The ESC Textbook of Cardiovascular

Medicine (3 edn)
A. John Camm (ed.) et al.

https://doi.org/10.1093/med/9780198784
906.001.0001
Published: 2018 Online ISBN:
9780191827143 Print ISBN:
9780198784906

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

CHAPTER

37.9 Chronic heart failure diagnosis: biomarkers 

Christian Mueller

https://doi.org/10.1093/med/9780198784906.003.0409_update_002 Pages 1779–1781

Published: July 2018 This version: July 2020

Updated in this version:

Update:

This chapter has been updated to include links to enhanced, animated versions of figures
 Abstract
Natriuretic peptides including B-type natriuretic peptide (BNP), N-terminal (NT)-proBNP, and
midregional pro-atrial natriuretic peptide (MR-proANP) are the biomarkers of choice in the diagnosis
of heart failure. Assays measuring either BNP, NT-proBNP, or MR-proANP are widely available and
run on large analysers operating in the central laboratory or as point-of-care options. Natriuretic
peptides are considered quantitative markers of haemodynamic cardiac stress and therefore
quantitative markers of heart failure itself. The clinical introduction of natriuretic peptides constitutes

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

the most important advance in the diagnosis of heart failure in the last decade.

Keywords: dyspnoea, natriuretic peptides, accuracy, haemodynamic cardiac stress, BNP, heart failure,
obesity, renal failure, MR-proANP, NT-proBNP
Collection: Oxford Medicine Online

Update:

This chapter has been updated to include links to enhanced, animated versions of figures

Summary
Natriuretic peptides including B-type natriuretic peptide (BNP), N-terminal proBNP, and midregional pro-
atrial natriuretic peptide are the biomarkers of choice in the diagnosis of heart failure1. They are considered
quantitative markers of haemodynamic cardiac stress and therefore quantitative markers of heart failure
itself. The clinical introduction of natriuretic peptides constitutes the most important advance in the
diagnosis of heart failure in the last decade.

Natriuretic peptides

Natriuretic peptides including B-type natriuretic peptide (BNP), N-terminal (NT)-proBNP, and midregional
pro-atrial natriuretic peptide (MR-proANP) are the biomarkers of choice in the diagnosis of heart
1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20
failure. Assays measuring either BNP, NT-proBNP or MR-proANP are
widely available and run on large analysers operating in a central laboratory or as point-of-care options.
Natriuretic peptides are considered quantitative markers of haemodynamic cardiac stress and therefore
10
quantitative markers of heart failure itself. The clinical introduction of natriuretic peptides constitutes the
4,18
most important advance in the diagnosis of heart failure in the last decade.
Pathophysiology

Intracardiac volume and/or pressure overload trigger, as a counter-regulatory response, the release of ANP
1,2,3,4,5,6,7,8,9,10
and BNP from the heart—mainly the left and right cardiac ventricles—into the circulation.
Recent data suggest that left ventricular end-diastolic wall stress and wall sti ness may be the predominate
triggers of BNP and NT-proBNP synthesis and release. However, it is important to highlight that the
individual natriuretic peptide level re ects the combined haemodynamic consequences of systolic and
diastolic left ventricular dysfunction, as well as valvular dysfunction and right ventricular dysfunction

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

6
(Figure 37.9.1).

Figure 37.9.1

Natriuretic peptides are quantitative markers of heart failure summarizing the extent of le ventricular (LV) systolic and diastolic
dysfunction, valvular dysfunction, and right ventricular (RV) dysfunction. ANP, atrial natriuretic peptide; BNP, B-type natriuretic
peptide; CNP, C-type natriuretic peptide.
An enhanced, animated version of this figure is available from the ESC – view animated version

Clinical use

Natriuretic peptides are released into blood in relation to disease severity and correspond to the New York
Heart Association functional classi cation system. Accordingly, natriuretic peptides not only allow heart
failure to be diagnosed, they are also powerful tools to quantify the severity of heart failure. In patients with
chronic heart failure, there is a strong and near linear association between the natriuretic peptide plasma
concentrations and the risk of dying or being hospitalized for acute heart failure.

Two important principles underlie the clinical use of natriuretic peptides. First, a natriuretic peptide level is
not a stand-alone test. It is always of greatest value when it complements the physician’s clinical skills,
10,18
along with other available diagnostic tools. Second, natriuretic peptide concentrations should be
interpreted and used as continuous variables in order to make full use of the biological information provided
10
by the measurement. The higher the natriuretic peptide concentration, the higher the probability that
1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20
dyspnoea is caused by heart failure.

Natriuretic peptides have consistently been shown to have high accuracy in the diagnosis of heart failure.
Natriuretic peptides levels are very high in patients with heart failure, and in the normal range in patients
with healthy hearts and/or patients with other causes of dyspnoea.

The diagnostic utility of natriuretic peptides for heart failure has been clearly documented for the two
settings in which heart failure is usually diagnosed. First, patients with mild symptoms usually presenting
to primary care. Second, in patients presenting with acute dyspnoea to the emergency department. While
natriuretic peptides have very high diagnostic accuracy for heart failure in both settings with areas under
the receiver-operating characteristic curve exceeding 90%, the optimal cut-o levels to achieve a high
negative predictive for the rule-out of heart failure and high positive predictive value for the rule-in of
heart failure di er (Table 37.9.1). The clinical impact of using the diagnostic and prognostic information
provided by BNP or NT-proBNP levels was demonstrated also in several randomized controlled studies
documenting a reduction in the time to the appropriate diagnosis and treatment, and as a result a reduction
in the time to discharge (Figure 37.9.2). Accordingly, the use of natriuretic peptide levels is supported by a
1
strong and consistent class I recommendation in current guidelines.

Table 37.9.1 Decision limits for natriuretic peptides for the diagnosis of heart failure

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

No HF ʻGrey zoneʼ HF

Primary care (NYHA I–II)

BNP (pg/mL) 35 35–100 >100

NT-proBNP (pg/mL) 125 125–300 >300

Emergency department (NYHA III–IV)

BNP (pg/mL) <100 100–400 > 400

NT-proBNP (pg/mL):

Age <50 years <300 300–450 >450

Age 50–75 years <300 300–900 >900

Age >75 years <300 300–1800 >1800

MR-proANP (pmol/L) <120 120–300 >300

BNP, B-type natriuretic peptide; HF, heart failure; MR-proANP, midregional pro-atrial natriuretic peptide; NT-proBNP, N-terminal
B-type natriuretic peptide; NYHA, New York Heart Association.
Figure 37.9.2

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

The use of B-type natriuretic peptide (BNP) reduces the time to the initiation of adequate therapy among patients presenting
with acute dyspnoea to the emergency department.

Reproduced with permission from Christian Mueller, André Scholer, Kirsten Laule-Kilian, et al. Use of B-Type Natriuretic Peptide
in the Evaluation and Management of Acute Dyspnea. N Engl J Med 2004; 350:647–654. DOI: 10.1056/NEJMoa031681. Copyright
© 2004 Massachusetts Medical Society.

The vast majority of patients will present with either low or high natriuretic peptide lconcentrations. Rule-
out and/or rule-in of heart failure is straightforward in these patients. However, about 20% of patients will
present with natriuretic peptide concentrations in the grey zone. These patients often have mild and
sometimes preclinical heart failure.

Confounders

Two confounders should be considered when interpreting natriuretic peptide plasma concentrations, that
is, obesity and renal dysfunction:

◆ Obesity is associated with lower natriuretic peptide concentration. The predominate mechanisms are
incompletely understood, but may include the increased breakdown of natriuretic peptides via
natriuretic peptide type C receptors abundant on adipocytes.

◆ Renal dysfunction is associated with higher natriuretic peptide concentration, likely due, at least in
part, to impaired renal secretion and/or clearance.
When using NT-proBNP, the use of an age-adjusted upper cut-o level largely obviates the need for further
adjustments for renal function.

While the combination of clinical assessment of symptoms and signs and natriuretic peptides allows heart
failure to be reliably diagnosed, it is critical to stress that all patients diagnosed with heart failure require
echocardiography as an additional diagnostic procedure to delineate the structural and functional cardiac
abnormalities underlying heart failure. Using this approach substantially facilitates, for example, the
diagnosis of heart failure with preserved ejection fraction.

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

BNP or NT-proBNP or MR-proANP?

Overall, the three clinically available natriuretic peptides seem to o er comparable diagnostic
1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20
accuracy. Some direct comparisons have suggested that BNP may have
19,20
even higher diagnostic accuracy as compared to NT-proBNP and MR-proANP. This bene t seems
counterbalanced by the recent controversy regarding the increased clinical use of the angiotensin receptor–
®
neprilysin inhibitor sacubitril/valsartan (Entresto ) and its possible e ect on the clinical utility of BNP (and
24
possibly also MR-proANP) for the diagnosis of heart failure. This concern is based on data suggesting that,
the BNP plasma concentration in patients on sacubitril/valsartan no longer re ects exclusively the severity
of heart failure, but also reduced clearance of BNP (and ANP) due to the speci c e ect of sacubitril as a
24,25
neprilysin inhibitor. This e ect impairs the use of BNP for treatment monitoring. However, it is unlikely
that it would a ect to a relevant extent the diagnostic utility of BNP overall as patients on
sacubitril/valsartan will remain only a very small subset of all patients undergoing diagnostic testing for the
presence of heart failure.

In contrast, NT-proBNP is the preferred biomarker to monitor heart failure patients with reduced left
26
ventricular ejection fraction on sacubitril/valsartan.

Controversy

Do all conditions with elevated natriuretic peptide levels represent heart failure? This question mainly
relates to the uncertainty in the de nition of heart failure. From a pathophysiological perspective it would
seem appropriate to broaden the scope of the de nition of heart failure to conditions associated with
symptoms and elevated natriuretic peptides such as in the very elderly, or patients with tachyarrhythmias
21
irrespective of the presence of other criteria.

Outlook

Beyond the diagnosis of heart failure, biomarkers provide important additional information regarding the
trigger of the heart failure episode: for example, in ammatory biomarkers such as C-reactive protein and
procalcitonin for the presence of systemic infection, cardiac troponin for acute myocardial infarction,
thyroid function test for hypo- and hyperthyroidism, haemoglobin for anaemia, D-dimers for pulmonary
embolism. Some biomarkers even contribute to the characterization of the underlying cardiac disease: for
example, ferritin for haemochromatosis, thiamine for vitamin B de ciency, thyroid function tests for hypo-
and hyperthyroidism, and cardiac troponin for myocarditis.
References
1. Davis M, Espiner E, Richards G, Billings J, Town I, Neill A, Drennan C, Richards M, Turner J, Yandle T. Plasma brain natriuretic
peptide in assessment of acute dyspnea. Lancet 1994;343:440–4.
Google Scholar WorldCat PubMed

2. Wright SP, Doughty RN, Pearl A, Gamble GD, Whalley GA, Walsh HJ, Gordon G, Bagg W, Oxenham H, Yandle T, Richards M,
Sharpe N. Plasma amino-terminal pro-brain natriuretic peptide and accuracy of heart-failure diagnosis in primary care: a
randomized, controlled trial. J Am Coll Cardiol 2003;42:1793–800.

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

Google Scholar WorldCat PubMed

3. Cowie MR, Struthers AD, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Sutton GC. Value of natriuretic peptides in
assessment of patients with possible new heart failure in primary care. Lancet 1997;350:1349–53.
Google Scholar WorldCat PubMed

4. Mueller C, Christ M, Cowie M, Cullen L, Maisel AS, Masip J, Miro O, McMurray J, Peacock FW, Price S, DiSomma S, Bueno H,
ZeymerU, Mebazaa A; Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association. European Society of
Cardiology-Acute Cardiovascular Care Association Position paper on acute heart failure: a call for interdisciplinary care. Eur
Heart J Acute Cardiovasc Care 2017;6:81–6.
Google Scholar WorldCat

5. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH,
Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA; Breathing Not Properly
Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure.
N Engl J Med 2002;347:161–7.
Google Scholar WorldCat PubMed

6. Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, Pfisterer M, Perruchoud AP. Use of B-type natriuretic
peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647–54.
Google Scholar WorldCat PubMed

7. McCullough PA, Nowak RM, McCord J, Hollander JE, Herrmann HC, Steg PG, Duc P, Westheim A, Omland T, Knudsen CW,
Storrow AB, Abraham WT, Lamba S, Wu AH, Perez A, Clopton P, Krishnaswamy P, Kazanegra R, Maisel AS. B-type natriuretic
peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational
Study. Circulation 2002;106:416–22.
Google Scholar WorldCat PubMed

8. Zaphiriou A, Robb S, Murray-Thomas T, Mendez G, Fox K, McDonagh T, Hardman SM, Dargie HJ, Cowie MR. The diagnostic
accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK
natriuretic peptide study. Eur J Heart Fail 2005;7:537–41.
Google Scholar WorldCat PubMed

9. Mogelvang R, Goetze JP, Schnohr P, Lange P, Sogaard P, Rehfeld JF, Jensen JS. Discriminating between cardiac and
pulmonary dysfunction in the general population with dyspnea by plasma pro-B-type natriuretic peptide. J Am Coll Cardiol
2007;50:1694–701.
Google Scholar WorldCat PubMed

10. Maisel A, Mueller C, Adams K, Jr, Anker SD, Aspromonte N, Cleland JG, Cohen-Solal A, Dahlstrom U, DeMaria A,
Di Somma S, Filippatos GS, Fonarow GC, Jourdain P, Komajda M, Liu PP, McDonagh T, McDonald K, Mebazaa A, Nieminen MS,
Peacock WF, Tubaro M, Valle R, Vanderhyden M, Yancy CW, Zannad F, Braunwald E. State of the art: using natriuretic peptide
levels in clinical practice. Eur J Heart Fail 2008;10:824–39.
Google Scholar WorldCat PubMed

11. Potocki M, Breidthardt T, Reichlin T, Hartwiger S, Morgenthaler NG, Bergmann A, Noveanu M, Freidank H, Taegtmeyer AB,
Wetzel K, Boldanova T, Stelzig C, Bingisser R, Christ M, Mueller C. Comparison of midregional pro-atrial natriuretic peptide with
N-terminal pro-B-type natriuretic peptide in the diagnosis of heart failure. J Intern Med 2010;267:119–29.
Google Scholar WorldCat PubMed

12. Rutten JH, Steyerberg EW, Boomsma F, van Saase JL, Deckers JW, Hoogsteden HC, Lindemans J, van den Meiracker AH.
N-terminal pro-brain natriuretic peptide testing in the emergency department: beneficial e ects on hospitalization, costs, and
outcome. Am Heart J 2008;156:71–7.
Google Scholar WorldCat PubMed

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

13. Januzzi JL, van Kimmenade R, Lainchbury J, Bayes-Genis A, Ordonez-Llanos J, Santalo-Bel M, Pinto YM, Richards M. NT-
proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of
1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006;27:330–7.
Google Scholar WorldCat PubMed

14. Mueller C, Frana B, Rodriguez D, Laule-Kilian K, Perruchoud AP. Emergency diagnosis of congestive heart failure: impact of
signs and symptoms. Can J Cardiol 2005;21:921–4.
Google Scholar WorldCat PubMed

15. Mueller C, Laule-Kilian K, Schindler C, Klima T, Frana B, Rodriguez D, Scholer A, Christ M, Perruchoud AP. Cost-
e ectiveness of B-type natriuretic peptide testing in patients with acute dyspnea. Arch Intern Med 2006;166:1081–7.
Google Scholar WorldCat PubMed

16. Breidthardt T, Laule K, Strohmeyer AH, Schindler C, Meier S, Fischer M, Scholer A, Noveanu M, Christ M, Perruchoud AP,
Mueller C. Medical and economic long-term e ects of B-type natriuretic peptide testing in patients with acute dyspnea. Clin
Chem 2007;53:1415–22.
Google Scholar WorldCat PubMed

17. Moe GW, Howlett J, Januzzi JL, Zowall H. N-terminal pro-B-type natriuretic peptide testing improves the management of
patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF
study. Circulation 2007;115:3103–10.
Google Scholar WorldCat PubMed

18. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA
, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH,
van der Meer P; Authors/Task Force Members. 2016 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;37:2129–200.
Google Scholar WorldCat

19. Maisel A, Mueller C, Nowak R, Peacock WF, Landsberg JW, Ponikowski P, eMockel M, Hogan C, Wu AH, Richards M,
Clopton P, Filippatos GS, Di Somma S, Anand I, Ng L, Daniels LB, Neath SX, Christenson R, Potocki M, McCord J, Terracciano G,
Kremastinos D, Hartmann O, von Haehling S, Bergmann A, Morgenthaler NG, Anker SD. Mid-region pro-hormone markers for
diagnosis and prognosis in acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial. J Am Coll Cardiol
2010;55:2062–76.
Google Scholar WorldCat PubMed

20. Seronde MF, Gayat E, Logeart D, Lassus J, Laribi S, Boukef R, Sibellas F, Launay JM, Manivet P, Sadoune M, Nouira S,
Solal AC, Mebazaa A; Great network. Comparison of the diagnostic and prognostic values of B-type and atrial-type natriuretic
peptides in acute heart failure. Int J Cardiol 2013;168:3404–11.
Google Scholar WorldCat

21. Mueller C, McDonald K, de Boer RA, Maisel A, Cleland JGF, Kozhuharov N, Coats AJS, Metra M, Mebazaa A, Ruschitzka F,
Lainscak M, Filippatos G, Seferovic PM, Meijers WC, Bayes-Genis A, Mueller T, Richards M, Januzzi JL Jr; Heart Failure Association
of the European Society of Cardiology. Heart Failure Association of the European Society of Cardiology practical guidance on the
use of natriuretic peptide concentrations. Eur J Heart Fail 2019;21:715–31.
Google Scholar WorldCat

22. Januzzi JL Jr, Chen-Tournoux AA, Christenson RH, Doros G, Hollander JE, Levy PD, Nagurney JT, Nowak RM, Pang PS,
Patel D, Peacock WF, Rivers EJ, Walters EL, Gaggin HK; ICON-RELOADED Investigators. N-Terminal Pro-B-Type Natriuretic Peptide
in the Emergency Department: The ICON-RELOADED Study. J Am Coll Cardiol 2018;71:1191–200.
Google Scholar WorldCat

23. Kozhuharov N, Sabti Z, Wussler D, Nowak A, Badertscher P, Twerenbold R, Wildi K, Stallone F, Vogt F, Hilti J, Puelacher C,
du Fay de Lavallaz J, Shrestha S, Flores D, Nestelberger T, Koechlin L, Boeddinghaus J, Zimmermann T, Walter J, Schumacher C,

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

Rentsch K, von Eckardstein A, Keller DI, Goudev A, Pfister O, Breidthardt T, Mueller C; BASEL V Investigators. Prospective
validation of N-terminal pro B-type natriuretic peptide cut-o concentrations for the diagnosis of acute heart failure. Eur J Heart
Fail 2019;21:813–5.
Google Scholar WorldCat

24. Packer M, McMurray JJ, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile M,
Andersen K, Arango JL, Arnold JM, Bělohlávek J, Böhm M, Boytsov S, Burgess LJ, Cabrera W, Calvo C, Chen CH, Dukat A,
Duarte YC, Erglis A, Fu M, Gomez E, Gonzàlez-Medina A, Hagège AA, Huang J, Katova T, Kiatchoosakun S, Kim KS, Kozan Ö,
Llamas EB, Martinez F, Merkely B, Mendoza I, Mosterd A, Negrusz-Kawecka M, Peuhkurinen K, Ramires FJ, Refsgaard J,
Rosenthal A, Senni M, Sibulo AS Jr, Silva-Cardoso J, Squire IB, Starling RC, Teerlink JR, Vanhaecke J, Vinereanu D, Wong RC;
PARADIGM-HF Investigators and Coordinators. Angiotensin receptor neprilysin inhibition compared with enalapril on the risk of
clinical progression in surviving patients with heart failure. Circulation 2015;131:54–61.
Google Scholar WorldCat

25. Ibrahim NE, McCarthy CP, Shrestha S, Gaggin HK, Mukai R, Szymonifka J, Apple FS, Burnett JC Jr, Iyer S, Januzzi JL Jr.
E ect of neprilysin inhibition on various natriuretic peptide assays. J Am Coll Cardiol 2019;73:1273–84.
Google Scholar WorldCat

26. Januzzi JL Jr, Prescott MF, Butler J, Felker GM, Maisel AS, McCague K, Camacho A, Piña IL, Rocha RA, Shah AM,
Williamson KM, Solomon SD; PROVE-HF Investigators. Association of change in N-terminal pro-B-type natriuretic peptide
following initiation of sacubitril-valsartan treatment with cardiac structure and function in patients with heart failure with
reduced ejection fraction. JAMA 2019;19:1085–95.
Google Scholar WorldCat
Further reading
Januzzi JL, van Kimmenade R, Lainchbury J, Bayes-Genis A, Ordonez-Llanos J, Santalo-Bel M, Pinto YM, Richards M. NT-proBNP
testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256
patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006;27:330–7.
Google Scholar WorldCat PubMed

Maisel A, Mueller C, Adams K, Jr, Anker SD, Aspromonte N, Cleland JG, Cohen-Solal A, Dahlstrom U, DeMaria A, Di Somma S,
Filippatos GS, Fonarow GC, Jourdain P, Komajda M, Liu PP, McDonagh T, McDonald K, Mebazaa A, Nieminen MS, Peacock WF,

Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023

Tubaro M, Valle R, Vanderhyden M, Yancy CW, Zannad F, Braunwald E. State of the art: using natriuretic peptide levels in clinical
practice. Eur J Heart Fail 2008;10:824–39.
Google Scholar WorldCat PubMed

Maisel A, Mueller C, Nowak R, Peacock WF, Landsberg JW, Ponikowski P, eMockel M, Hogan C, Wu AH, Richards M, Clopton P,
Filippatos GS, Di Somma S, Anand I, Ng L, Daniels LB, Neath SX, Christenson R, Potocki M, McCord J, Terracciano G,
Kremastinos D, Hartmann O, von Haehling S, Bergmann A, Morgenthaler NG, Anker SD. Mid-region pro-hormone markers for
diagnosis and prognosis in acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial. J Am Coll Cardiol
2010;55:2062–76.
Google Scholar WorldCat PubMed

Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P,
Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA; Breathing Not Properly Multinational
Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med
2002;347:161–7.
Google Scholar WorldCat PubMed

McCullough PA, Nowak RM, McCord J, Hollander JE, Herrmann HC, Steg PG, Duc P, Westheim A, Omland T, Knudsen CW,
Storrow AB, Abraham WT, Lamba S, Wu AH, Perez A, Clopton P, Krishnaswamy P, Kazanegra R, Maisel AS. B-type natriuretic
peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational
Study. Circulation 2002;106:416–22.
Google Scholar WorldCat PubMed

Moe GW, Howlett J, Januzzi JL, Zowall H. N-terminal pro-B-type natriuretic peptide testing improves the management of
patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF
study. Circulation 2007;115:3103–10.
Google Scholar WorldCat PubMed

Mogelvang R, Goetze JP, Schnohr P, Lange P, Sogaard P, Rehfeld JF, Jensen JS. Discriminating between cardiac and pulmonary
dysfunction in the general population with dyspnea by plasma pro-B-type natriuretic peptide. J Am Coll Cardiol 2007;50:1694–
701.
Google Scholar WorldCat PubMed

Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, Pfisterer M, Perruchoud AP. Use of B-type natriuretic peptide
in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647–54.
PubMed

Rutten JH, Steyerberg EW, Boomsma F, van Saase JL, Deckers JW, Hoogsteden HC, Lindemans J, van den Meiracker AH. N-
terminal pro-brain natriuretic peptide testing in the emergency department: beneficial e ects on hospitalization, costs, and
outcome. Am Heart J 2008;156:71–7.
Google Scholar WorldCat PubMed

Zaphiriou A, Robb S, Murray-Thomas T, Mendez G, Fox K, McDonagh T, Hardman SM, Dargie HJ, Cowie MR. The diagnostic
accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK
natriuretic peptide study. Eur J Heart Fail 2005;7:537–41.
 Downloaded from https://academic.oup.com/esc/book/35489/chapter/312422147 by European Society of Cardiology user on 12 June 2023
© European Society of Cardiology
PubMed
WorldCat
Google Scholar