Key result
NT-proBNP loses its prognostic value for acute HF mortality in class III obesity.
Why the study?
Although the inverse relationship between BMI and NT-proBNP levels is well known, the impact of BMI and obesity on the prognostic performance of NT-proBNP in acute HF remained uncertain.
Does body mass index (obesity) modify the prognostic value of NT-proBNP for predicting mortality in patients hospitalized with acute heart failure?
Cohort (n=118,527)
Yes
Does body mass index (obesity) modify the prognostic value of NT-proBNP for predicting mortality in patients hospitalized with acute heart failure?
In patients hospitalized for acute heart failure, NT-proBNP maintains independent prognostic value for mortality up to a BMI of 35 kg/m², but its predictive performance is significantly blunted in severe obesity (BMI ≥35 kg/m²).
NT-proBNP interpretation warrants caution for mortality risk in acute HF with BMI ≥35; leaves open whether alternative biomarkers improve prediction in severe obesity.
Background Although the inverse relationship between body mass index (BMI) and N-terminal pro–B-type natriuretic peptide (NT-proBNP) level is well known, the impact of BMI on the prognostic performance of NT-proBNP in acute heart failure (HF) remains uncertain. Purpose We aimed to evaluate the impact of obesity on the prognostic value of NT-proBNP in acute HF. Methods We used data from the China Cardiovascular Association (CCA) database-Heart Failure Centre Registry. Patients were classified as underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5-23 kg/m²), overweight (BMI 23-24.9 kg/m²), obese I (BMI 25-29.9 kg/m²), obese II (BMI 30-34.9 kg/m²) and obese III (BMI ≥35 kg/m²). We evaluated the prognostic value of NT-proBNP across BMI categories, using multivariable Cox models and restricted cubic splines. We used the Harrell C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) to investigate whether NT-proBNP added incremental prognostic information for mortality prediction across BMI categories. Results The study population included 118527 patients (mean age 68±13 years, 40.4% women, mean left ventricular ejection fraction 46%±13%). NT-proBNP level inversely correlated with BMI (P < 0.01). After adjustment for demographics and traditional clinical risk factors, higher NT-proBNP level was associated with increased death risk in underweight (HR 1.37, 95% CI 1.31-1.43), normal weight (HR 1.40, 95% CI 1.37-1.43) , overweight (HR 1.45, 95% CI 1.40-1.49), obese I (HR 1.43, 95% CI 1.39-1.48) and obese II patients (HR 1.47, 95% CI 1.36-1.59), but not in obese III patients (HR 1.12, 95% CI 0.91-1.39) (P for interaction<0.01) (Figure). And according to the change in C-statistic, NRI and IDI, the addition of NT-proBNP to fully adjusted model improved risk prediction ability across BMI categories, with the exception of obese III patients. Conclusions In a national cohort of patients hospitalized for HF, BMI modified the association between NT-proBNP and mortality. NT-proBNP maintains its independent prognostic value up to 35 kg/m² BMI, while the predictive value of NT-proBNP was compromised in obese III patients.
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Ge et al. (2026) conducted a cohort in Acute heart failure (n=118,527). Higher NT-proBNP level in obese III patients (BMI ≥35 kg/m²) vs. Lower BMI categories (<35 kg/m²) was evaluated on All-cause mortality (HR 1.12, 95% CI 0.91-1.39, p=<0.01 for interaction). NT-proBNP predicted mortality in acute HF up to BMI <35 kg/m², but lost prognostic value in obese III patients (BMI ≥35: HR 1.12, 95% CI 0.91-1.39; P<0.01 for interaction).
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