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Critical Pathways in Cardiology: 2002;1:67-73

Algorithms for Using B-Type Natriuretic Peptide Levels in the Diagnosis and Management of Congestive Heart Failure. Alan Maisel, MD, FACC Division of Cardiology and Department of Medicine, San Diego VA Healthcare System and University of California, San Diego, California.

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Critical Pathways in Cardiology: 2002;1:67-73

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  1. Algorithms for Using B-Type Natriuretic Peptide Levels in the Diagnosis and Management of Congestive Heart Failure Alan Maisel, MD, FACCDivision of Cardiology and Department of Medicine, San Diego VA Healthcare System and University of California, San Diego, California. Critical Pathways in Cardiology: 2002;1:67-73

  2. Symptoms and signs in the diagnosis of heart failure Symptoms and signs are important as they alert the possibility that heart failure exists The clinical suspicion of heart failure must be confirmed by more objective tests, particularly aimed at assessing cardiac function Text from Eur Heart J, Vol. 22, issue 17, September 2001

  3. BNP (pg/ml) III IV I II (NYHA - Class) BNP levels in CHF

  4. PrTP BNP PsTP Heart Failure Diagnosis Nomogram Triage BNP Improves Diagnostic Accuracy Significantly In Patient with 50% Probability - BNP Value of 1,000 pg/ml - BNP Value of 20 pg/ml Maisel A. Critical Pathways In Cardiology: 2002;1:67-73

  5. Patient presenting with dyspnea Physical examination, Chest X-ray, ECG, BNP level BNP (100 - 400) pg/ml BNP < 100 pg/ml BNP > 400 pg/ml Baseline LV dysfunction, Underlying COR pulmonale, or acute pulmonary embolism ? “No” “Yes” No Possible exacerbation of CHF (25%) CHF very unlikely (2%) CHF likely (75%) CHF very likely (95%)

  6. Draw BNP BNP can confirm whether patient’s CHF has truly decompensated Suspect decompensation BNP not elevated from baseline BNP elevated >50% From baseline Decompensation Unlikely- consider: Medications Depression Sepsis Pneumonia Decompensation likely Maisel A. Critical Pathways In Cardiology: 2002;1:67-73

  7. Maisel A. Critical Pathways n Cardiology: 2002;1:67-73

  8. BNP - Guided Treatment of CHF-REDHOT * BNP Value in pg/ml CHF Pulmonary Edema or Shock Hemodynamically Stable (Draw BNP) BNP < 400 * BNP 400 - 1000 * BNP > 1000 * Moderate Treatment: Treat for 2 - 4 hours (I.V. Diuretics) Adjust Oral Medications Intensive Treatment: Treat for 6 - 12 hours (Diuretics, Vasodilators) Draw BNP q 3 hrs No Improvement No Improvement Improvement Improvement BNP < 20% Decrease from Baseline BNP ≥ 20% Decrease from Baseline Discharge after 2-4 hrs (Draw BNP) Admit (Draw BNP) Admit (Draw BNP) Admit Discharge Admit

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