NT-proBNP Values for Excluding Heart Failure

Diagnostic Thresholds

The American College of Cardiology recommends an NT-proBNP threshold of <125 pg/mL to exclude chronic heart failure in outpatients under 75 years, with a negative predictive value of 99% 1, 2
For acute heart failure in the emergency department, an NT-proBNP threshold of <300 pg/mL excludes the condition with a negative predictive value of 99% 2
BNP levels <35 pg/mL also exclude chronic heart failure, according to the American College of Cardiology 1
Age-adjusted thresholds for NT-proBNP are recommended for confirming the diagnosis of heart failure: >450 pg/mL for patients <50 years, >900 pg/mL for patients 50-75 years, and >1,800 pg/mL for patients >75 years 2

In obese patients (BMI ≥30 kg/m²), the NT-proBNP threshold should be reduced by 20-30% because obesity decreases natriuretic peptide levels 3
In patients with advanced age (>75 years), the NT-proBNP threshold should be increased by 20-30% because age elevates NT-proBNP levels 3
In patients with atrial fibrillation, the NT-proBNP threshold should be increased by 20-30% because atrial fibrillation elevates NT-proBNP levels 3
In patients with renal insufficiency (eGFR <60 mL/min/1.73m²), NT-proBNP levels are significantly elevated, but a threshold of <1,200 pg/mL can be used to exclude heart failure 3
In black patients, the NT-proBNP threshold should be reduced by 20-30% because black patients typically have lower NT-proBNP levels 3

NT-proBNP levels are not affected by neprilysin inhibitors (sacubitril/valsartan) and can be used without adjustments 3
BNP levels should not be used to monitor response to treatment with neprilysin inhibitors until more data are available 3
In heart failure with preserved ejection fraction (HFpEF), NT-proBNP levels are generally lower than in heart failure with reduced ejection fraction, but the same diagnostic thresholds apply (NT-proBNP <125 pg/mL excludes HFpEF) 1
Elevations in NT-proBNP can occur in pulmonary hypertension, pulmonary embolism, renal insufficiency, and sepsis, reflecting ventricular stress but not necessarily primary heart failure 2

The American College of Cardiology recommends NT-proBNP levels <125 pg/ml and BNP levels <35 pg/ml to exclude chronic heart failure 4, 5, 6
For acute heart failure diagnosis in patients with dyspnea, BNP levels >100 pg/ml suggest heart failure, while levels between 100-500 pg/ml are in a gray zone, and levels >500 pg/ml indicate high probability of heart failure 7, 8
The European Society of Cardiology suggests using NT-proBNP levels <300 pg/ml to exclude acute heart failure 4, 9

Advanced age increases NT-proBNP levels, requiring threshold adjustments in 20-30% of patients over 75 years old 4, 6
Atrial fibrillation increases NT-proBNP levels by 20-30% 4, 6
Renal insufficiency significantly elevates NT-proBNP levels 9, 10
Obesity decreases NT-proBNP levels by 20-30% in patients with BMI ≥30 kg/m² 4, 11
Black race typically has 20-30% lower NT-proBNP values 4, 6

NT-proBNP has greater in vitro stability than BNP 10
In patients with significant renal insufficiency (eGFR <60 ml/min/1.73m²), a NT-proBNP cutoff of 1200 pg/ml is recommended to exclude heart failure 9, 10
In obese patients (BMI >35 kg/m²), a BNP cutoff of 55 pg/ml is recommended 10
The use of neprilysin inhibitors (such as sacubitril/valsartan) affects BNP measurement but not NT-proBNP measurement 4, 12

A decrease of >30% in BNP levels during treatment is associated with improved survival 7, 9