Updating the role of natriuretic peptide levels in cardiovascular disease

Artificial Intelligence-Enabled Electrocardiography Detects B-Type Natriuretic Peptide and N-Terminal Pro-Brain Natriuretic Peptide

BACKGROUND: The B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (pBNP) are predictors of cardiovascular morbidity and mortality. Since the artificial intelligence (AI)-enabled electrocardiogram (ECG) system is widely used in the management of many cardiovascular diseases (CVDs), patients requiring intensive monitoring may benefit from an AI-ECG with BNP/pBNP predictions. This study aimed to develop an AI-ECG to predict BNP/pBNP and compare their values for future mortality. METHODS: The development, tuning, internal validation, and external validation sets included 47,709, 16,249, 4001, and 6042 ECGs, respectively. Deep learning models (DLMs) were trained using a development set for estimating ECG-based BNP/pBNP (ECG-BNP/ECG-pBNP), and the tuning set was used to guide the training process. The ECGs in internal and external validation sets belonging to nonrepeating patients were used to validate the DLMs. We also followed-up all-cause mortality to explore the prognostic value. RESULTS: The DLMs accurately distinguished mild (≥500 pg/mL) and severe (≥1000 pg/mL) an abnormal BNP/pBNP with AUCs of ≥0.85 in the internal and external validation sets, which provided sensitivities of 68.0-85.0% and specificities of 77.9-86.2%. In continuous predictions, the Pearson correlation coefficient between ECG-BNP and ECG-pBNP was 0.93, and they were both associated with similar ECG features, such as the T wave axis and correct QT interval. ECG-pBNP provided a higher all-cause mortality predictive value than ECG-BNP. CONCLUSIONS: The AI-ECG can accurately estimate BNP/pBNP and may be useful for monitoring the risk of CVDs. Moreover, ECG-pBNP may be a better indicator to manage the risk of future mortality.

N-Terminal Pro-Brain Natriuretic Peptide Levels Are Associated with Post-Stroke In-Hospital Complications

Previous studies have shown the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) with stroke mortality and functional outcome after an acute ischemic stroke (AIS). Knowledge of its association with systemic and neurological in-hospital complications is scarce. Our objective is to analyze this. We performed an observational, retrospective study that included consecutive AIS patients during a 1-year period (2020). A multivariate analysis was performed to identify if NT-proBNP levels were independently associated with in-hospital complications. 308 patients were included, of whom 96 (31.1%) developed systemic and 62 (20.12%) neurological in-hospital complications. Patients with any complication (39.3%) showed higher NT-proBNP levels than those without (median (IQR): 864 (2556) vs. 142 (623) pg/dL, p < 0.001). The receiver operating characteristic curve (ROC) pointed to 326 pg/dL of NT-proBNP as the optimal cutoff level for developing in-hospital systemic complications (63.6% sensitivity and 64.7% specificity for any complication; 66.7% and 62.7% for systemic; and 62.9% and 57.7% for neurological complications). Multivariate analyses showed that NT-proBNP > 326 pg/dL was associated with systemic complications (OR 2.336, 95% CI: 1.259–4.335), adjusted for confounders. This did not reach statistical significance for neurological complications. NT-proBNP could be a predictor of in-hospital systemic complications in AIS patients. Further studies are needed.

The association between DNA methylation of 6p21.33 and AHRR in blood and coronary heart disease in Chinese population

BACKGROUND

Early detection could significantly improve the prognosis of coronary heart disease (CHD). In-invitro diagnostic technique may provide a solution when sufficient biomarkers could be identified. Pertinent associations between blood-based aberrant DNA methylation and smoking, the pathogenesis of atherosclerosis, and CHD have been robustly demonstrated and replicated, but that studies in Chinese populations are rare. The blood-based methylation of aryl-hydrocarbon receptor repressor (AHRR) cg05575921 and 6p21.33 cg06126421 has been associated with cardiovascular mortality in Caucasians. Here, we aim to investigate whether the AHRR and 6p21.33 methylation in the blood is associated with CHD in the Chinese population.

METHODS

In this case-control study, 180 CHD patients recruited at their first registration in our study center, and 184 controls randomly selected from the people who participated in the annual health examination were enrolled. Methylation intensities of 19 CpG sites, including AHRR cg05575921, 6p21.33 cg06126421, and their flanking CpG sites, were quantified by mass spectrometry. The association between methylation intensities and CHD was estimated by logistic regression analyses adjusted for covariant.

RESULTS

Compared to the controls, lower methylation of 6p21.33_CpG_4.5/cg06126421 was independently associated with increased odds of being a CHD patient (OR per - 10% methylation = 1.42 after adjustment for age, gender, and batch effect; p = 0.032 by multiple testing corrections). No association between blood-based AHRR methylation and CHD was found.

CONCLUSIONS

6p21.33 methylation exhibits a significant association with CHD. The combination of 6p21.33 methylation and conventional risk factors might be an intermediate step towards the early detection of CHD.

Association of Natriuretic Peptide With Adverse Outcomes and Disease Severity After Intracerebral Hemorrhage: A Systematic Review

Background: Over the past decade, many studies have reported the association of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with clinical outcome of intracerebral hemorrhage (ICH). However, a broad consensus has not been reached. Objective: To evaluate the role of BNP/NT-proBNP levels in prognosis and disease severity assessment in patients with ICH. Methods: A systematic literature search was conducted utilizing PubMed, Embase, Web of Science and the Cochrane Library databases up to July 23, 2021. Studies that explored the association between BNP/NT-proBNP level and clinical outcome or disease severity in ICH patients were eligible. Outcome measures were all-cause mortality, poor functional outcome, adverse cardiac events and markers of disease severity. Results: Ten studies, involving 1,373 patients with ICH, met the inclusion criteria. Nine studies focused on clinical outcomes (five all-cause mortality, five functional outcomes, and one adverse cardiac event) and seven on disease severity. In terms of prognosis, all five studies showed an association between elevated BNP/NT-proBNP level and increased risk of all-cause mortality in ICH patients. Four of the five studies reported poor functional outcomes in patients with higher BNP/NT-proBNP levels and one study associated higher BNP/NT-proBNP levels with increased risk of adverse cardiac events. Moreover, two studies identified an additional predictive ability of BNP/NT-proBNP level beyond that of pre-existing prognostic variables. In terms of disease severity, five studies (71%) reported that BNP/NT-proBNP level correlated positively with hematoma volume in addition to ICH and GCS scores. Conclusion: Elevated BNP/NT-proBNP level is associated with increased risk of all-cause mortality, poor functional outcome, adverse cardiac events and disease severity in patients with ICH. Thus, BNP/NT-proBNP level is a promising prognostic indicator for ICH and also an effective marker of disease severity. Current evidence remains limited by the small number and high heterogeneity of included studies. Further appropriately designed, large-scale studies are required to confirm the current findings.

Heart rate modulates the relationship of augmented systolic blood pressure with the blood natriuretic peptide levels

AIMS

Augmented central systolic blood pressure (cSBP), which is known to affect the cardiac afterload, is an independent risk factor for cardiovascular disease. While an inverse relationship is known to exist between the heart rate (HR) and the cSBP, it has not yet been clarified if the HR also modulates the association between the cSBP and the cardiac afterload. The present study was conducted to clarify whether the association of the cSBP with the serum levels of the N-terminal fragment B-type natriuretic peptide (NT-proBNP) differs between subjects with high and low HRs, using data obtained from the same subjects on two occasions (2009 and 2012) so as to confirm their consistency.

METHODS AND RESULTS

The radial augmentation index, systolic pressure at the second peak of the radial pressure waveform (SBP2), and serum NT-proBNP levels were measured and analysed in a worksite cohort of 2000 middle-aged men in 2009 and in 2012. The subjects were divided into three groups by the HR (i.e. ≤69, 70-79, and ≥80 b.p.m.). While the serum NT-proBNP levels were similar among the three groups, the radial augmentation index increased (from 61 ± 12% to 72 ± 13%, P < 0.01 in 2009 and from 61 ± 13% to 73 ± 12%, P < 0.01 in 2012) and the SBP1-2 decreased (from 18 ± 7 to 13 ± 7 mmHg, P < 0.01 in 2009 and from 19 ± 7 to 13 ± 6 mmHg, P < 0.01 in 2012) significantly with decreasing HR. After the adjustment, the SBP2 showed a significant association with the serum NT-proBNP levels in the overall study population [non-standardized coefficient (B) = 0.005, standard error (SE) = 0.001, P < 0.01 in 2009 (n = 2257) and B = 0.004, SE = 0.001, P < 0.01 in 2012 (n = 1986)]. In subgroup analyses, the SBP2 showed a significant association with the serum NT-proBNP levels [B = 0.004, SE = 0.002, P = 0.02 in 2009 (n = 1291) and B = 0.005, SE = 0.001, P < 0.01 in 2012 (n = 1204)] only in the subject group with an HR of ≤69 b.p.m.

CONCLUSIONS

In middle-aged Japanese men, the relationship between the cSBP and the cardiac afterload appears to differ depending on the HR; the results of our analysis showed that the relationship between the cSBP and the cardiac overload may be more pronounced and strongly significant in patients with low HRs as compared with patients with high HRs.

Development of a Rapid Diagnostic Kit for Congestive Heart Failure Using Recombinant NT-proBNP Antigen

Background and Objectives: In patients with congestive heart failure, brain natriuretic peptide (BNP) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) are released due to excessive heart muscle expansion; they can be used for the early detection, progress monitoring, and treatment of congestive heart failure. Recently, considerable efforts have been made to develop an NT-proBNP-based biomarker for detecting heart failure. This study attempts to develop a rapid and accurate congestive heart failure diagnostic kit using NT-proBNP. Materials and Methods: A new gene based on NT-proBNP was selected, recombined, and expressed in Escherichia coli strains, and then monoclonal antibodies were produced using the hybridoma technique. Additionally, antigen-antibody reactivity was confirmed using indirect enzyme-linked immunosorbent assay (ELISA). Furthermore, the first pair and full-strip pair tests were conducted to select candidate clones; these were applied to a rapid diagnosis kit based on gold conjugates and compared with other currently available antigens. Results: NT-proBNP-based antigens with high specificity and monoclonal antibodies were produced, and the optimal antigen-antibody reactivity was confirmed using indirect ELISA. The first pair and full-strip pair tests were performed to select the optimal candidate clones, and a rapid diagnosis kit with excellent reactivity was developed by applying these to a rapid diagnosis kit based on gold conjugates. Conclusions: The development of this rapid diagnosis kit with excellent performance in congestive heart failure is expected to improve disease management by providing an early assessment of the risk of heart failure.

Prognostic Value of NT-proBNP After Ischemic Stroke: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUND

Many studies have evaluated the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) and its prognostic value in ischemic stroke. However, a widespread consensus has not been reached. Therefore, we completed a meta-analysis to evaluate the prognostic significance of NT-proBNP for mortality and functional outcome in patients with ischemic stroke.

METHODS

We performed a systematic search and review using the PubMed and EMBASE databases to identify literature that reported a correlation between NT-proBNP and mortality and functional outcome in ischemic stroke patients.

RESULTS

Eleven studies inclusive of 10,498 patients met the inclusion criteria. Elevated plasma NT-proBNP levels were associated with increased risk of mortality in ischemic stroke patients (all-cause mortality: odds ratio [OR] = 2.43, 95% confidence interval [CI] 1.62-3.64, P < .001, I²=74.3%; cardiovascular mortality: OR = 2.01, 95% CI 1.55-2.61, P < .001, I² = 42.6%). In addition, unfavorable functional outcomes were observed in patients with higher levels of NT-proBNP (OR = 1.68, 95% CI 1.13-2.50, P = .01, I² = 90.8%) after ischemic stroke.

CONCLUSIONS

This meta-analysis demonstrates that NT-proBNP could be a predictor of mortality and functional outcome in ischemic stroke patients.

Association of cardiac magnetic resonance-detected myocardial abnormalities with disease characteristics and brain natriuretic peptide levels in systemic sclerosis without cardiac symptoms

AIM

This study aimed to evaluate the association between myocardial abnormalities and left ventricular (LV) geometry as assessed using cardiac magnetic resonance imaging (CMRI) in systemic sclerosis (SSc) patients without cardiac symptoms.

METHODS

SSc patients without cardiac symptoms or cardiovascular risk factors underwent contrast CMRI. CMRI were assessed for structural and functional LV parameters and myocardial fibrosis based on myocardial late gadolinium enhancement (LGE). The correlation between brain natriuretic peptide (BNP) levels and LGE status was evaluated.

RESULTS

Among 49 patients, 27 (55%) showed LGE positivity. The most common identified LGE pattern was a linear pattern. LGE was not consistent with coronary artery distribution. There was no difference in ejection fraction between those with and without LGE. LV morphological changes were observed in 29% of SSc patients. An abnormal LV structure was detected in 44% and 14% of patients in the LGE+ and LGE- groups, respectively. The BNP levels were higher by 57% in the LGE+ group than in the LGE-group. Receiver operating characteristic analysis showed that BNP levels reliably detected myocardial abnormalities (area under the curve, 0.72; 95% confidence interval 0.58-0.88).

CONCLUSIONS

Myocardial abnormalities were common in SSc patients without cardiac symptoms. We suggest that LV morphological changes may have resulted from myocardial abnormalities. BNP may be useful as a screening tool for the detection of myocardial abnormalities in SSc patients.

Inverse relationship of bone mineral density and serum level of N-terminal pro-B-type natriuretic peptide in peritoneal dialysis patients

OBJECTIVE

Chronic kidney disease is associated with decreased bone mineral density (BMD). In this study, the relationship between BMD and the fasting serum concentration of N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) was evaluated in peritoneal dialysis (PD) patients.

MATERIAL AND METHODS

Fasting blood samples were obtained from 52 PD patients. BMD was measured by dual energy X-ray absorptiometry of the lumbar vertebrae (L2-L4). The serum NT-pro-BNP level was measured by an electrochemiluminescence immunoassay.

RESULTS

Ten patients (19.2%) had osteoporosis, 23 patients (44.2%) had osteopenia, and 19 patients had normal BMD. Increased serum NT-pro-BNP (p < 0.001), advanced age (p = 0.012), decreased body mass index (p = 0.006), body height (p = 0.018), and body weight (p = 0.004) were associated with lower lumbar T-scores, but sex, menopausal status, PD modality, diabetes mellitus, and hypertension were not. Multivariate forward stepwise linear regression analysis with adjustment for age, body height, body weight, body mass index, and log-NT-pro-BNP indicated that a high serum level of log-NT-pro-BNP (R2 change = 0.346; p < 0.001) and low body weight (R2 change = 0.208; p < 0.001) were significantly and independently associated with poor lumbar BMD.

CONCLUSION

A high serum level of NT-pro-BNP and low body weight were associated with poor BMD in PD patients.

Diagnostic and prognostic utilities of multimarkers approach using procalcitonin, B-type natriuretic peptide, and neutrophil gelatinase-associated lipocalin in critically ill patients with suspected sepsis

Background

We investigated the diagnostic and prognostic utilities of procalcitonin (PCT), B-type natriuretic peptide (BNP), and neutrophil gelatinase-associated lipocalin (NGAL) in critically ill patients with suspected sepsis, for whom sepsis was diagnosed clinically or based on PCT concentrations.

Methods

PCT, BNP, and NGAL concentrations were measured in 340 patients and were followed up in 109 patients. All studied biomarkers were analyzed according to the diagnosis, severity, and clinical outcomes of sepsis.

Results

Clinical sepsis and PCT-based sepsis showed poor agreement (kappa = 0.2475). BNP and NGAL showed significant differences between the two groups of PCT-based sepsis (P = 0.0001 and P < 0.0001), although there was no difference between the two groups of clinical sepsis. BNP and NGAL were significantly different according to the PCT staging and sepsis-related organ failure assessment subscores (P < 0.0001, all). BNP and PCT concentrations were significantly higher in the non-survivors than in the survivors (P = 0.0002) and showed an equal ability to predict in-hospital mortality (P = 0.0001). In the survivors, the follow-up NGAL and PCT concentrations were significantly lower than the initial values (148.7 ng/mL vs. 214.5 ng/mL, P < 0.0001; 0.61 ng/mL vs. 5.56 ng/mL, P = 0.0012).

Conclusions

PCT-based sepsis diagnosis seems to be more reliable and discriminating than clinical sepsis diagnosis. Multimarker approach using PCT, BNP, and NGAL would be useful for the diagnosis, staging, and prognosis prediction in the critically ill patients with suspected sepsis.

Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications--a systemic review and meta-analysis

BACKGROUND

We aimed to undertake a systematic review and meta-analysis of studies addressing perioperative natriuretic peptide (NP) levels to predict postoperative major adverse cardiac events (MACE) after major surgery.

METHODS

We searched MEDLINE and Embase with no language restrictions up to May 2013. The end points were major cardiac complications. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models.

RESULTS

Of the 662 retrieved articles, 24 studies satisfied the predefined eligibility criteria, including 5438 patients along with 712 (13.1%) events. After major surgery, the diagnostic odds ratio (DOR) of NP in predicting postoperative MACE was 14.3 (95% confidence interval [CI], 9.87-20.7) for overall population, 13.9 (8.43-22.8) for patients undergoing cardiac surgery, and 15.0 (8.84-25.5) for patients undergoing noncardiac surgery. The pooled sensitivity was 0.84 (95% CI, 0.79-0.88) and specificity was 0.76 (95% CI, 0.71-0.81). Postoperative measurement (DOR, 18.9; 7.68-46.3) was associated with higher predictive value than preoperative measurement (DOR, 13.6; 7.68-46.3). Results were similar for a subgroup with the composite outcome including mortality (DOR, 16.4; 10.6-25.5). B-type natriuretic peptide was associated with higher predictive accuracy (area under the summary receiver operating characteristic, 0.84; 0.81-0.87) than N-terminal pro-b-type natriuretic peptide (area under the summary receiver operating characteristic, 0.90; 0.87-0.92).

CONCLUSIONS

The existing literature suggests that perioperative NP testing have reasonable accuracy and can be useful in perioperative risk stratification. Natriuretic peptide testing has high rule-out value and low rule-in value for predicting postoperative MACE. Medical decisions should be made in the context of these characteristics.

Clinical Significance of B-type Natriuretic Peptide in Heart Failure

Biochemical tests to detect B-type natriuretic peptide (BNP) or N-terminal pro-brain BNP (NT-proBNP) are useful diagnostic methods for patients with possible HF. These tests are valuable prognostic predictors for the entire spectrum of HF disease severity. Therefore, the measurements of BNP or NT-proBNP taken along with conventional clinical assessments may assist clinicians in deciding treatment. The following review briefly summarizes the available information regarding the clinical significance of BNP and NT-proBNP.

N-terminal pro-B-type natriuretic peptide level inversely associates with metabolic syndrome in elderly persons

AIMS

Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) was lower in the general population with metabolic syndrome (MetS). The aim of this study was to evaluate the relationship between MetS and fasting serum NT-proBNP concentration in elderly persons.

METHODS

Fasting blood samples were obtained from 84 elderly volunteers aged 65 years or older. MetS and its components were defined using diagnostic criteria from the International Diabetes Federation.

RESULTS

Thirty-eight elderly persons (45.2%) had MetS. Fasting NT-proBNP level was negatively correlated with MetS among elderly patients (p = 0.001). Univariate linear regression analysis showed that age (r = 0.338; p = 0.002) was positively correlated with fasting serum log-NT-proBNP levels, while height (r = -0.253; p = 0.020), body weight (r = -0.238; p = 0.029), waist circumference (r = -0.270; p = 0.013), body fat mass (r = -0.356; p = 0.002) and triglyceride (r = -0.291; p = 0.007) were negatively correlated with fasting serum log-NT-proBNP levels among the elderly persons. Multivariate forward stepwise linear regression analysis of the significant variables showed that age (R2 change = 0.114, p = 0.011), triglyceride (R2 change = 0.118, p < 0.001), body fat mass (R2 change = 0.084, p < 0.001), and height (R2 change = 0.101, p < 0.001) were the independent predictor of fasting serum log-NT-proBNP levels in elderly persons.

CONCLUSIONS

NT-proBNP level is significantly reduced in elderly persons affected by MetS, and is significantly positively related to age, while negatively related to triglyceride, body fat mass, height in these subjects.

Value of plasma brain natriuretic peptide levels for predicting postoperative atrial fibrillation: a systemic review and meta-analysis

BACKGROUND

Blood natriuretic peptide (NP) levels have been reported to be useful for predicting postoperative atrial fibrillation (AF). We aimed to quantitatively synthesize the current evidence of the accuracy of using NP levels in predicting postoperative AF.

METHODS AND RESULTS

Medline, Embase, and reference lists were searched. Studies were included if either brain natriuretic peptide (BNP) or N-terminal pro-b type natriuretic peptide (NT-proBNP) had been evaluated perioperatively to predict postoperative AF. Data were analyzed to obtain summary accuracy estimates. Data from 1,844 patients in 10 studies were analyzed. Summary estimates for the sensitivity and specificity of using NP levels for predicting postoperative AF were 75 % [95 % confidence interval (CI) 67-79 %] and 80 % (95 % CI 62-91 %), respectively. The overall diagnostic odds ratio was 3.28 (95 % CI 2.23-4.84). Subgroup analysis showed that elevated NP levels in the perioperative period were a strong independent predictor of postoperative AF. NT-proBNP appeared to have better predictive value than BNP, as did postoperative assessment over preoperative assessment. BNP had a better correlation with postoperative AF in patients undergoing thoracic surgery than in patients undergoing cardiac surgery.

CONCLUSIONS

Perioperative assessment of the natriuretic peptide level in patients undergoing major cardiothoracic surgery could be a valuable diagnostic aid for identifying patients at high risk of developing postoperative AF, and for providing critical clinical information to guide prophylactic antiarrhythmic therapy in the perioperative period.

Emerging role of echocardiographic strain/strain rate imaging and twist in systolic function evaluation and operative procedure in patients with aortic stenosis

Systolic function of the left ventricle is vital for patients with aortic stenosis. Unfortunately, the most widely used clinical parameter, the left ventricular ejection fraction, is not sensitive enough, especially for patients with left ventricular hypertrophy. Echocardiographic strain/strain rate and twist are emerging parameters for left ventricular systolic and diastolic function evaluation. Aortic stenosis could reduce strain/strain rate while magnifying twist. Furthermore, strain/strain rate correlates well with the prognosis of patients with aortic stenosis. Most importantly the circumferential strain, strain rate and twist also play a role in differentiating cardiac compensation or decompensation. In any case, these parameters could normalize after successful surgical aortic valve replacement or transcatheter aortic valve replacement. Regardless of these advantages, clinical evidence is needed to ensure their usefulness.

Early emergency management of acute decompensated heart failure

PURPOSE OF REVIEW

Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation.

RECENT FINDINGS

Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted.

SUMMARY

ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.

Brain natriuretic peptide-guided therapy in the inpatient management of decompensated heart failure

Heart failure is extremely prevalent and is associated with significant mortality, morbidity and cost. Studies have already established mortality benefit with the use of neurohormonal blockade therapy in systolic failure. Unfortunately, physical signs and symptoms of heart failure lack diagnostic sensitivity and specificity, and medication doses proven to improve mortality in clinical trials are often not achieved. Brain natriuretic peptide (BNP) has proven to be of clinical use in the diagnosis and prognosis of heart failure, and recent efforts have been taken to further elucidate its role in guiding heart failure management. Multiple studies have been conducted on outpatient guided management, and although still controversial, there is a trend towards improved outcomes. Inpatient studies are lacking, but preliminary data suggest various BNP cut-off values, as well as percentage changes in BNP, that could be useful in predicting outcomes and improving mortality. In the future, heart failure management will probably involve an algorithm using clinical assessment and a multibiomarker-guided approach.