Natriuretic peptide levels run lower in people with obesity, for reasons that include adipose tissue clearance and reduced secretion. A BNP or NT-proBNP just under the usual cut-off in a breathless patient with a raised BMI therefore reassures less than it would in someone of normal weight.
In practice, keep HFpEF on the list when the story fits — exertional breathlessness, atrial fibrillation, hypertension, diabetes, raised filling pressures on echo — even if the peptide is only modestly raised or borderline, and consider exercise testing rather than stopping at a normal resting study.
- Expect lower BNP and NT-proBNP in patients with obesity.
- Do not dismiss HFpEF on a borderline peptide when the clinical picture fits.
- Atrial fibrillation, hypertension and diabetes raise the pre-test probability.
- A normal resting echo does not exclude HFpEF; exertional testing may be needed.
Why it matters
The patients most likely to have HFpEF are also those in whom the screening blood test reads falsely low.
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