The Challenges of NT-proBNP Testing in HFpEF

Shooting Arrows in the Wind

James L. Januzzi, JR, MD; Peder L. Myhre, MD, PHD


JACC Heart Fail. 2020;8(5):382-385. 

In This Article

Abstract and Introduction


The diagnosis of heart failure (HF) and preserved left ventricular ejection fraction (LVEF) (HFpEF) represents a major challenge for clinicians and clinical trialists alike. In contrast to HF with reduced LVEF (HFrEF), there are no definite echocardiographic parameters for HFpEF, and a gold standard clinical definition for the syndrome is debated. With the introduction of testing for B-type natriuretic peptide (BNP) and its N-terminal equivalent (NT-proBNP) came the hope that a circulating biomarker might assist in the evaluation and management of HFpEF. Indeed, these markers play an important role every day in clinical evaluation of patients for their diagnostic and prognostic importance, and natriuretic peptides (NPs) are now widely used in trials of the diagnosis: following the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial) experiences, it was realized that significant differences in baseline risk may occur when allowing optional enrollment through either NP testing or HF hospitalization.[1] Thus, recent randomized controlled trials in HFpEF now require elevation of NPs to be enrolled. There are indubitable advantages to this approach, both for improving the diagnostic specificity and to enrich risk. However, there are a several caveats that must be discussed.