Answering your questions; protocol for BNP orders

Q What is the praiseed protocol for ordering BNP tests? in what way often should BNPs be ordered to be clinically significant? At our hospital, a certain number of doctors are ordering BNPs each morning for 10 to 15 days, with little change in issues From the lab viewpoint, I think this is a bit most remote Is there a clinically significant reason to order this many BNP upon a single patient?

A B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are biomarkers that mirror hemodynamic stress. As with many trials in laboratory medicine, caregivers could potentially petition these measurements to assist with screening, diagnosis, disease classification, risk assessment, guide management, or assess the issue of intervention. The focus of the question is by what mode BNP and NT-proBNP should be supplicationed and the appropriate ordering oftenness for this test. The following answer will assume that the testing is askinged in the context of patients with suspected or established heart failure.

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The American Heart Association (AHA) and American community of Cardiology (ACC) are in the proces of publishing an update of practice guidelines for adult chronic heart failure patients. A summary of these guidelines is accessible upon the Web at www.acc.org/clinical/guidelines/failure/summary.pdf. Clearly, a major contribution of BNP and NT-proBNP has been as an aid for the diagnosis of decompensated heart failure in the symptomatic necessity Medicine population. Reflecting this contribution, the AHA/ACC document states that "measurement of BNP can be useful in the evaluation of patients presenting in the pressing care setting in whom the clinical diagnosis of heart failure is uncertain." This is a Class IIa recommendation, meaning that the weight of evidence is in favor of experiment use; the level of evidence for utilization is rated as "A," which is the true highest. For management of heart failure in hospitalized patients, appropriate utilization of BNP and NT-proBNP is les clear.

It is noted in the AHA/ACC guideline document that serum BNP and NT-proBNP measurements parallel the clinical severity of heart failure. However, it cannot be assumed that BNP and NT-proBNP can be used effectively for adjustment of therapy in individual patients. The AHA/ACC guidelines state that "the value of serial measurements of BNP and NT-proBNP to guide therapy for patients with heart failure is not well established." The recommendation for use in guiding therapy is listed as Class IIb, meaning that use in these patients is les well established by means of evidence; the level of evidence for guiding therapy is rated "C" which is the weakest grade and indicates that the recommendation is based sole on consensus opinions of adroits and case studies.

Clearly BNP and NT-proBNP are useful ordeals to assist in the diagnosis of decompensated heart failure in the importunate care setting. For use of the experiment in hospitalized patients, most ables state that BNP and NT-proBNP horizontals do not need to be drawn each day. Expert consensus is that appropriate inpatient utilization is upon admission, after a major treatment event and when discharge is contemplated, i.e. euvolemia is achieved (BNP Consensus Panel 2004: at liberty PDF download available at www.lejacq.com/JournalSpecialSupplements.cfm?CFID=32691&CFTOKEN=89747650). Other dexterouss feel that this ordering oftenness is excessive, and that BNP and NT-proBNP measurements upon admission, and when discharge is contemplated, provides adequate information for patient care. Still, other heart-failure prompts do not endorse drawing BNP horizontals at all while patients are in-house, reflecting the paucity of hard evidence squeeze outed in the AHA/ACC guidelines.

Obviously, there is substantial polemics surrounding utilization of BNP and NT-proBNP for inpatient monitoring. more [i]or[/i] less evidence-based guidance is provided however, by means of the recent AHA/ACC guidelines and dexterous consensus. It is noteworthy that knowledge upon appropriate clinical utilization of BNP and NT-proBNP is evolving rapidly, and that ongoing trials will help to better define the character of serial BNP and NT-proBNP measurements as an aid in the management of heart failure.

Edited through Daniel M. Baer, MD

--Robert H Christenson, PhD DABCC, FACB

Professor of Pathology;

Professor of Medical and Research Technology;

Director, Rapid reply Laboratories

University of Maryland institute of Medicine

Baltimore, MD

Daniel M Baer, MD is professor emeritus of laboratory medicine at Oregon Health and Science University in Portland, OR, and a member of MLO's editorial advisory board.

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