Persistent NT-proBNP Despite GDMT — EECC MCQ

Correct answer: C — Persistent NT-proBNP elevation despite GDMT indicates ongoing myocardial wall stress and identifies patients at high risk for death and HF hospitalisation — it should prompt consideration of advanced therapies (transplant/LVAD assessment) if LVEF remains ≤35% with persistent symptoms

NT-proBNP is released in response to myocardial wall stretch; in established HFrEF, a persistently very high value after optimisation of disease-modifying therapy is not “normal” and has prognostic significance. This patient’s NT-proBNP is 4,500 pg/mL (equivalent to 4,500 ng/L), well above the NICE “very high” threshold of >2,000 ng/L, which is associated with poorer prognosis. In a patient with dilated cardiomyopathy, LVEF 30% and ongoing NYHA III symptoms despite 6 months of optimal quadruple GDMT, persistent NT-proBNP elevation indicates ongoing haemodynamic/myocardial stress and identifies a high-risk phenotype for death and heart-failure hospitalisation. It should prompt specialist reassessment for reversible drivers, adherence and congestion, device eligibility, and—because symptoms and LVEF remain severe despite optimal therapy—consideration of advanced heart-failure referral, including transplant/LVAD assessment where appropriate. Narrow QRS (110 ms) makes CRT unlikely to be indicated; the key teaching point is that persistent elevation remains clinically meaningful and adverse prognostically.

Reference: NICE. Chronic heart failure in adults: diagnosis and management (NG106), 2018, updated 2025: https://www.nice.org.uk/guidance/ng106; NICE Quality standard QS9, updated 2025, notes NT-proBNP >2,000 ng/L is very high and associated with poorer prognosis: https://www.nice.org.uk/guidance/qs9/chapter/Quality-statement-2-Specialist-assessment