The European Journal of Heart Failure 6 (2004) 257260

Essential biochemistry and physiology of (NT-pro)BNP

Christian Hall*
Research Institute for Internal Medicine, University of Oslo, Rikshospitalet, 0037 Oslo, Norway

Received 3 December 2003; accepted 20 December 2003

Abstract

Brain natriuretic peptide (BNP) is a 32 amino acid cardiac natriuretic peptide hormone originally isolated from porcine brain
tissue. The human BNP gene is located on chromosome 1 and encodes the prohormone proBNP. The biologically active BNP
and the remaining part of the prohormone, NT-proBNP (76 amino acids) can be measured by immunoassay in human blood.
Cardiac myocytes constitute the major source of BNP related peptides. The main stimulus for peptide synthesis and secretion is
myocyte stretch. Recently, cardiac fibroblasts have also been shown to produce BNP. Other neurohormones may stimulate cardiac
BNP production in different cardiac cell types. In contrast to atrial natriuretic peptides (ANPyNT-proANP), which originate
mainly from atrial tissue, BNP related peptides are produced mainly from ventricular myocytes. Ventricular (NT-pro)BNP
production is strongly upregulated in cardiac failure and locally in the area surrounding a myocardial infarction. In peripheral
organs BNP binds to the natriuretic peptide receptor type A causing increased intracellular cGMP production. The biological
effects include diuresis, vasodilatation, inhibition of renin and aldosterone production and of cardiac and vascular myocyte growth.
In mice BNP gene knockout leads to cardiac fibrosis, gene over-expression to hypotension and bone malformations. BNP is
cleared from plasma through binding to the natriuretic peptide clearance receptor type C, but it seems relatively resistant to
proteolysis by neutral endopeptidase NEP 24.11. Clearance mechanisms for NT-proBNP await further study. While the plasma
concentration of NT-proBNP and BNP is approximately equal in normal controls, NT-proBNP plasma concentration is 210 times
higher than BNP in patients with heart failure. This relative change in peptide levels may be explained by shifts in cardiac
secretion andyor clearance mechanisms.
2004 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Brain natriuretic peptide; Human; Prohormone

1. Introduction peptide containing a disulfide bridge constituting a ring

The suspicion that the heart may have an endocrine
function was raised approximately 50 years ago. At the
time it was shown that dilatation of cardiac atria pro-
duced natriuresis w1x. Furthermore, demonstration by
electron microscopy of intracellular granules in atrial
myocytes resembling those found in endocrine cells,
supported the notion that the heart might be an endocrine
organ w2x. The definitive demonstration of this was
provided by deBold and associates in their classic
experiment published in 1981 w3x. They injected extracts
from atrial myocytes into rats and a brisk natriuresis
and diuresis was observed. Flynn later showed that the
active factor, termed atrial natriuretic factor (ANF), later
atrial natriuretic peptide (ANP), was a 28 amino acid
*Tel.: q47-23073612; fax: q47-23073630.
E-mail address: Christian.hall@klinmed.uio.no (C. Hall).
structure w4x.
In 1988 Sudoh working in Matsuos research group
demonstrated an ANP-like natriuretic peptide from por-
cine brain, named brain natriuretic peptide (BNP) w5x.
Subsequent experiments showed that BNP was produced
in cardiac myocytes and that it shared peripheral recep-
tors with ANP w6x. Thus, today we know that the heart
secretes two cardiac natriuretic peptides with a homol-
ogous structure, ANP and BNP (Fig. 1). A third homol-
ogous natriuretic peptide, termed CNP, is produced in
brain and endothelium, but apparently not in cardiac
myocytes.
2. Structure and measurement of (Nt-pro)BNP
The human BNP gene is located on chromosome 1
and encodes the 108 amino acid prohormone proBNP.
In the circulation the biologically active 32 amino acid

1388-9842/04/$ - see front matter 2004 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejheart.2003.12.015
258 C. Hall / The European Journal of Heart Failure 6 (2004) 257260

Fig. 1. Cardiac natriuretic peptides ANP (28 aminoacids) and BNP (32 aminoacids) are homologous in structure, forming a ring with a disulfide
bridge. Identical aminoacids are marked black.

BNP hormone is separate from the n-terminal part of be found in the circulation and split prohormone can be
the prohormone termed NT-proBNP (Fig. 2). It is found in cellular extracts. Data from in vitro experiments
currently debated when and where the prohormone split indicate that the proteolytic enzyme furin is responsible
takes place since small amounts of intact proBNP may for splitting the prohormone into its two subsections w7x.

Fig. 2. Schematic drawing of proBNP showing enzymatic cleavage into biologically active BNP and NT-proBNP.
 C. Hall / The European Journal of Heart Failure 6 (2004) 257260
Table 1
Qualitative summary of some clinically relevant physiologic charac-
teristics of cardiac natriuretic peptide systems ANP and BNP
Characteristic ANP BNP
Localisation within heart Atrial Atrial and ventricular
Atrial storage pool Large Small
Basal cardiac secretion qq (q)
Gene transcription response to stretch Slow Rapid
Relative increase in heart failure q qqq
NT-proBNP and BNP can be measured by immuno-
assay. The first measurement of NT-ProBNP was report-
ed by Hunt w8x while other groups have also developed
their in-house methods w911x. Early work utilized
competitive radioimmunoassays while a commercially
available method from Roche Diagnostics utilizes a two-
site sandwich principle and detection by
chemiluminescence.
3. Secretion of (Nt-pro)BNP
Cardiac myocytes constitute the major source of BNP-
related peptides in the circulation. Recently, cardiac
fibroblasts have also been shown to produce BNP w12x.
The quantitative contribution of this latter source to
circulating plasma concentrations is not known. The
main stimulus for ANP and BNP peptide synthesis and
secretion is cardiac wall stress w13x. In addition in vitro
experiments have indicated that other neurohormones
may modulate cardiac BNP production in a paracrine
and possibly endocrine fashion w14x. Since increased
cardiac wall stress is a common denominator of many
cardiac diseases, it follows that circulating natriuretic
peptides may serve as clinical biochemical markers of
these states.
There are clear differences between the two cardiac
natriuretic peptide systems with regard to intracellular
storage and secretion mechanisms (Table 1). ANP is
stored in atrial granules and atrial stretch is accompanied
by a rapid outpouring of ANP-related peptides. With
respect to denovo synthesis of peptide there is a rela-
tively slow activation of the ANP gene. In contrast (Nt-
pro)BNP is secreted by a constitutive mechanism. This
implies that only small amounts are stored in granules
and the cells are dependent on activation of the BNP
gene when increased peptide secretion is called upon.
However, in comparison to ANP, the activation of the
BNP gene occurs more rapidly w15x. In summary, in
settings where acute changes in atrial stretch is incurred
the change in the circulating peptide levels are more
rapid for the ANP related than for BNP related peptides
w16x.
Studies comparing the peptide production in different
cardiac chambers have disclosed further important dif-
ferences between the two natriuretic peptide systems
259
(Table 1). In the normal organism the atria is the main
source of both peptides. However, with chronic myocyte
stretch as in chronic heart failure there is an upregulation
of ventricular natriuretic peptide production w1719x. In
relative terms this upregulation seems quantitatively
more important for the BNP related peptides than for
the ANP related peptides. Thus, in the literature BNP is
often called the ventricular hormone, but this represents
an oversimplification. Nevertheless, it seems clear that
when atrial tissue is taken as a reference, ventricular
BNP production is higher than that of ANP, especially
in heart failure. Similarly, after myocardial infarction
ventricular BNP production seems to be upregulated to
a greater degree than ANP production, possibly second-
ary to local stretch mechanisms in the area surrounding
the infarcted area w20x.
4. Physiological effects of (Nt-pro)BNP
The physiological effects of BNP have been studied
by injection of BNP into the intact organism, by expos-
ing cells or organs to increased BNP concentrations, or
by the design of mice overexpressing BNP, or with BNP
gene knockout. This work has shown that BNP (like
ANP) binds to the natriuretic peptide receptor type A,
causing increased intracellular cyclic GMP production
w6x. The biological effects thus produced include diure-
sis, vasodilatation, inhibition of renin and aldosterone
production and of cardiac and vascular myocyte growth.
Mice overexpressing the BNP gene exhibit systemic
hypotension and bone malformations w21x. BNP knock-
out mice exhibit cardiac fibrosis, but no hypertension
w22x. This has led to the speculation that there may be
a separate hitherto unknown receptor for BNP in cardiac
fibroblasts. In addition to the natriuretic peptide receptor
A, BNP also binds to natriuretic peptide receptor type
C, which is thought to function as a clearance receptor.
Whether NT-proBNP has biological effects on its own
is currently unknown. Likewise it is unknown whether
intact prohormone can bind to the peripheral receptors.
5. Clearance of (Nt-pro)BNP
Natriuretic peptides are cleared from plasma by bind-
ing to the natriuretic peptide receptors, but also through
proteolysis by peptidases, the most closely studied being
neutral endopeptidase (NEP) 24.11. Compared to ANP,
BNP, seems relatively resistant to NEP degradation w23x.
Studies in sheep have demonstrated that NT-proBNP has
a longer half-life than BNP w24x. Renal excretion is
currently regarded its main clearance mechanism, but
this topic awaits further study. Interestingly, some data
have indicated that the relative concentration between
NT-proBNP and BNP may shift when healthy individ-
uals are compared with patients with heart failure w25x.
The mechanism underlying this concentration shift is
260 C. Hall / The European Journal of Heart Failure 6 (2004) 257260
unknown, but it may be related to intracardiac produc-
tion changes as well as a shift in the degradation and
half-life secondary to receptor regulation andyor cardiac
output redistribution.
6. Summary
Cardiac myocytes produce BNP prohormone, proBNP,
which is encoded from the BNP gene located on
chromosome 1. ProBNP is split into NT-proBNP and
BNP by the protease furin. The main regulatory mech-
anism for cardiac (Nt-pro)BNP production is cardiac
wall stress. When chronic heart failure develops there is
a relative shift in cardiac (Nt-pro)BNP production from
the atria to the ventricles. After secretion, BNP binds to
natriuretic peptide receptors A and C. The biological
effects include diuresis, vasodilatation, inhibition of
renin and aldosterone production and of cardiac and
vascular myocyte growth. The biological effects of NT-
proBNP are unknown. Its half-life is considerably longer
than that of BNP. The cardiac wall stress-hormone
production link constitutes the basis for using NT-
proBNP and BNP as clinical biochemical markers of
cardiac disease.
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