Evidence-Based Application of Natriuretic Peptides in the Evaluation of Chronic Heart Failure With Preserved Ejection Fraction in the Ambulatory Outpatient Setting.
Summary
Across derivation and multiple validation cohorts using gold-standard exercise catheterization, standard NT-proBNP thresholds misclassified HFpEF, particularly in obesity and AF. BMI- and AF-stratified rule-in/out thresholds substantially reduce error; in AF with dyspnea, NT-proBNP adds little beyond AF status itself.
Key Findings
- Diagnostic reference standard was exercise catheterization; derivation (n=414) and multiple validation cohorts (n=560, 207, 77) plus three external validations.
- Conventional rule-out threshold (<125 pg/mL) yielded high error rates; performance varied by BMI and AF.
- In patients with AF and dyspnea, NT-proBNP provided limited incremental diagnostic value; BMI-stratified thresholds improved classification.
Clinical Implications
Adopt BMI- and AF-stratified NT-proBNP thresholds in outpatient dyspnea to triage for exercise hemodynamic testing; avoid over-reliance on low thresholds in obesity or AF.
Why It Matters
Refines a ubiquitous diagnostic test by context-specific thresholds, directly addressing common sources of misclassification in HFpEF workups.
Limitations
- Exact cut-points and operating characteristics are not detailed in the abstract.
- Generalizability to acute care settings or populations without chronic dyspnea is uncertain.
Future Directions
Prospective implementation studies to test BMI-/AF-stratified algorithms on clinical pathways, outcomes, and resource use; integration with echocardiography/AI models.
Study Information
- Study Type
- Cohort
- Research Domain
- Diagnosis
- Evidence Level
- II - Prospective cohorts with invasive reference standard and external validations
- Study Design
- OTHER