Wet BNP, fluid and hemodynamic status at discharge in acute heart failure

We comment the noteworthy results of Pimenta et al. concerning the significance of discharge BNP levels in acute HF patients. The innovation of Pimento's study is the systematic research of the potential relationship between BNP and clinical and hemodynamic parameters. We focused the attention on the importance of wet "BNP" in managing HF and its ability to reflect congestion and multiple underlying patho-physiological disturbances. The first observation, regarding the statistical order, underlines the importance of renal insufficiency at discharge in genesis of higher BNP levels. Secondly, we note that the relationship between natriuretic peptides and the non-invasive measurement of the fluid status assessed by bioelectrical impedance analysis was already demonstrated. Thirdly, we comment on the potential therapeutical implication of the verified relationship between BNP and albumin levels and we argue on the clinical utility of the albumin supplementation or hypertonic solutions in unstable HF management due to their oncotic power. Fourthly, we wish to further examine the role of central volemia. We underline that some studies had demonstrated that systemic congestion may be a mirror of central congestion and may also influence these levels alone in acute and also chronic HF patients. We believe that a concealed or poorly-assessed accumulation of systemic fluid is of crucial importance in managing HF, which frequently remains undiagnosed or inappropriately treated, thus requiring recurrent hospital readmission and disease progression. Furthermore not only BNP at discharge but also bioimpedance detection may be helpful to discover misdiagnosed congestion. We are of the opinion that, in cases of hospitalized HF and thereafter in ambulatory setting, the achievement and, then, maintenance of dry-wet tailoring diuretics, fluid and sodium intake is the key approach leading to a euvolemic status, a lowering of the NYHA class and an improvement in cardiac hemodynamics. All of these factors are conducive to lowered BNP plasma levels.