Congestive heart failure laboratory tests: Difference between revisions
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BNP or its amino-terminal cleavage equivalent (NT-proBNP) is generated by cardiomyocytes in the context of numerous triggers, most notably myocardial stretch. | BNP or its amino-terminal cleavage equivalent (NT-proBNP) is generated by cardiomyocytes in the context of numerous triggers, most notably myocardial stretch. | ||
Their measurement is helpful for diagnosis or ruling out heart failure especially in acute setting. | Their measurement is helpful for diagnosis or ruling out heart failure especially in acute setting. | ||
{| class="wikitable" | |||
! | |||
!Cardiac cause | |||
!Non cardiac causes | |||
|- | |||
|Elevated BNP | |||
| | |||
* Heart failure | |||
* [[Acute coronary syndromes|Acute coronary syndrome]] | |||
* Heart muscle disease, including [[Left ventricular hypertrophy|LVH]] | |||
* [[Valvular heart disease]] | |||
* [[Pericardial disease]] | |||
* [[Atrial fibrillation]] | |||
* [[Myocarditis]] | |||
* Cardiac surgery | |||
* [[Cardioversion]] | |||
| | |||
* Advancing age | |||
* [[Anemia]] | |||
* [[Renal failure]] | |||
* Pulmonary: [[obstructive sleep apnea]], severe [[pneumonia]], [[pulmonary hypertension]] | |||
* Critical illness | |||
* Bacterial [[sepsis]] | |||
* Severe burns | |||
* Toxic-metabolic insults, including cancer [[chemotherapy]] and [[envenomation]] | |||
* Advancing age • Anemia • Renal failure • Pulmonary: obstructive sleep apnea, severe pneumonia, pulmonary hypertension • Critical illness • Bacterial sepsis • Severe burns • Toxic-metabolic insults, including cancer chemotherapy and envenomation | |||
|} | |||
==2013 ACCF/AHA Guideline for the Management of Heart Failure/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)<ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>== | ==2013 ACCF/AHA Guideline for the Management of Heart Failure/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)<ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>== | ||
Revision as of 20:20, 17 November 2016
 |
Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]
Overview
BNP levels may be useful in the initial establishment of the diagnosis of heart failure in the patient with dyspnea of unclear etiology. In a meta-analysis, BNP was superior N-terminal pro-BNP (NTproBNP) and was associated with a sensitivity of 85% and specificity of 84% in the diagnosis of heart failure in the primary care setting.[1] Once the diagnosis of heart failure is made, subsequent laboratory studies should be directed toward the identification of an underlying cause of heart failure.
Laboratory Tests
Renal Function
Renal function should be assessed as a rough guide to the patient's intravascular volume status and renal perfusion. A urinalysis is helpful in the assessment of the patient's volume status. Electrolyte assessment and the correction of electrolyte disturbances such as hypokalemia, hyperkalemia and hypomagnesemia is critical in those patients treated with diuretics. Hyponatremia (due to poor stimulation of the baroreceptors and appropriate ADH release and free water retention) is associated with a poor prognosis.
Hematologic Studies
A complete blood count should be obtained to assess for the presence of anemia which may exacerbate heart failure and to assess the patients coagulation status which may be impaired due to hepatic congestion.
Thyroid Studies
The assessment of thyroid function tests is particularly important in the patient who is being treated with concomitant therapy with an agent such as amiodarone.
Biomarkers
Biomarkers are going to play a great role in diagnosis of heart failure. In addition to routine laboratory tests, they are gaining attention in heart failure management.
Natriuretic Peptides: BNP or NT-proBNP
BNP or its amino-terminal cleavage equivalent (NT-proBNP) is generated by cardiomyocytes in the context of numerous triggers, most notably myocardial stretch. Their measurement is helpful for diagnosis or ruling out heart failure especially in acute setting.
| Cardiac cause | Non cardiac causes | |
|---|---|---|
| Elevated BNP |
|
|
2013 ACCF/AHA Guideline for the Management of Heart Failure/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)[2][3]
Initial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)[2][3]
| Class I |
| "1. Initial laboratory evaluation of patients presenting with heart failure should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C) " |
| "2. Serial monitoring, when indicated, should include serum electrolytes and renal function. (Level of Evidence: C) " |
| "3. A 12-lead ECG should be performed initially on all patients presenting with HF. (Level of Evidence: C) " |
| "4. In ambulatory patients with dyspnea, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty.[4][5] (Level of Evidence: A) " |
| "5. In hospitalized patients/acute setting, measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.[6][7] (Level of Evidence: A) " |
| "6. In hospitalized patients/acute setting, Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF.[8][9] (Level of Evidence: A) " |
| "7. Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF.[10][11][12](Level of Evidence: A) " |
| Class III (No Benefit) |
| "1. Routine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with heart failure. (Level of Evidence: C) " |
| Class IIa |
| "1. BNP- or NT-proBNP–guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients followed in a well-structured HF disease management program. (Level of Evidence: B) " |
| "2. Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF (Level of Evidence: C) " |
| "3. Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with heart failure in whom there is a clinical suspicion of these diseases. (Level of Evidence: C) " |
Serial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)[2][3]
| Class IIb |
| "1. The usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patients with HF is not well established. (Level of Evidence: B) " |
| "2. The usefulness of BNP- or NT-proBNP–guided therapy for acutely decompensated HF is not well established. (Level of Evidence: C) " |
| "3. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF. (Level of Evidence: A) " |
| "4. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF. (Level of Evidence: B) " |
Vote on and Suggest Revisions to the Current Guidelines
Sources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [2]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [3]
References
- ↑ Ewald B, Ewald D, Thakkinstian A, Attia J (2008). "Meta-analysis of B type natriuretic peptide and N-terminal pro B natriuretic peptide in the diagnosis of clinical heart failure and population screening for left ventricular systolic dysfunction". Intern Med J. 38 (2): 101–13. doi:10.1111/j.1445-5994.2007.01454.x. PMID 18290826.
- ↑ 2.0 2.1 2.2 2.3 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
- ↑ 3.0 3.1 3.2 3.3 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
- ↑ Costello-Boerrigter LC, Boerrigter G, Redfield MM, Rodeheffer RJ, Urban LH, Mahoney DW, Jacobsen SJ, Heublein DM, Burnett JC (2006). "Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide in the general community: determinants and detection of left ventricular dysfunction". J. Am. Coll. Cardiol. 47 (2): 345–53. doi:10.1016/j.jacc.2005.09.025. PMC 2647136. PMID 16412859.
- ↑ Vasan RS, Benjamin EJ, Larson MG, Leip EP, Wang TJ, Wilson PW, Levy D (2002). "Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: the Framingham heart study". JAMA. 288 (10): 1252–9. PMID 12215132.
- ↑ Januzzi JL, Sakhuja R, O'donoghue M, Baggish AL, Anwaruddin S, Chae CU, Cameron R, Krauser DG, Tung R, Camargo CA, Lloyd-Jones DM (2006). "Utility of amino-terminal pro-brain natriuretic peptide testing for prediction of 1-year mortality in patients with dyspnea treated in the emergency department". Arch. Intern. Med. 166 (3): 315–20. doi:10.1001/archinte.166.3.315. PMID 16476871.
- ↑ Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L, Clopton P, Alberto J, Hlavin P, Maisel AS (2001). "Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting". J. Am. Coll. Cardiol. 37 (2): 379–85. PMID 11216950.
- ↑ van Kimmenade RR, Pinto YM, Bayes-Genis A, Lainchbury JG, Richards AM, Januzzi JL (2006). "Usefulness of intermediate amino-terminal pro-brain natriuretic peptide concentrations for diagnosis and prognosis of acute heart failure". Am. J. Cardiol. 98 (3): 386–90. doi:10.1016/j.amjcard.2006.02.043. PMID 16860029.
- ↑ Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A (2004). "N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients". Circulation. 110 (15): 2168–74. doi:10.1161/01.CIR.0000144310.04433.BE. PMID 15451800.
- ↑ Tang WH, Girod JP, Lee MJ, Starling RC, Young JB, Van Lente F, Francis GS (2003). "Plasma B-type natriuretic peptide levels in ambulatory patients with established chronic symptomatic systolic heart failure". Circulation. 108 (24): 2964–6. doi:10.1161/01.CIR.0000106903.98196.B6. PMID 14662703.
- ↑ Berger R, Huelsman M, Strecker K, Bojic A, Moser P, Stanek B, Pacher R (2002). "B-type natriuretic peptide predicts sudden death in patients with chronic heart failure". Circulation. 105 (20): 2392–7. PMID 12021226.
- ↑ Neuhold S, Huelsmann M, Strunk G, Stoiser B, Struck J, Morgenthaler NG, Bergmann A, Moertl D, Berger R, Pacher R (2008). "Comparison of copeptin, B-type natriuretic peptide, and amino-terminal pro-B-type natriuretic peptide in patients with chronic heart failure: prediction of death at different stages of the disease". J. Am. Coll. Cardiol. 52 (4): 266–72. doi:10.1016/j.jacc.2008.03.050. PMID 18634981.