A Clinical Prediction Model for Selective NT-proBNP Testing in Hypertension

N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing is recommended for pre-heart failure (pre-HF) screening. However, universal NT-proBNP testing is infeasible and inefficient. We analyzed data from 4642 U.S. adults with hypertension in NHANES 1999-2004. Heart stress, a biomarker-defined pre-HF state, was defined using age-specific NT-proBNP cutoffs. Multivariable logistic regression was used to identify factors associated with prevalent heart stress, and a point-based score was constructed. Model discrimination and calibration were internally validated using 1000 bootstrapped samples. Heart stress was present in 31% of individuals with hypertension. Factors associated with heart stress included older age, current smoking, prior coronary heart disease/myocardial infarction, higher systolic blood pressure, lower diastolic blood pressure, and reduced estimated glomerular filtration rate. The derivation model showed acceptable discrimination (AUC 0.71; 95% CI 0.70-0.73) and good calibration. An optimal cutoff of 6 points was identified using the Youden index and was internally validated (AUC 0.71; 95% CI 0.69-0.74). Model performance was consistent across race/ethnicity and body mass index subgroups, with relatively lower discrimination in females than in males (AUC 0.66 vs. 0.78). When stratified by a predicted heart stress probability threshold of 50%, individuals in the higher-probability group had higher cumulative risk of all-cause (hazard ratio 3.90; 95% CI 3.55-4.29) and cardiovascular mortality (hazard ratio 5.18; 95% CI 4.44-6.04) than those in the lower-probability group. These findings suggest that a simple model using readily obtainable clinical variables can help identify individuals with hypertension who are likely to have prevalent heart stress, offering a practical strategy to guide selective NT-proBNP testing.