deciphering diagnostics
Deciphering BNP
By Kim McCarron, RN, CRNP, MS
Clinical Associate Professor • Towson University • Towson, Md.
Benjamin Labovitz
Senior Nursing Student • Towson University • Towson, Md.
Mary Hartley, 82, comes to your ED with
BNP is a noticeable fatigue and breathlessness. She
protein first has 3+ pretibial edema and an oxygen satu-
discovered ration value of 86% on room air. Her initial
in the brains brain natriuretic peptide (BNP) level, which
is drawn within 30 minutes of admission, is
3,266 pg/mL. Eighteen hours later after
of pigs.
furosemide, a beta-blocker, and an an-
giotensin-converting enzyme (ACE) in-
hibitor are prescribed and oxygen is ad-
ministered, her BNP level continues to
rise at 3,405 pg/mL. One day later,
with continued therapy, her BNP level
drops to 2,462 pg/mL and 2 days later,
it has dropped to 1,050 pg/mL and her
symptoms have markedly improved.
Mrs. Hartley’s heart failure is classi-
fied as New York Heart Association
(NYHA) Class IV and biventricu-
lar pacing is prescribed to assist
her failing myocardial pump.
If you practice in an ED or car-
diac area, many of your patients
will have BNP values drawn. I’ll
help you understand what this diagnostic
test reveals about your patient’s condition.
Nature’s diuretic
In practical terms, natriuresis is the elimi-
nation of sodium and water from the re-
nal tubules, and for this reason BNP can
be considered nature’s diuretic. Natriure-
sis also causes arteriolar and venous va-
sodilation, with the effect of lowering BP.
BNP reduces output from the sympathetic
nervous system and the renin-angioten-
sion-aldosterone system, moderating heart
rate and cardiac afterload. It has a bonus
effect of endothelial protection and in-
hibits ventricular remodeling, lessening
the harmful structural changes that result
in hypertrophy of cardiac muscle.
10 Nursing made Incredibly Easy! May/June 2009
BNP is present in minute quantities in a
healthy person, but levels rise significantly
in response to cardiac chamber stretch.
When the ventricles become distended due
to volume overload, BNP production is
stimulated. Type A receptors, present in
large blood vessels and kidney and adrenal
tissue, respond to rising levels of BNP and
through assorted mechanisms work to pro-
mote homeostasis. It’s important to note
that age and gender are influencing factors.
BNP levels increase in both genders as a
person ages, and women secrete higher
plasma levels of BNP. BNP levels are lower
in obese individuals and among patients
who are prescribed diuretics, ACE inhib-
itors, digoxin, or vasodilators.
Determining heart failure
Current heart failure practice guidelines
support drawing BNP levels for patients
who arrive at the urgent care setting and
for whom the clinical diagnosis of heart
failure is uncertain. Heart failure patients
typically present with fatigue, dyspnea, de-
creased oxygen saturation, and weight
gain as fluid is retained in body tissues.
This constellation of symptoms may indi-
cate left ventricular systolic or diastolic
dysfunction or right ventricular pressure
overload states such as pulmonary em-
bolism, cor pulmonale, or primary pul-
monary hypertension. Also, conditions that
cause extracellular fluid volume expansion,
such as renal failure and liver cirrhosis,
will result in elevated levels of natriuretic
hormones.
In addition to differentiating heart failure
from other disorders, BNP assessment is
used as a prognostic marker in cardiac
patients. After a patient is diagnosed with
heart failure, it’s staged functionally accord-
ing to the NYHA Heart Failure Classification.
BNP levels correlate with NYHA Classes I to Relationship of BNP to heart failure
IV, increasing as the level of heart function
declines (see Relationship of BNP to heart
failure). Researchers are monitoring levels
1500

and collecting data on hospitalization rates,

length of stay, and mortality. A systematic
review of studies reveals that the relative risk
of death increases by 35% for every 100
pg/mL increase in BNP concentration.
1000

Optimal measurement of BNP is within 2

to 4 hours after the onset of acute symptoms;

BNP (pg/mL)
BNP is detectable from 5 to 5,000 pg/mL. If
the patient’s serum level is less than 100
pg/mL, conditions other than heart failure
are explored as the cause of dyspnea. A value
500

that exceeds 100 pg/mL is suggestive of

heart failure. Rapid assessment is crucial to
guiding therapy. An assay may be drawn for
the active hormone, BNP, or the lab may
measure the inactive peptide, NT-proBNP.
0

Be aware that there are subtle differences

Normal Class I Class II Class III Class IV

between the two, but clinically both provide

NYHA Classification

important information about the condition of

the heart. After heart failure treatment is initi-
ated, cyclical BNP levels may demonstrate combined they provide crucial information
the effectiveness of therapy. about heart function.

What you need to do A tool in the arsenal

If your patient is scheduled to have her
BNP levels drawn, explain the purpose of
the test. Evaluate patient outcomes and
monitor appropriately for heart failure. Ex-
plain to your patient the need for possible
follow-up tests and medication therapy.
It’s important to stress that BNP as a diag-
nostic test compliments, but doesn’t substi-
tute for, careful physical assessment. Ob-
taining a complete history is crucial; howev-
er, in the acutely ill patient this may not be
feasible. Observing breathing patterns and
accessory muscle use, auscultating absent
breath sounds or adventitious sounds, mea-
suring jugular venous pressure, listening for
An increased BNP level signals cardiac
distress because it primes the system to
reduce volume overload. Measurement is
relatively easy and cost effective while
supplying the healthcare provider with in-
formation about the severity of a patient’s
heart failure. And the use of BNP in moni-
toring the effectiveness of treatment and
planning for discharge are tools that can
be utilized when formulating the care
plan. ■
Learn more about it
Agruss JC, Garrett K. New markers for CVD. Nurse Pract.
2005;30(11):26,29-31.

the third heart sound (S3), and assessing for
peripheral edema are all assessments that
should be performed for the patient experi-
encing symptoms of heart failure. In addi-
tion, the echocardiogram is regarded as the
gold standard for assessment of heart failure.
Echocardiography has a greater sensitivity
and specificity than BNP measurement and
Fischbach F. A Manual of Laboratory and Diagnostic Tests.
7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2004:362-364.
Ford CM, Pruitt R, Parker V, Reimels E. CHF: effects of
cardiac rehabilitation and brain natriuretic peptide. Nurse
Pract. 2004; 29(3):36-39.
Kinkade E, Frazier SK. BNP assays: predicting the future
of CHF patients. Nurse Pract. 2006;31(13):36-41.
Sikaris K. BNP—considering a heartfelt message. Heart
Lung Circ. 2004;13(suppl 3):S31-S37.

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