**Abstract:**  
  
B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in
the left ventricle. It is secreted in response to ventricular volume expansion
and pressure overload, factors often found in congestive heart failure (CHF).
Used in conjunction with other clinical information, rapid measurement of BNP
is useful in establishing or excluding the diagnosis and assessing the
severity of CHF in patients with acute dyspnea so that appropriate and timely
treatment can be initiated. This test is also used to predict the long-term
risk of cardiac events or death across the spectrum of acute coronary
syndromes when measured in the first few days after an acute coronary event.  
  
Evidence has accumulated to support use of BNP measurements for prognostic
purposes in individuals with heart failure and a low ejection fraction and to
improve dosing in guideline-directed medical therapy (GDMT) (Yancy et al.,
2013). Berger et al. (2002) studied use of BNP levels to predict sudden death
in heart failure patients and suggested BNP levels could be used to determine
which patients might benefit from an implantable cardioverter-defibrillator
(ICD). Other authors have shown a relationship between BNP levels and CHF
morbidity and mortality (Anand et al., 2003; Taub et al., 2009; Maeda et al.,
2000; and Neuhold et al., 2008). Januzzi et al, 2011; Jourdain et al., 2007;
Berger et al., 2010; and Lainchbury et al., 2010 studied the use of BNP to
guide therapy in CHF. Porapakkam et al, 2010 and Felker et al, 2009 performed
meta-analyses showing the benefit of using BNP levels in the management of CHF
patients.  
  
Palladini et al. (2003) studied 152 consecutive patients seen at the time of
amyloidosis diagnosis and obtained NT-proBNP levels. Heart involvement was
estimated using clnical signs, electrocardiography, and echocardiography. NT-
proBNP was the most sensitive index of myocardial dysfunction and the best
predicted prognosis in patients with light-chain amyloidosis. Dispenzieri et
al. (2004) retrospectively studied 242 patients with newly-diagnosed primary
systemic amyloidosis in whom echocardiograms and NT-pro levels were obtained
and used to divide the patients into three stages to promote cross comparisons
of therapeutic outcomes, The National Comprehensive Cancer Network (NCCN)
clinical practice guidelines, "Systemic Light Chain Amyloidosis," list
recommend a BNP level be obtained in the initial diagnositic work-up.
Palladini et al. (2010) again evaluated the use of BNP levels to predict
prognosis. Levels of NT-proBNP, high-sensitivity (hs) cTnT, and tropronin were
obtained at initial diagnosis and six months later were obtained in 171
consecutive patients. The high-sensitivity and NT-proBNP ertr independent
prognostic determinants. The author recommended BNP levels be used to follow
response to therapy. For the purposes of this policy, either total or
N-terminal assays are acceptable.  
  
This local coverage determination (LCD) documents National Government Services
indications and limitations of coverage for BNP testing.  
  
 **Indications:**  
  
BNP measurements may be considered reasonable and necessary when used in
combination with other medical data such as medical history, physical
examination, laboratory studies, chest x-ray, and electrocardiography:  
  

  * To distinguish cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes. Plasma BNP levels are significantly increased in patients with CHF presenting with acute dyspnea compared with patients presenting with acute dyspnea due to other causes.
  * To distinguish decompensated CHF from exacerbated chronic obstructive pulmonary disease (COPD) in a symptomatic patient with combined chronic CHF and COPD. Plasma BNP levels are significantly increased in patients with CHF with or without concurrent lung disease compared with patients who have primary lung disease.
  * To establish prognosis or disease severity in chronic CHF when needed to guide therapy
  * To achieve optimal dosing of guideline-directed medical therapy (GDMT) in select clinically euvolemic patients followed in a well-structured heart failure (HF) disease management program
  * To guide therapeutic decision-making in individuals who have amyloidosis

  
  
**Limitations:**  
  
BNP measurements must be analyzed in conjunction with standard diagnostic
tests, medical history and clinical findings. The efficacy of BNP measurement
as a stand-alone test has not yet been established. Clinicians should be aware
that certain conditions such as ischemia, infarction and renal insufficiency,
may cause elevation of circulating BNP concentration and require alterations
of the interpretation of BNP results.