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Annals of Clinical Case Studies

2019 | Volume 1 | Article 1007022© 2019 - Medtext Publications. All Rights Reserved.

ISSN 2688-1241

Acute Heart Failure without Obvious Elevated NT-

ProBNP: A Case Report and a Short Review of Literature

Case Report

Sen Wang, Jin Qian, Zakaria lyan and Di Xu

Citation: Wang S, Qian J, lyan Z, Xu D. Acute Heart Failure without Obvious Elevated NT-ProBNP: A Case Report and a Short Review of

Literature. Ann Clin Case Stud. 2019;1(2):1007.

Copyright: © 2019 Sen Wang

Publisher Name: Medtext Publications LLC

Manuscript compiled: July 11

th , 2019 *Corresponding author: Di Xu, Department of Geriatric Cardiology,

AbstractMany studies have con?rmed signi?cant determinant role of plasma amino-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations in the patients

with acute dyspnea. It was recommended to di?erentiate cardiac asthma and non-cardiac asthma. We discuss the case of an old male patient who presented

with acute heart failure secondary to pulmonary infection without early obvious elevated NT-proBNP concentration. ?e NT-proBNP concentration elevated 2

days a?er onset of the symptom. A?er intensive pharmacological therapy for heart failure, the condition of the patient is stabilized and improved. ?e acute le?

heart failure cannot be excluded when NT-proBNP is normal or slightly elevated. We should be aware for acute heart failure with normal plasma NT-proBNP

concentration. Keywords: Amino-terminal pro-B type natriuretic peptide (NT-proBNP); Acute heart failure; Dyspnea

Introduction

Acute dyspnea is a main chief complaint of most patients admitted to the Emergency Department (ED). Assess plasma B-type natriuretic peptide (BNP) and amino-terminal pro B-type natriuretic peptide (NT-

proBNP) concentration are recommended in admitted dyspnea patients with uncertain clinical diagnosis, as both have been proven to have good

discriminate value for distinguishing between acute heart failure (AHF) and non-AHF [1-3]. Compared with BNP, plasma NT-proBNP level is more stable, as the half time of NT-proBNP is 120 minutes, while the half time of BNP is only 22 minutes. Eventually, NT-proBNP is more and more used for detecting heart failure. However, in clinical practice, can we exclude acute dyspnea patient from heart failure when the NT- proBNP is not signi?cantly elevated?

Case Presentation

A 82-year-old man was admitted to the hospital with severe dyspnea associated with chest distress. A review of his past history revealed that he had hypertension and liver cancer. ?e patient woke up at 3 o'clock in the morning and go to bathroom for defecation. ?en he felt sudden chest discomfort, dyspnea, and body sweating when using forces for defecation. Patient was admitted to emergency department at 6 o'clock in

the morning. His pulse was 110 beats/min, Blood Pressure (BP) 180/90 mmHg, Body Temperature (BT) 36.8, Respiratory Rate (RR) 30 breaths/

min, and oxygen saturation 91% in 3 L/min of oxygen administered through a nasal cannula (Table 1). ?e patient had poor nutrition with the BMI 17.71, he had clear consciousness and no the jugular vein distension. Upon auscultation, wheeze and moist rales can be heard in both lungs, but no obvious pathological murmur on heart valves. ?ere was no palpable mass, liver and spleen costal margin also were not palpable, lower limbs were not swollen. ?e X-rays showed pulmonary edema and electrocardiography revealed slightly ST depression on lead I, aVL, V4, V5, V6 (Figure 1 and 2). Cardiac biomarkers showed Myoglobulin 72 ug/L (0-46 ug/L), hs-cTnT 95.79 ng/L (0-14), CK-MB

45.5 umol/L (0-25) and the plasma concentration of the NT-proBNP

was 740.1 pg/mL. A?er patient received oxygen, diuretic, and vasodilator drug therapy, the patient felt signi?cant recovery. As the patient has ST depression and cardiac biomarker elevation, we follow up the ECG and

cardiac biomarkers, which shows no dynamic alteration ?rstly and the echocardiography did not show a reduction in abnormal contraction

and the LVEF was 60.2% (Figure 3A). We also monitored plasma NT- proBNP concentration and found that the concentration was remain elevated even a?er the symptom of acute heart failure was relieved 27 hours a?er the onset of dyspnea (Figure 3B). ?e patient felt severe dyspnea again when taking food a?er 51 hours from the ?rst dyspnea attack and during this current time, the plasma concentration of cardiac biomarker and NT-proBNP obviously elevated (Figure 3A and B).Admission vital signs

Heart rate110 beats/min

BP180/90 mmHg

BT36.8ºC

RR30 breaths/min

Saturation

91% in 3 L of oxygen administered through a

nasal cannula

Laboratory

data

Reference

range

RBC3.36

10 9 g/L4.3-5.8

WBC8.7

10 9 g/L3.5-9.5HB94 g/L130-195 PLT70 10 9 g/L125-350

ALT18.4 U/LSep-50

AST30.2 U/L15-40

Cr82.4 umol/L44-133

BUN6.67 mmol/L2.9-8.2

K+3.9 mmol/L3.5-5.3

Na+140.5 mmol/L137-147

Table 1: ?e patient's pro?le.

BP: Blood Pressure; BT: Blood Temperature; RR: Respiratory Rate; RBC: Red Blood Cell; WBC: White Blood Cell; Hb: Hemoglobin; PLT: Platelet; ALT: Alanine Aminotransferase; AST: Aspartate Transaminase; Cr: Creatinine; BUN: Blood Urea Nitrogen; K: Potassium; Na: Sodium © 2019 - Medtext Publications. All Rights Reserved. 023

Annals of Clinical Case Studies

2019 | Volume 1 | Article 1007

Discussion

We present the case of an old man without obviously elevated NT- proBNP at the beginning of the acute heart failure. Acute dyspnea is a main symptom of acute heart failure and both plasma BNP and NT- proBNP are recommended to distinguish Acute Heart Failure (AHF) from non-AHF. Measurement of plasma natriuretic peptide levels has increased diagnostic accuracy, thus leading many guidelines recommend these markers for diagnosing heart failure [4]. When volume or pressure overloads, the ventricular musculature will secrete pro-BNP which will be cleaved into two molecules; the biologically active BNP and the biologically inert NT-proBNP [5]. Compared to BNP, the NT-proBNP is more stable and used more and more in the heart failure detection. NT-proBNP values of <300 pg/ml in the setting of an acutely dyspneic patient makes the diagnosis of congestive heart failure less likely, and NT-proBNP values of >1800 pg/ ml in the age more than 75 means that the AHF diagnosis more likely [2,6]. Many studies in the past decades had focus on the importance of BNP or NT-proBNP levels in diagnosing acute dyspnea due to HF and distinguishing non-cardiac dyspnea. Some studies also show that other cases causes NT-proBNP elevation besides heart failure, such as renal heart failure [7,8]. While little attention was put on the acute heart failure with normal or slight elevated NT-proBNP. We show a case with typical symptom of acute heart failure which presented as severe dyspnea, high blood pressure, tachycardia, wet rales on both lungs, etc. ?e X-rays showed pulmonary edema while the initial NT-proBNP was not elevated obviously (740.1 pg/ml). Combining this case and literature review, we ?nd plasma NT-proBNP concentration may be not elevated in the AHF patient who have the following characteristics: (1) sex: male, (2) BMI, compared with normal counterparts, overweight; obese patients with acute CHF have lower circulating NT-proBNP and BNP levels [9]. (3) First incidence of acute heart failure, and did not have chronic heart failure before. Our case showed that the NT-proBNP was not obviously elevated during ?rst admission while it was obviously elevated a?er the second incidence. (4) ?e time from the onset of the disease to treatment is short and a timely treatment is given a?er the onset of acute dyspnea.

Conclusion

?erefore, the diagnosis for acute le? ventricular failure should be more comprehensive judgment. We should not exclude acute heart failure according to plasma BNP or NT-proBNP concentration, awareness of acute le? heart failure with normal BNP level should be increased. For some unexplained dyspnea cases, we should not exclude acute le? ventricular failure according to single NT-proBNP level value. Multiple assessments of patients such as proper approach from the history, physical examination, cardiac ultrasound, chest X-ray should be done carefully in dyspnea patient with normal NT-proBNP. We should alert for acute le? heart failure with normal plasma BNP or NT-proBNP.

References

1. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-7. 2. Januzzi Jr JL, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, et al. ?e N-terminal pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. 2005;95(8):948-54. 3. Mueller T, Gegenhuber A, Poelz W, Haltmayer M. Diagno stic accuracy of B type natriuretic pepti de and amino terminal proBNP in the emergency diagnosis of heart failure. Heart. 2005;91(5):606-12. 4. Alkhawam H, El-Hunjul M, Nguyen J, Desai R, Syed U, Vittorio TJ. Natriuretic peptide hormones in congestive heart failure: challenges, clinical interpretation and review of studies. Acta Cardiol. 2016;71(4):417-24. 5. Cacciaputo F. Natriuretic Peptide System and Cardiovascular Disease. Heart Views.

2010;11(1):10-5.

6. Baggish AL, van Kimmenade R, Bayes-Genis A, Davis M, Lainchbury JG, Frampton C, et al. Hemoglobin and N-terminal pro-brain natriuretic peptide: Independent and synergistic predictors of mortality in patients with acute heart failure Results from the International Collaborative of NT-proBNP (ICON) Study. Clin Chim Acta.

2007;381(2):145-50.

7. Baig JA, Alam JM, Ansari MA, Hussain A, Naheed S, Shaheen R, et al. Evaluation of NT pro BNP of diagnostic signi?cance in patients with chronic kidney diseases. Pak J

Biochem Mol Biol. 2010;43(2):99-104.

8. David S, Kumpers P, Seidler V, Biertz F, Haller H, Fliser D. Diagnostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for le? ventricular dysfunction in patients with chronic kidney disease stage 5 on haemodialysis.

Nephrol Dial Transplant. 2008;23(4):1370-7.

9. Krauser DG, Lloyd-Jones DM, Chae CU, Cameron R, Anwaruddin S, Baggish AL, et al. E?ect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: A ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy. Am Heart J. 2005;149(4):44-50. Figure 1: Chest X-ray, posterior-anterior view showing pulmonary edema. Figure 2: Electrocardiogram of the patient. Sinus rhythm, slightly ST

Figure 3

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