholds for acute decompensated heart failure: a systematic review.
        Ann Intern Med. 2017; 166: 180-190
        • Pang P.S.
        • Xue Y.
        • Defilippi C.
        • Silver M.
        • Januzzi J.
        • Maisel A.
        The role of natriuretic peptides: from the emergency department throughout hospitalization.
        Congest Heart Fail. 2012; 18: S5-8
        • Packer M.
        Should B-type natriuretic peptide be measured routinely to guide the diagnosis and management of chronic heart failure?.
        Circulation. 2003; 108: 2950-2953
        • Agostoni P.
        • Cattadori G.
        • Bianchi M.
        • Wasserman K.
        Exercise-induced pulmonary edema in heart failure.
        Circulation. 2003; 108: 2666-2671
        • Cattadori G.
        • Wasserman K.
        • Meloni C.
        • et al.
        Alveolar membrane conductance decreases as BNP increases during exercise in heart failure. Rationale for BNP in the evaluation of dyspnea.
        J Card Fail. 2009; 15: 136-144
        • Lauri G.
        • Rossi C.
        • Rubino M.
        • et al.
        B-type natriuretic peptide levels in patients with pericardial effusion undergoing pericardiocentesis.
        Int J Cardiol. 2016; 212: 318-323
        • Agostoni P.
        • Caldara G.
        • Bussotti M.
        • et al.
        Continuous positive airway pressure increases haemoglobin O2 saturation after acute but not prolonged altitude exposure.
        Eur Heart J. 2010; 31: 457-463
        • Omar H.R.
        • Guglin M.
        A single BNP measurement in acute heart failure does not reflect the degree of congestion.
        J Crit Care. 2016; 33: 262-265
        • Omar H.R.
        Acute cardiogenic pulmonary edema with normal BNP: the value of repeat BNP testing.
        Am J Emerg Med. 2015; 33: e5-6
        • Weber M.
        • Hamm C.
        Role of B-type natriuretic peptide (BNP) and NT-proBNP in clinical routine.
        Heart. 2006; 92: 843-849
        • de Lemos J.A.
        • McGuire D.K.
        • Drazner M.H.
        B-type natriuretic peptide in cardiovascular disease.
        Lancet. 2003; 362: 316-322
        • Fonarow G.C.
        • Peacock W.F.
        • Phillips C.O.
        • Givertz M.M.
        • Lopatin M.
        Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure.
        J Am Coll Cardiol. 2007; 49: 1943-1950
        • Salah K.
        • Kok W.E.
        • Eurlings L.W.
        • et al.
        A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ELAN-HF Score.
        Heart. 2014; 100: 115-125
        • Seronde M.F.
        • Gayat E.
        • Logeart D.
        • et al.
        Comparison of the diagnostic and prognostic values of B-type and atrial-type natriuretic peptides in acute heart failure.
        Int J Cardiol. 2013; 168: 3404-3411
        • De Vecchis R.
        • Ariano C.
        • Baldi C.
        An admission-to-discharge BNP increase is a predictor of six-month all-cause death in ADHF patients: inferences from multivariate analysis including admission BNP and various clinical measures of congestion.
        J Clin Forensic Med. 2016; 5