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BNP vs NT-proBNP on ARNI — EECC MCQ

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ModerateHeart FailureBNP vs NT-proBNP on ARNIEECC

A 58-year-old man with HFrEF (LVEF 20%) is admitted with acute decompensation. His BNP is 2,400 pg/mL. He is on sacubitril/valsartan. Why is BNP (not NT-proBNP) elevated despite ARNI therapy, and which biomarker should be used for monitoring?

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Correct answer: D — Sacubitril inhibits neprilysin which degrades BNP — so BNP levels are ARTIFACTUALLY elevated on ARNI and should NOT be used for monitoring; NT-proBNP is NOT a neprilysin substrate and therefore accurately reflects HF severity during ARNI therapy

This is a critical practical point for ARNI prescribing: sacubitril inhibits neprilysin, which normally degrades BNP (among other substrates). Therefore: (1) BNP levels RISE on sacubitril/valsartan — this is a PHARMACOLOGICAL effect, NOT a sign of worsening HF; using BNP to monitor HF severity on ARNI gives falsely elevated/alarming results; (2) NT-proBNP is NOT a neprilysin substrate (it is cleared by different pathways) — therefore NT-proBNP accurately reflects myocardial wall stress and HF severity during ARNI therapy; (3) the ESC 2023 HF Guidelines recommend NT-proBNP (not BNP) for monitoring patients on sacubitril/valsartan. NT-proBNP may initially decrease on ARNI (reflecting genuine clinical improvement from the drug's therapeutic effect), providing a reliable marker of treatment response.

Reference: ESC (2023): HF Guidelines