Cardiovascular Research 51 (2001) 442449
www.elsevier.com / locate / cardiores
Review
Plasma A- and B-type natriuretic peptides: physiology, methodology and
clinical use
Frans Boomsma*, Anton H. van den Meiracker
Internal Medicine /Cardiovascular Research Institute COEUR, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
Received 17 November 2000; accepted 20 December 2000
Keywords: Natriuretic peptide; Atrial function; Ventricular function
1. Introduction
In the 20 years which have passed since the first
description by de Bold of a natriuretic and diuretic
substance produced in the heart [1], a large body of
research has firmly established the position of the heart as
an endocrine organ. Two peptides, both containing a 17-
amino acid ring structure, have been a focus of much
interest: atrial natriuretic peptide (ANP), and brain (or
B-type) natriuretic peptide (BNP). A third member of this
family of peptides, C-type natriuretic peptide, has been
described; it is mainly produced by the endothelium and
not by the heart, has no diuretic or natriuretic activity, and
will not be discussed here.
ANP is produced mainly in the cardiac atria, while BNP,
originally isolated from porcine brain, was soon reported
to be mainly produced in the cardiac ventricles. In recent
years, however, it has become clear that in fact both ANP
and BNP are produced both in atria and in ventricles, and
that ANP is normally predominant; under pathological
conditions production of BNP rises strongly in both atria
and ventricles and plasma concentrations may overtake
those of (also risen) ANP [2,3]. Both are formed as
pre-pro-polypeptides. Pro-atrial natriuretic peptide is a
126-amino acid peptide stored in atrial granulae; upon
secretion it is cleaved by a serine protease into equimolar
amounts of the active ANP (amino acids 99126) and the
inactive N-terminal fragment N-ANP (amino acids 198)
[4]. Further degradation of N-ANP may lead to several
*Corresponding author. University Hospital Dijkzigt, Internal Medi-
cine, Rm L-276, Dr. Molewaterplein 40, 3015 GD Rotterdam, The
Netherlands. Tel.: 131-10-463-3764; fax: 131-10-463-4531.
E-mail address: boomsma@inw1.azr.nl (F. Boomsma).
0008-6363 / 01 / $ see front matter 2001 Elsevier Science B.V. All rights reserved.
PII: S0008-6363( 01 )00195-X
smaller fragments some of which may also have biological
activity [5]. Less is known about the procession of BNP; it
is believed to be more constitutively expressed. Pro-brain
natriuretic peptide is a 108-amino acid peptide also cleaved
into equimolar amounts of the 32-amino acid active BNP
and an inactive N-terminal fragment, N-BNP. ANP, BNP,
N-ANP and N-BNP all circulate in plasma. In animals, the
structure of the natriuretic peptides is often very different,
especially for BNP, which is much less conserved than
ANP.
The triggering factor for release / production of ANP and
BNP is an increase in stretch and / or pressure, but neuro-
humoral factors such as angiotensin II and endothelin may
also play a role. Most effects of ANP and BNP are
mediated through binding to the A-type natriuretic peptide
receptor, which activates guanyl cyclase, leading to the
formation of cyclic guanosine monophosphate (cGMP).
Clearance of ANP and BNP from the blood is effected in
two ways: through a special clearance receptor, the C-type
natriuretic peptide receptor, and through enzymatic degra-
dation by neutral endopeptidase. The inactive N-terminal
fragments have no specific clearance receptor. As a result
they have a longer half-life, especially N-ANP, which
therefore circulates in plasma in much higher concen-
trations than ANP. Also, the concentration is thereby more
stable, being less influenced by short bursts of secretion.
In the following, we will briefly discuss the physiology
of ANP and BNP, the methodology for measurements, the
(potential) use of such measurements in clinical practice,
and pharmacological manipulation, based on what is
known at present and on our own experiences over the past
10 years in collaboration with many colleagues.
Time for primary review 25 days.
 F. Boomsma, A.H. van den Meiracker / Cardiovascular Research 51 (2001) 442 449
2. Physiological effects of ANP and BNP
The principal function of ANP and BNP is to protect the
cardiovascular system from volume overload. ANP and
BNP exert their effects by interaction with the subtype
A-natriuretic peptide receptor resulting in an increase in
intracellular cGMP concentration. The subtype A-receptor
is expressed in a variety of tissues, including kidney, blood
vessels, adrenal glands, heart, lungs, adipose tissue, eye,
pregnant uterus and placenta [6,7]. The other two subtypes
are the B-receptor, for which C-type natriuretic peptide has
by far the highest affinity, and the C-receptor, which is the
clearance receptor. Natriuretic peptides have both nat-
riuretic and diuretic effects. In addition, these peptides
cause intravascular volume contraction by inducing a shift
of fluid from the capillary bed to the interstitium, resulting
in a decrease in preload and blood pressure [810].
The natriuretic action of ANP is effected by several
mechanisms. In isolated kidneys as well as in normal
human subjects ANP increases glomerular filtration rate
(GFR), indicating that the renal haemodynamic effect of
ANP in part accounts for its natriuretic action. Contrary to
ANP, and notwithstanding a comparable natriuretic effect,
BNP does not increase GFR in humans [11]. Apart from
increasing GFR, ANP directly inhibits sodium transport in
the proximal tubule and in the inner medullary collecting
duct [1214]. Furthermore, ANP as well as BNP inhibit
aldosterone release from adrenal cells [15]. Moreover,
there is evidence that both natriuretic peptides inhibit renal
renin release. Because of these various actions natriuretic
peptides, from a functional point of view, may be regarded
as the natural antagonists of the sodium and volume
conserving and blood pressure elevating reninangiotensin
system [16,17].
In human subjects information about the physiological
role of ANP has indirectly been obtained by studying the
effects of prolonged low-dose infusions of ANP or BNP on
sodium balance and systemic haemodynamics [18]. From
this study it appears that an approximately two-fold
increase in plasma ANP concentration is sufficient to
induce a negative sodium balance, a fall in systolic and
diastolic blood pressure as well as an increase in heart rate.
The effects of equimolar low-dose infusions of ANP and
BNP, resulting in plasma levels of the respective peptides
as observed in mild-to-moderate heart failure (56-fold
increase), have been compared in a study performed in
hypertensive subjects. This study revealed that the nat-
riuretic and blood pressure lowering effects of BNP were
23-fold those of ANP [19]. Interestingly, despite the
greater natriuretic effect of BNP, urinary cGMP excretion
was lower with this peptide than with ANP.
Important information about the physiological role of
the natriuretic peptides has further been obtained in
experimental studies with HS-142-1, a selective antagonist
of the natriuretic peptide A and B receptor. Studies with
HS-142-1 performed in dogs have confirmed a role for the
443
endogenous natriuretic peptides in the control of renal
sodium excretion and in the natriuretic response to volume
expansion [20,21].
3. Methodology
3.1. Blood sampling conditions
With many neurohormonal parameters, measurements
are influenced by body position during blood sampling or
by venepuncture itself. With the natriuretic peptides, this is
not a great source of variation: blood sampling after 30
min of sitting gave the same values for ANP, BNP and
N-ANP as after 30 min of bed rest, although sampling
blood directly upon arrival or while standing resulted in
somewhat higher values (least for N-ANP) [22]. This is in
line with results of measurements after exercise, where
N-ANP increased by only 5%, versus 59% for ANP, 38%
for BNP and 24% for N-BNP [23].
3.2. Measurement
Ever since the discovery of the natriuretic peptides much
effort has been put into the development of reliable
methods for measuring them. All methods are based on
immunoassays, mostly radioactive ones. Various research
groups developed their own in-house radioimmunoassays
(RIAs), but several immunoassay kits have now become
commercially available [2430]. For many reported meth-
ods a prior extraction step from plasma using SepPak C-18
minicolumns is necessary. Since this extraction step leads
to losses in recovery (often 2030%), is laborious, and is
time-consuming, methods have been developed which
obviate the need for prior extraction and which can be
performed directly with plasma, giving results in 12 days.
Since the characteristics of antibodies can differ greatly,
outcomes of measurements can also vary greatly. Apart
from the natriuretic peptide of interest, varying amounts of
fragments, with partial or full cross-reactivity, may also
circulate in plasma, and thus can influence the outcome of
measurements. With (extraction) RIA kits for ANP (Nich-
ols, Wijchen, The Netherlands) and BNP (Peninsula,
Belmont, CA, USA) e.g. we determined normal ranges of
1535 and 716 pmol / l, respectively, while using the
non-extraction sandwich immunoradiometric assay
(IRMA) kits from Shionoria (Osaka, Japan) normal ranges
of 115 and 110 pmol / l, respectively, were determined
for ANP and BNP. Correlations are however good: in a
series of 48 samples, measured with both methods for ANP
and BNP, correlation coefficients of 0.83 and 0.91 were
found. Usually similar results are obtained regarding
elevations under pathophysiological conditions. An exam-
ple is shown in Table 1, where (mean6S.E.) values of
ANP and BNP are given in 20 controls and in 20 patients
with congestive heart failure, measured with the above-
444 F. Boomsma, A.H. van den Meiracker / Cardiovascular Research 51 (2001) 442 449
Table 1
Comparison of ANP and BNP as measured with radioimmunoassays and
with immunoradiometric assays a
Control Congestive heart failure
RIA IRMA RIA IRMA
ANP (pmol / l) 39.163.4 4.660.8 256.1648.9 59.4612.0
BNP (pmol / l) 12.160.6 4.460.5 102.9616.4 147.0625.3
a
Data are means6S.E. in 20 control subjects and in 20 patients with
congestive heart failure.
mentioned RIA as well as IRMA methods. The elevations
in CHF are obvious with both methods, although the
percentage increases compared to control vary. It is thus
imperative that for each method normal ranges are estab-
lished; data from different methods cannot be compared
directly.
In general, the methods used for ANP measurements
give the largest differences, although most report upper
levels of normal ,15 pmol / l. BNP normal ranges differ
less, and normal values are commonly reported to be lower
than 12 pmol / l. The concentration of N-ANP is higher due
to the longer half-life; with a non-extraction RIA from
Biotop (Oulu, Finland) we have determined a normal
range of 150500 pmol / l, which seems to agree reason-
ably well with most other methods available. Some
commercial kits for N-BNP have recently become avail-
able, but few if any experimental data are known at
present. In-house methods report upper levels of normal
,15 pmol / l, barely higher than BNP concentrations. An
upper limit of 200 pmol / l however has been reported with
an immunoluminometric method [31].
When looking at normal ranges, it should be borne in
mind that the concentrations of natriuretic peptides in-
crease with age, and there have also been reports that
females generally have higher ANP and BNP concen-
trations than males [27,32].
Transformation of different units of measurement can be
done using the following: 1 pmol / l of ANP;3.1 pg / ml; 1
pmol / l of BNP;3.5 pg / ml; 1 pmol / l of N-ANP;10.5
pg / ml, and 1 pmol / l of N-BNP;8.6 pg / ml.
3.3. Stability
The best way for reliable ANP and BNP measurements
is to collect blood in chilled EDTA-tubes (1.9 mg / ml) also
containing the protease inhibitor aprotinin (Trasylol; 100
kIU / ml), to prepare plasma as soon as possible (within 1
h, in the meantime kept on ice), and to store the plasma
preferably at 2708C, or for up to 2 months at 2208C.
Under these conditions, both ANP and BNP are stable, in
contrast to a single report on ANP, refuted by many others
[3341]. Stability is less in the absence of aprotinin. The
N-terminal peptides are more stable than the C-terminal
ones. In whole blood (containing aprotinin), BNP has been
reported to be stable for up to 3 days at room temperature,
and N-ANP for up to 4 days, which allows for uncooled
mail transport [42,43].
4. Use of natriuretic peptide measurements
4.1. Congestive heart failure ( CHF)
In view of the localization and secretion mechanism of
ANP and BNP, it is not surprising that elevated plasma
levels of these hormones are found in conditions of
increased cardiac wall stress. In CHF, circulating con-
centrations of both peptides (as well as of the N-terminal
ones) are clearly elevated [4449]. The elevation reflects
the severity of the condition. An example is given in Fig.
1, where ANP and N-ANP median values of 74 patients,
classified as NYHA class 0 (n57), I (n513), II (n543)
and III (n511) are depicted; the trend is highly significant
for both peptides [50]. In CHF, ANP is higher in patients
with atrial fibrillation, than in patients with a sinus rhythm
[51]. During long-standing atrial fibrillation ANP levels
decrease again and may even fall to very low levels due to
deficient ANP production by the degenerated, standstill
atria [52].
It has become increasingly clear that measurement of
one or more of the natriuretic peptides can be very helpful
in the often still difficult diagnosis of incipient or mild
CHF [53,54]. For example, in a study for diagnosis of CHF
in GP practices in a suburb of Rotterdam, it was shown
that combining history taking and a medical examination
with measurement of ANP, BNP or N-ANP resulted in a
receiver operating characteristic (ROC) of 0.870.92 for
correct diagnosis of heart failure, similar to ROC values
for more elaborate examinations including chest X-ray and
echocardiography [55].
Of interest is whether natriuretic peptides are useful
Fig. 1. Median ANP and N-ANP plasma concentrations in patients of
NYHA class 03.
 F. Boomsma, A.H. van den Meiracker / Cardiovascular Research 51 (2001) 442 449
markers for the very early detection of cardiac damage or
heart failure when patients are still asymptomatic. There is
limited evidence that this may be the case. For instance, in
a population-based study performed in 80 asymptomatic
patients with impaired left ventricular function (ejection
fraction 0.560.1), 26 patients with a persistently low
ejection fraction (0.460.1) 1.3 years after the first exami-
nation had elevated ANP and BNP concentrations (60 and
20 pmol / l, respectively). In the 54 patients in which the
ejection fraction had regressed to a normal value
(0.760.1), the ANP and BNP concentrations (34 and 13
pmol / l, respectively) were not different from normal
control values [56]. Repeated determination of atrial
natriuretic peptides may also be of value for the early
detection of cardiac damage induced by chemotherapy,
radiation or other conditions. In a follow-up study in 56
breast cancer patients, treated with anthracycline-contain-
ing adjuvant chemotherapy, it was shown that 17 patients
with exertional dyspnea, as an early sign of heart damage,
had significantly higher N-ANP plasma levels than the
patients without dyspnea [57]. Similarly, in 20 patients
with carcinoid syndrome (where heart failure is a cause of
high mortality) N-ANP was elevated in 70% of the patients
[58].
Although a normal natriuretic peptide concentration
virtually excludes the presence of heart failure (negative
predictive value .90%), the reverse is not true. Elevated
levels have a positive predictive value of only 3040%, as
other conditions like renal failure or pulmonary embolism
may elevate the concentration of natriuretic peptides as
well. For the diagnosis of CHF it is still open to discussion
which of the natriuretic peptides can most profitably be
used. For reasons of in-vitro and in-vivo stability in blood,
the N-terminal peptides may have advantages, but at this
time most experience has been obtained with BNP [59,60].
Several studies have clearly shown that natriuretic
peptides are excellent prognostic indicators for survival in
heart failure [6164]. Our own results in 372 patients with
congestive heart failure, followed-up for 5 years, indicate
that ANP, BNP and N-ANP are superior over the more
classical neurohormones like noradrenaline and renin [65].
It is interesting that several studies seem to indicate that
natriuretic peptides have a higher predictive value for
survival of CHF than ejection fraction.
Follow-up of treatment in CHF is another useful reason
for measuring natriuretic peptides: a continued increase in
plasma concentrations would be indicative of unsuccessful,
and a decrease of successful, treatment [66]. A first
encouraging study in which pharmacotherapy for heart
failure was guided by plasma concentrations of N-BNP has
recently been published [67].
With the advent of rapid simple methods for on-the-spot
measurements of natriuretic peptides hsuch as the recently
launched Triage system for BNP (Biosite Diagnostics, La
Jolla, CA, USA), which provides results in 15 min [68]j, it
is foreseen that plasma levels of atrial natriuretic peptides
445
will be used with increasing frequency both for diagnosis
and follow-up of patients with CHF.
4.2. Acute coronary syndromes
In myocardial infarction ANP and BNP concentrations
are also elevated, and are of prognostic value for indicating
patients most at risk [6976]. N-ANP and N-BNP, mea-
sured a few days after myocardial infarction, appear to
have a better predictive value in this respect than ANP.
In patients with unstable angina pectoris BNP, but not
ANP, concentrations were found to be four times higher as
compared to values obtained in patients with stable angina
pectoris or healthy control subjects [77].
4.3. Right ventricular overload
As mentioned previously, elevations in plasma ANP
and / or BNP concentrations might also give information
about the condition of the right ventricle. Indeed, in
asymptomatic patients with right ventricular pressure
overload due to congenital heart disease both BNP and
ANP plasma levels were significantly increased, and
correlated inversely with right ventricular ejection fraction
as determined by magnetic resonance imaging [78].
Elevated plasma BNP concentrations have also been
found in patients with an acute pulmonary embolism
[79,80].
4.4. Renal failure
In chronic renal failure natriuretic peptides are often
markedly elevated [8183]. Overfilling, a diminished
clearance and myocardial dysfunction may all contribute to
this elevation. Plasma concentrations in patients with end-
stage renal failure can vary widely. In seven patients on
chronic haemodialysis, we found predialysis plasma ANP
concentrations ranging from 90 to 2617 pmol / l and plasma
BNP concentrations ranging from 6 to 2235 pmol / l. One
hour after dialysis concentrations had declined by (median
values of) 32% for ANP and 7% for BNP, most likely
indicating that overfilling contributed to the elevated
levels. This is supported by other studies showing a
decrease in plasma ANP and BNP concentrations after
hemodialysis [84,85]. Of interest is that an impaired renal
function in CHF is a strong independent predictor of
mortality, and that it is inversely related to increased levels
of N-ANP [86]. In patients with chronic renal failure
concentrations of BNP have been found to be independent
prognostic parameters for survival, just as in CHF [85].
4.5. Hypertension
In hypertensive patient reports on whether natriuretic
peptides are elevated are not uniform, but most studies
report an elevation [8789]. To some extent this may be
446 F. Boomsma, A.H. van den Meiracker / Cardiovascular Research 51 (2001) 442 449
related to the absence or presence of left ventricular
hypertrophy (LVH) [9095]. If hypertension is compli-
cated by left ventricular hypertrophy atrial natriuretic
peptides are usually elevated, and as expected, plasma
BNP concentration correlates better with left ventricular
mass than with plasma ANP concentration.
In elderly, never-previously treated hypertensive sub-
jects without overt heart failure, both ANP and BNP
concentrations have been shown to be elevated in those
subjects with concentric LVH, but not in those without
LVH or in those with eccentric remodelling of the left
ventricle [9698]. Measurement of BNP as a marker for
left ventricular dysfunction has been advocated [99102].
In a recently published population-based study in 610
middleaged subjects plasma BNP concentration as com-
pared to control subjects were significantly and markedly
increased in subjects with an increased LV mass as well as
in subjects with systolic dysfunction [103]. After perform-
ing a multivariate analysis the positive and negative
predictive value of BNP as a non-invasive marker to detect
LVH was respectively 32 and 86%, respectively. This
means that a substantial number of positively tested
subjects will not suffer from this condition if BNP is used
as a screening test for LVH. Thus, although BNP de-
termination may be useful as a screening test to detect
LVH in the hypertensive population, its value as a screen-
ing test in a population-based study for the detection of
LVH remains doubtful.
5. Pharmacological manipulation
Administration of ANP has been successfully used for
increasing natriuresis and diuresis in patients with heart
failure [19,104106]. As natriuretic peptides have to be
given by a continuous intravenous infusion, an important
alternative to ANP administration would be drugs that can
increase the concentrations of ANP and / or BNP. Two
alternative therapeutic options are now available.
The first is the use of drugs that inhibit neutral endo-
peptidase, the enzyme responsible for break-down of ANP.
One such drug, candoxatril, indeed increases ANP con-
centrations [107]. Much more promising is the develop-
ment of combined neutral endopeptidase / angiotensin-con-
verting enzyme inhibitors of which omapatrilat presently is
investigated in phase II and III clinical trials in patients
with CHF and hypertension. In a recently published study
performed in patients with CHF 12-weeks of administra-
tion of omapatrilat appeared to have advantages over
lisinopril [108]. Whether in the long run the effect of
agents that increase endogenous concentrations of nat-
riuretic peptides will be counteracted by an increase in the
expression of the clearance receptor, the alternative way of
degrading ANP, remains uncertain.
A second method may be the use of beta-blockers.
Beta-blockers are now used with increasing frequency in
patients with CHF. The mechanism by which beta-blockers
Fig. 2. ANP and BNP plasma concentrations in hypertensive patients:
basal and after 6 weeks of treatment with Losartan or Bisoprolol. Data are
means6S.E. *P,0.0001 vs. basal.
improve myocardial function and survival in CHF is still
not completely understood. In our own hands, administra-
tion of bisoprolol, a beta 1 -selective beta-blocker to 24
patients with hypertension increased ANP concentrations
from 50.1 to 83.0 pmol / l, and BNP from 6.6 to 14.7
pmol / l, while administration of losartan, an angiotensin II
receptor antagonist, did not effect ANP or BNP con-
centrations (Fig. 2) [109]. If such increases in atrial
natriuretic peptides are therapeutically beneficial, they
might lead to improvement of CHF, and thereby to a
decrease in ANP and BNP secretion. This might well
explain that, despite clinical improvement, chronic beta-
blocker treatment in patients with advanced CHF is not
associated with changes in plasma ANP or N-ANP con-
centrations [110].
In conclusion, measurements of plasma N-ANP and / or
N-BNP are of increasing importance for assessing the
condition of the heart, as is serum creatinine concentration
for renal function. Natriuretic peptide measurements will
become invaluable tools for diagnosis of diseases as CHF
and pulmonary embolism, for early and timely detection of
the beginning of ventricular or atrial problems in con-
ditions associated with an increased risk of heart failure,
for identifying heart failure patients most at risk, and for
the follow-up of the effects of treatment in CHF. Pharma-
cological manipulation aimed to increase the concentra-
tions of ANP and BNP and thereby enhancing their
natriuretic, diuretic and vasodilatory effects in patients
with heart failure as well as hypertension is underway and
will become of increasing interest.
Acknowledgements
We gratefully acknowledge the fruitful cooperations we
had with many colleagues in the investigations of the
 F. Boomsma, A.H. van den Meiracker / Cardiovascular Research 51 (2001) 442 449
natriuretic peptides. In particular, we thank D.J. van
Veldhuisen, G. Tjeerdsma, W. Terpstra, A. Teisman and
M.P. van den Berg (Cardiology, University Hospital
Groningen), M. Meinardi, E.G.E. de Vries and D.T. Sleijfer
(Oncology, University Hospital Groningen), I.I. Tulevski
and B.J.M. Mulder (Cardiology, Academic Medical Center
Amsterdam), A. Mosterd, A.A.M. Wijbinga and A.H.M.M.
Balk (Cardiology, University Hospital Dijkzigt, Rotter-
dam) and B. Cost, D.E. Grobbee, A.W. Hoes and A.
Hofman (Epidemiology, Erasmus University Rotterdam).
Special thanks are due to Usha M. Bhaggoe for her
excellent technical expertise in the measurement of nat-
riuretic peptides.
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