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Heart Failure Markers: BNP, NT-proBNP & More

Heart failure markers are blood-based laboratory values that are elevated when the heart is under stress. They help doctors diagnose heart failure and monitor disease progression.

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Things worth knowing about "Heart failure markers"

Heart failure markers are blood-based laboratory values that are elevated when the heart is under stress. They help doctors diagnose heart failure and monitor disease progression.

What are heart failure markers?

Heart failure markers are biological measurements – usually proteins found in the blood – that indicate stress or damage to the heart muscle. They are released when the heart is subjected to increased pressure or mechanical strain, as occurs in heart failure (cardiac insufficiency). Measuring these markers in the blood is a key component of cardiac diagnosis.

The most important heart failure markers

BNP (B-type natriuretic peptide)

BNP (B-type natriuretic peptide) is produced primarily in the ventricular muscle cells of the heart and released into the bloodstream when the heart wall is stretched due to pressure overload. Elevated BNP levels are a strong indicator of existing heart failure. Normal values are generally below 100 pg/ml; values above 400 pg/ml are strongly suggestive of heart failure.

NT-proBNP (N-terminal pro-BNP)

NT-proBNP is an inactive cleavage product generated when BNP is released. It has a longer half-life in the blood and is therefore easier to measure reliably. NT-proBNP is now considered one of the most sensitive and reliable markers for heart failure. Reference ranges vary by age: values above 125 pg/ml are considered abnormal in patients under 75 years of age, while values above 450 pg/ml are significant in older patients.

MR-proANP

MR-proANP (mid-regional pro-atrial natriuretic peptide) is another natriuretic peptide marker released when the atria of the heart are stretched. It is used as an alternative to BNP and NT-proBNP and demonstrates comparable diagnostic value.

Troponin

Although troponin (troponin T and troponin I) is classically known as a marker for heart attacks, it can also be elevated in chronic heart failure. Elevated troponin in heart failure indicates ongoing damage to the heart muscle cells and is associated with a poorer prognosis.

Galectin-3 and ST2

Galectin-3 and soluble ST2 protein (sST2) are newer biomarkers that reflect fibrosis (scarring) processes within the heart muscle. They provide additional prognostic information and can help estimate the risk of hospitalization and mortality in patients with heart failure.

When are heart failure markers measured?

Heart failure markers are used in the following clinical situations:

When new-onset heart failure is suspected (e.g., in cases of breathlessness or fluid retention)
To differentiate cardiac from non-cardiac causes of shortness of breath
For ongoing monitoring in patients with known heart failure
To evaluate treatment response after initiating therapy
For risk stratification and prognosis assessment

Factors influencing test results

Various factors can affect the concentration of heart failure markers in the blood:

Renal insufficiency: Impaired kidney function leads to elevated NT-proBNP levels, as the marker is excreted via the kidneys.
Age: Older individuals naturally have higher BNP and NT-proBNP levels.
Sex: Women tend to have higher values than men.
Obesity: Excess body weight can lead to falsely low BNP values.
Medications: Certain heart medications (e.g., sacubitril/valsartan) increase BNP levels while leaving NT-proBNP unaffected.

Relevance for diagnosis and therapy

Heart failure markers play a central role in the current guidelines of the European Society of Cardiology (ESC). A normal BNP or NT-proBNP value makes heart failure a very unlikely cause of symptoms such as shortness of breath. Conversely, significantly elevated values confirm the suspicion and prompt further diagnostic steps such as echocardiography. During treatment, a decline in marker levels can indicate a good response to therapy.

References

McDonagh T.A. et al. - 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 2021.
Yancy C.W. et al. - 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 2017.
World Health Organization (WHO) - Cardiovascular diseases: Diagnosis and management guidelines. WHO, Geneva, 2022.

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