A 68-year-old man with heart failure has an NT-proBNP level of 450 pg/mL. According to the ESC guidelines, which statement is correct regarding the use of natriuretic peptides in diagnosing heart failure in a non-acute setting?
- A NT-proBNP <125 pg/mL makes heart failure unlikely and should prompt investigation for alternative diagnoses ✓
- B NT-proBNP >125 pg/mL confirms the diagnosis of heart failure
- C NT-proBNP >900 pg/mL is required for a definitive diagnosis of HFrEF
- D NT-proBNP has no diagnostic utility in patients on ARNI therapy
Correct answer: A. NT-proBNP <125 pg/mL makes heart failure unlikely and should prompt investigation for alternative diagnoses
Explanation
ESC guidelines recommend NT-proBNP <125 pg/mL (non-acute setting) as a rule-out threshold, making heart failure unlikely. Values above this threshold warrant echocardiographic evaluation but are not diagnostic alone, as elevated levels occur in renal failure, atrial fibrillation, and advanced age. The rule-out threshold has high negative predictive value. ARNI therapy increases BNP (not NT-proBNP) because neprilysin degrades BNP, so NT-proBNP remains valid for diagnosis.
Reference: Braunwald's Heart Disease, 12th ed.
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