A symbolic representation of heart failure diagnosis challenges in the elderly.

Heart Failure in the Elderly: Is the Standard Diagnostic Test Missing the Mark?

Reese Marlowe in Health & Wellness December 2025 • 4 min read.

"New research suggests that common heart failure tests may not be as accurate for seniors, potentially leading to missed diagnoses and inadequate care. Here’s what you need to know."

Heart failure (HF) is a serious condition affecting millions worldwide, and its prevalence increases with age. In fact, the average age of a newly diagnosed heart failure patient is 76, a number that's expected to rise as populations age. This makes accurate and timely diagnosis in older adults absolutely critical.

One of the key tools in diagnosing heart failure is measuring levels of a substance called N-terminal pro-brain natriuretic peptide (NT-proBNP) in the blood. NT-proBNP is released by the heart when it's under stress, and elevated levels can indicate heart failure. However, NT-proBNP levels naturally increase with age, even in the absence of heart disease, raising questions about its reliability in older patients.

A recent study published in The American Journal of Cardiology sheds light on this issue, suggesting that the standard NT-proBNP test may not be as accurate in patients over 80 compared to younger individuals. This has significant implications for how we diagnose and manage heart failure in our aging population.

The NT-proBNP Dilemma: Why Age Matters

A symbolic representation of heart failure diagnosis challenges in the elderly.

The study, conducted at a tertiary hospital in the United Kingdom, analyzed data from nearly 2,000 patients admitted for suspected heart failure. The researchers found that NT-proBNP was less accurate at identifying heart failure in patients over 80. Specifically, the area under the curve (AUC), a measure of diagnostic accuracy, was lower in this age group compared to younger patients (60-79 years).

This means that using the standard NT-proBNP cutoff values could lead to both false positives (diagnosing heart failure when it's not present) and false negatives (missing a diagnosis of heart failure). The researchers even noted that the lowest NT-proBNP level recorded in a heart failure patient over 80 was 466 pg/mL, higher than the standard cutoff of 300 pg/mL recommended by guidelines.

Reduced Accuracy: NT-proBNP's ability to accurately diagnose heart failure decreases with age, especially in those over 80.
Higher Thresholds: The standard NT-proBNP cutoff of 300 pg/mL may be too low for older adults, potentially leading to false negatives.
Risk of Misdiagnosis: Relying solely on NT-proBNP levels can result in missed or delayed diagnoses of heart failure in the elderly.

So, what's the reason behind this age-related difference? Several factors could be at play. As we age, our kidneys become less efficient at clearing NT-proBNP from the blood, leading to naturally higher levels. Additionally, other age-related conditions, such as kidney disease or atrial fibrillation, can also elevate NT-proBNP, making it harder to distinguish heart failure from other causes.

Rethinking Heart Failure Diagnosis in the Elderly

The study authors suggest that the NT-proBNP threshold for ruling out heart failure in patients over 80 may need to be modified. This means raising the cutoff value to improve accuracy and reduce the risk of missed diagnoses. They emphasize that clinicians should consider a higher cut point for NT-proBNP, around 466 pg/mL, to avoid missing potential HF cases in the >80 age bracket.

About this Article -

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This article is based on research published under:

DOI-LINK: 10.1016/j.amjcard.2018.09.004, Alternate LINK

Title: Comparison Of The Diagnostic Accuracy Of Plasma N-Terminal Pro-Brain Natriuretic Peptide In Patients ≪80 To Those ≫80 Years Of Age With Heart Failure

Subject: Cardiology and Cardiovascular Medicine

Journal: The American Journal of Cardiology

Publisher: Elsevier BV

Authors: Jane Draper, Jessica Webb, Tom Jackson, Hamish Jones, Christopher A Rinaldi, Rebekah Schiff, Theresa Mcdonagh, Reza Razavi, Gerald S Carr-White

Published: 2018-12-01

Everything You Need To Know

What is NT-proBNP, and why is it used in diagnosing heart failure?

NT-proBNP (N-terminal pro-brain natriuretic peptide) is a substance released by the heart when it's under stress. Doctors measure its levels in the blood to help diagnose heart failure (HF). Elevated levels of NT-proBNP can indicate that the heart is struggling to pump blood effectively. However, it's important to note that NT-proBNP levels can increase with age, even without heart disease, which complicates its use in older adults.

How accurate is the standard NT-proBNP test for diagnosing heart failure in people over 80?

Research indicates that the standard NT-proBNP test may be less accurate in patients over 80 compared to younger individuals. The study found a lower area under the curve (AUC), which measures diagnostic accuracy, in those over 80. This means the test is more likely to produce false positives (diagnosing HF when it's not present) and false negatives (missing a heart failure diagnosis) in this age group. This reduced accuracy is a concern because it can lead to delayed or missed diagnoses, impacting treatment and quality of life.

Why might the standard NT-proBNP cutoff values be problematic for older adults?

The standard NT-proBNP cutoff of 300 pg/mL, recommended by guidelines, may be too low for older adults. Because NT-proBNP levels naturally increase with age and can be affected by other age-related conditions, a lower cutoff can lead to missed diagnoses of heart failure. In the study, a patient over 80 with heart failure had an NT-proBNP level of 466 pg/mL, which is higher than the standard cutoff, highlighting that the current cutoffs may not be appropriate.

What factors contribute to the age-related differences in NT-proBNP levels?

Several factors contribute to the age-related differences in NT-proBNP levels. As people age, their kidneys become less efficient at clearing NT-proBNP from the blood, leading to naturally higher levels. Additionally, other age-related conditions like kidney disease or atrial fibrillation can also elevate NT-proBNP, making it harder to distinguish heart failure from other causes. These factors can lead to the misinterpretation of NT-proBNP results in older patients.

What changes are suggested for diagnosing heart failure in elderly patients using NT-proBNP?

Researchers suggest that the NT-proBNP threshold for ruling out heart failure in patients over 80 may need to be modified. This means that the cutoff value should be raised to improve accuracy and reduce the risk of missed diagnoses. Clinicians should consider a higher cut point, around 466 pg/mL, for NT-proBNP in this age group to avoid overlooking potential heart failure cases. This modification is crucial to ensure that elderly patients receive the correct diagnosis and appropriate treatment for their condition.