The BNP Enigma in a Patient with Osteoporosis and Heart Failure

December 23, 2023by Dr. S. F. Czar0

Case Study:


  • 65-year-old woman with a 10-year history of osteoporosis and a recent diagnosis of heart failure with preserved ejection fraction (HFpEF).
  • No prior history of cardiovascular disease or significant comorbidities.
  • Medications: calcium and vitamin D supplements, bisphosphonates for osteoporosis, and diuretics for HFpEF.


  • Routine follow-up for osteoporosis reveals persistent back pain and a new fragility fracture of the wrist.
  • Echocardiogram confirms HFpEF with normal left ventricular ejection fraction but diastolic dysfunction.
  • Laboratory findings:
    • Serum calcium: 9.0 mg/dL (normal range: 8.5-10.5 mg/dL)
    • Parathyroid hormone: 30 pg/mL (normal range: 15-65 pg/mL)
    • BNP: 120 pg/mL (normal range: <40 pg/mL)

Clinical Dilemma:

The patient’s elevated BNP level despite normal ejection fraction presents a diagnostic conundrum. It could indicate:

  • BNP elevation due to HFpEF: BNP is often elevated in HFpEF even without overt structural abnormalities.
  • BNP elevation due to osteoporosis: The patient’s osteoporosis and fracture raise the possibility of BNP contributing to bone loss directly or indirectly through calcium homeostasis or RAAS modulation.
  • Combined effect of both conditions: The elevated BNP might be a culmination of both heart failure and osteoporosis.

Diagnostic Evaluation:

  • Holter monitoring reveals no significant arrhythmias.
  • Renal function tests and electrolytes are within normal limits.
  • Dual-energy X-ray absorptiometry (DXA) scan confirms ongoing bone loss despite previous treatment.
  • BNP levels are monitored over time to assess trends and response to therapy.


  • Optimization of HFpEF therapy with diuretics and lifestyle modifications.
  • Continued treatment for osteoporosis with bisphosphonates and adequate calcium and vitamin D supplementation.
  • Consideration of additional osteoporosis therapies based on DXA results and fracture risk assessment.
  • Close monitoring of BNP levels and clinical symptoms to differentiate the contributions of HFpEF and osteoporosis to BNP elevation and guide future management decisions.


This case illustrates the complex interplay between BNP, osteoporosis, and heart failure. The elevated BNP level challenges traditional diagnostic paradigms and highlights the need for a holistic approach to managing patients with overlapping conditions. While differentiating the exact cause of BNP elevation in this case remains difficult, close monitoring, serial BNP measurements, and careful evaluation of both cardiac and bone health are crucial for optimizing treatment and preventing future complications.

This case also underscores the potential of BNP as a biomarker for early detection of bone loss and fracture risk in patients with osteoporosis, especially those with concurrent cardiovascular conditions. Further research is needed to establish BNP’s utility in this context and develop effective management strategies for patients with the overlapping burden of osteoporosis and heart failure.

Note: This case study is for illustrative purposes only and does not constitute medical advice. Please consult with a qualified healthcare professional for personalized recommendations regarding the diagnosis and management of osteoporosis and heart failure.

I hope this case study provides a practical example of how the BNP enigma manifests in a clinical setting and emphasizes the importance of considering the bone-heart-hormone axis for comprehensive patient care.

Leave a Reply

Your email address will not be published. Required fields are marked *

© 2023. All rights reserved.