B-Type Natriuretic Peptide Can Predict the Medium-Term Risk in Patients With Acute Heart Failure and Preserved Systolic Function

An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure

INTRODUCTION

Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification.

AREAS COVERED

This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF.

EXPERT OPINION

NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.

Gender-Related Differences in Heart Failure Biomarkers

Important differences in comorbidities and clinical characteristics exist between women and men with heart failure (HF). In particular, differences in the kinetics of biological circulating biomarkers—a critical component of cardiovascular care—are highly relevant. Most circulating HF biomarkers are assessed daily by clinicians without taking sex into account, despite the multiple gender-related differences observed in plasma concentrations. Even in health, compared to men, women tend to exhibit higher levels of natriuretic peptides and galectin-3 and lower levels of cardiac troponins and the cardiac stress marker, soluble ST2. Many biological factors can provide a reliable explanation for these differences, like body composition, fat distribution, or menopausal status. Notwithstanding, these sex-specific differences in biomarker levels do not reflect different pathobiological mechanisms in HF between women and men, and they do not necessarily imply a need to use different diagnostic cut-off levels in clinical practice. To date, the sex-specific prognostic value of HF biomarkers for risk stratification is an unresolved issue that future research must elucidate. This review outlines current evidence regarding gender-related differences in circulating biomarkers widely used in HF, the pathophysiological mechanisms underlying these differences, and their clinical relevance.

Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care

AIMS

The UK National Institute for Health and Care Excellence (UK-NICE) and European Society of Cardiology (ESC) guidelines advise natriuretic peptide (NP) assessment in patients presenting to primary care with symptoms possibly due to chronic heart failure (HF), to determine need for specialist involvement. This prospective service evaluation aimed to describe the diagnostic and prognostic utility of these guidelines.

METHODS AND RESULTS

We prospectively collected clinical, echocardiography and outcomes data (minimum 5 years) from all patients referred to the Leeds HF Service for 12 months of following the initiation of the NP-guideline-directed pathway. Between 1 May 2012 and 1 August 2013, 1020 people with symptoms possibly due to HF attended either with a raised NT-pro-BNP or a previous myocardial infarction (MI) with an overall rate of left ventricular systolic dysfunction (LVSD) of 33%. Of these, 991 satisfied the ESC criteria (NT-pro-BNP ≥125 pg/mL) in whom the rate of LVSD was 32%, and 821 the UK-NICE criteria in whom the rate of LVSD was 49% in those with a previous MI, 25% in those with NT-pro-BNP concentration 400-2000 pg/mL, and 54% in those with NT-pro-BNP concentration of >2000 pg/mL. An NT-pro-BNP concentration 125-400 pg/mL had a 12% risk of LVSD. Specificity was poor in women >70 years, who made up the largest proportion of attendees. Elevated NT-pro-BNP levels were associated with lower survival even in the absence of LVSD.

CONCLUSION

In people referred through the ESC and UK-NICE guidelines, elevated NT-pro-BNP is a marker of increased mortality risk, but there is wide variation in specificity for LVSD. Age- and sex-adjusted criteria might improve performance.

The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure

Heart failure (HF) is a growing challenge in the Asia Pacific region. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-established tool for diagnosis of HF; however, it is relatively underutilized in predicting adverse outcomes in HF. Multiple studies have demonstrated the prognostic role of NT-proBNP in HF. A single value of NT-proBNP >5000 pg/mL predicts a worse outcome in hospitalized patients with HF with reduced ejection fraction (HFrEF). In stable outpatients with HFrEF, NT-proBNP > 1000 pg/mL predicts a poorer prognosis. NT-proBNP provides the same prognostic information in patients with HF with preserved ejection fraction (HFpEF) as in those with HFrEF. An expert panel composed of cardiologists mainly from Asia Pacific region was convened to discuss the utility of NT-proBNP in HF prognostication. This article summarizes available scientific evidence and consensus recommendations from the meeting.

Prognosis and NT-proBNP in heart failure patients with preserved versus reduced ejection fraction

BACKGROUND

We assessed the prognostic significance of absolute and percentage change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients hospitalised for acute decompensated heart failure with preservedejection fraction (HFpEF) versus heart failure with reduced ejection fraction (HFrEF).

METHODS

Patients with left ventricular ejection fraction ≥50% were categorised as HFpEF (n=283), while those with <40% as were categorised as HFrEF (n=776). Prognostic values of absolute and percentage change in NT-proBNP levels for 6 months all-cause mortality after discharge were assessed separately in patients with HFpEF and HFrEF by multivariable adjusted Cox regression analysis. Comorbidities were compared between heart failure groups.

RESULTS

Discharge NT-proBNP levels predicted outcome similarly in HFpEF and HFrEF: for any 2.7-factor increase in NT-proBNP levels, the HR for mortality was 2.14 for HFpEF (95% CI 1.48 to 3.09) and 1.96 for HFrEF (95% CI 1.60 to 2.40). Mortality prediction was equally possible for NT-proBNP reduction of ≤30% (HR 4.60, 95% CI 1.47 to 14.40 and HR 3.36, 95% CI 1.93 to 5.85 for HFpEF and HFrEF, respectively) and for >30%-60% (HR 3.28, 95% CI 1.07 to 10.12 and HR 1.79, 95% CI 0.99 to 3.26, respectively), compared with mortality in the reference groups of >60% reductions in NT-proBNP levels. Prognostically relevant comorbidities were more often present in patients with HFpEF than patients with HFrEF in low (≤3000 pg/mL) but not in high (>3000 pg/mL) NT-proBNP discharge categories.

CONCLUSIONS

Our study highlights-after demonstrating that NT-proBNP levels confer the same relative risk information in HFpEF as in HFrEF-the possibility that comorbidities contribute relatively more to prognosis in patients with HFpEF with lower NT-proBNP levels than in patients with HFrEF.

Performance of the MAGGIC heart failure risk score and its modification with the addition of discharge natriuretic peptides

Aims

Predictive models for heart failure patients are widely used in the clinical practice to stratify patients' mortality and enable clinicians to tailor and intensify their approach. However, such models have not been validated internationally. In addition, biomarkers are now frequently measured to obtain prognostic information, and the implications of this practice are not known. In this study, we aimed to validate the model performance of the Meta‐analysis Global Group in Chronic Heart Failure (MAGGIC) score in a Japanese acute heart failure registry and further explore the incremental prognostic value of discharge B‐type natriuretic peptide (BNP) level.

Methods and Results

In this study, we evaluated the registered data of 2215 consecutive acute HF patients (with 694 119 person‐years follow‐up) from a prospective multicentre registry (the West Tokyo Heart Failure) conducted in Japan from April 2006 to August 2016. The mean age was 73.0 ± 13.0, and 61.2% were male. The MAGGIC score demonstrated modest discrimination (c‐index = 0.71, 95% confidence interval 0.67–0.74) and good calibration (R² value = 0.97); there was constant overestimation for 1 year mortality. However, when the BNP level was added to the original MAGGIC variables, the model demonstrated good discrimination (c‐index = 0.74, 95% confidence interval 0.70–0.78) with adequate calibration (R² value = 0.91). The modified MAGGIC BNP score was externally validated in a separate Japanese registry (NaDEF) and demonstrated moderate discrimination (c‐index = 0.69, 95% confidence interval 0.65–0.73) and calibration (R² value = 0.85).

Conclusion

The original MAGGIC score performed modestly in Japanese patients, but the addition of discharge BNP level enhanced model performance. The addition of objective biomarkers may result in effective modification of preexisting internationally recognized risk models and aid in multinational comparisons of heart failure patients' outcomes.

Serial Measurement of Amino-Terminal Pro-B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Outcome in Children With Primary Myocardial Dysfunction and Acute Decompensated Heart Failure

OBJECTIVES

In children, elevated amino-terminal pro-B-type natriuretic peptide levels are associated with impaired heart function. The predictive value of serial monitoring of amino-terminal pro-B-type natriuretic peptide levels in acute decompensated heart failure is unclear.

DESIGN

Prospective observational study.

SETTING

Single, tertiary referral pediatric critical care unit.

PATIENTS

Patients aged 0-21 years with primary myocardial dysfunction and acute decompensated heart failure.

INTERVENTIONS

Amino-terminal pro-B-type natriuretic peptide levels were obtained on enrollment, day 2, and day 7. Clinical, laboratory, and imaging data were collected on enrollment. Adverse cardiovascular outcome was defined as heart transplant, ventricular assist device placement, extracorporeal membrane oxygenation, or death at 1 year after admission. Aminoterminal pro-B-type natriuretic peptide levels and the percent change from day 0 to day 2 and day 0 to day 7 were calculated and compared between those with and without adverse cardiovascular outcome.

MEASUREMENTS AND MAIN RESULTS

Sixteen consecutive patients were enrolled. Adverse cardiovascular outcome occurred in six patients (37.5%, four heart transplant and two ventricular assist device). In patients with an adverse cardiovascular outcome, median amino-terminal pro-B-type natriuretic peptide levels at day 7 were significantly higher (7,365 vs 1,196 pg/mL; p = 0.02) and the percent decline in amino-terminal pro-B-type natriuretic peptide was significantly smaller (28% vs 73%; p = 0.02) compared with those without an adverse cardiovascular outcome. Receiver operating curve analysis revealed that a less than 55% decline in amino-terminal pro-B-type natriuretic peptide levels at day 7 had a sensitivity and specificity of 83% and 90%, respectively, in predicting an adverse cardiovascular (area under the curve, 0.86; 95% CI, 0.68-1.0; p = 0.02).

CONCLUSIONS

In conclusion, children with primary myocardial dysfunction and acute decompensated heart failure, a persistently elevated amino-terminal pro-B-type natriuretic peptide, and/or a lesser degree of decline in amino-terminal pro-B-type natriuretic peptide during the first week of presentation were strongly associated with adverse cardiovascular outcome. Serial amino-terminal pro-B-type natriuretic peptide monitoring may allow the early identification of children at risk for worse outcome.

Risk factors for rehospitalization in heart failure with preserved ejection fraction compared with reduced ejection fraction

Although there have been several studies regarding heart failure with preserved ejection fraction (HFpEF), investigations of the risk factors for readmission of Japanese patients with HFpEF remain scarce. Therefore, our goal was to identify the risk factors for readmission of Japanese patients with heart failure (HF), particularly those with HFpEF. We analyzed 310 patients who were hospitalized for the first time with HF. Preserved EF was defined EF ≥50 %, and reduced EF (rEF) was EF <50 %. The study endpoint was readmission for HF after discharge. Medical history, vital signs, electrocardiograms, chest radiographs, blood tests and echocardiograms were compared between patients with HFpEF and with HFrEF. Among the 142 patients who had HFpEF, 43 reached the endpoint within 1 year. Multivariate analysis revealed depression (HR: 7.185), high brain natriuretic peptide (BNP) levels at discharge (HR: 1.003), and dilated inferior vena cava (HR: 1.100) as independent risk factors for readmission. In contrast, 39 of the 168 patients with HFrEF reached the endpoint. Risk factors for readmission of HFrEF patients were low sodium (HR: 0.856), high blood urea nitrogen (HR: 1.045), high BNP levels at discharge (HR: 1.003) and absence of beta-blocker prescription (HR: 0.395). In conclusion, our study suggests that the predictors of HF readmission differ between HFpEF and HFrEF patients.

B-type natriuretic peptide predicts 30-day readmission for heart failure but not readmission for other causes

BACKGROUND

B-type natriuretic peptide (BNP) is a marker for heart failure (HF) severity, but its association with hospital readmission is not well defined.

METHODS AND RESULTS

We identified all hospital discharges (n=109 875) with a primary diagnosis of HF in the Veterans Affairs Health Care System from 2006 to 2009. We examined the association between admission (n=53 585), discharge (n=24 326), and change in BNP (n=7187) and 30-day readmission for HF or other causes. Thirty-day HF readmission was associated with elevated admission BNP, elevated discharge BNP, and smaller percent change in BNP from admission to discharge. Patients with a discharge BNP ≥ 1000 ng/L had an unadjusted 30-day HF readmission rate over 3 times as high as patients whose discharge BNP was ≤ 200 ng/L (15% vs. 4.1%). BNP improved discrimination and risk classification for 30-day HF readmission when added to a base clinical model, with discharge BNP having the greatest effect (C-statistic, 0.639 to 0.664 [P<0.0001]; net reclassification improvement, 9% [P<0.0001]). In contrast, 30-day readmission for non-HF causes was not associated with BNP levels during index HF hospitalization.

CONCLUSIONS

In this study of over 50 000 veterans hospitalized with a primary diagnosis of HF, BNP levels measured during hospitalization were associated with 30-day HF readmission, but not readmissions for other causes. These data may help guide future study aimed at identifying the optimal timing for hospital discharge and help allocate high-intensity, HF-specific transitional care interventions to the patients most likely to benefit.

NT-proBNP provides incremental prognostic information in cardiac outpatients with and without echocardiographic findings

BACKGROUND

Outpatients frequently present with elevated natriuretic peptides in the absence of an obvious cardiac abnormality or with normal natriuretic peptides despite echocardiographic findings.

HYPOTHESIS

We aimed to determine the prognostic value of N-terminal pro B-type natriuretic peptide (NTpBNP) in outpatients with normal and abnormal echocardiography.

METHODS

A total of 433 cardiovascular outpatients were included. The prognostic value of NTpBNP in patients with normal and abnormal echocardiography during a 2-year follow-up was evaluated.

RESULTS

Patients with abnormal echocardiography and elevated NTpBNP had a mortality rate of 8.7% and an overall event rate of 20.2% (composite end point of overall mortality, myocardial infarction, and hospitalization for heart failure), which was significantly higher than in patients with abnormal echocardiography and normal NTpBNP, in which no mortality (P=0.011) and no events were observed (P<0.001). In patients with a normal echocardiography, mortality was 1.5% and 1.8% for patients with normal and elevated NTpBNP, respectively (P=1.000). Composite event rate was 1.5% and 8.9% (P=0.093), respectively.

CONCLUSIONS

Patients with low NTpBNP have an excellent prognosis irrespective of echocardiographic findings. Therefore, determination of NTpBNP appears useful in assessing the clinical relevance of echocardiographic findings.

Extremely high brain natriuretic peptide does not reflect the severity of heart failure

Brain natriuretic peptide (BNP) is important in the diagnosis and management of heart failure (HF). Sometimes, very high BNP levels encountered in clinical settings seem to be out of proportion to the severity of HF. The authors retrospectively identified 113 patients with 129 admissions with a BNP value >3000 pg/mL regardless of diagnosis. The data set was analyzed using the Student t test and bivariate analysis. Fewer than half of patients were admitted for HF. In 14 patients (10.9%), no signs of HF were found. The BNP level of those with and without HF was similar. There was no difference in BNP level in patients with and without systolic dysfunction or renal dysfunction and between different age groups. Extreme values of BNP do not necessarily correlate with the presence of HF, cardiomyopathy, or kidney dysfunction. When the magnitude of BNP elevation is very high, its clinical significance is limited.

Profiling B-type natriuretic peptide in a stable heart failure population: a valuable adjunct to care

AIM

To examine the prognostic importance of absolute values and change in values of BNP in patients with stable heart failure (HF).

METHODS

Five-hundred and fifty-nine patients attending a disease management programme were categorized into tertiles of BNP (group 1; ≤ 95 pg/ml, group 2; 96-249 pg/ml and group 3; ≥ 250 pg/ml). A change in BNP between two stable visits was recorded. Patients were followed up for 1 year for death and a composite morbidity measure of HF hospitalization, all-cause hospitalization, unscheduled visits for clinical deterioration(UC) of HF using survival analysis.

RESULTS

The risk of the combined morbidity outcome increased with increasing tertiles of BNP (Log rank = 17.8 (2), p < 0.001). Furthermore, a 50 and 25% increase in BNP predicted morbidity in stable HF patients with an initial BNP > 200 pg/ml (p = 0.02) and > 450 pg/ml (p = 0.03), respectively.

CONCLUSION

In a stable community HF population, an elevated BNP or an increase in BNP predicts an adverse prognosis thereby potentially identifying a population in need of closer clinical follow-up.

123I-MIBG imaging detects cardiac involvement and predicts cardiac events in Churg-Strauss syndrome

PURPOSE

In Churg-Strauss syndrome (CSS) it is important to detect cardiac involvement, which predicts poor prognosis. This study evaluated whether (123)I-metaiodobenzylguanidine (MIBG) scintigraphy could detect cardiac damage and predict cardiac events in CSS.

METHODS

(123)I-MIBG scintigraphy was performed in 28 patients with CSS, 12 of whom had cardiac involvement. The early and delayed heart to mediastinum ratio (early H/M and delayed H/M) and washout rate were calculated by using (123)I-MIBG scintigraphy and compared with those in control subjects.

RESULTS

Early H/M and delayed H/M were significantly lower and the washout rate was significantly higher in patients with cardiac involvement than in those without and in controls (early H/M, p = 0.0024, p = 0.0001; delayed H/M, p = 0.0002, p = 0.0001; washout rate, p = 0.0012, p = 0.0052 vs those without and vs controls, respectively). Accuracy for detecting cardiac involvement was 86% for delayed H/M and washout rate and 79% for early H/M and B-type natriuretic peptide (BNP). Kaplan-Meier analysis showed significantly lower cardiac event-free rates in patients with early H/M ≤ 2.18 and BNP > 21.8 pg/ml than those with early H/M > 2.18 and BNP ≤ 21.8 pg/ml (log-rank test p = 0.006).

CONCLUSION

Cardiac sympathetic nerve function was damaged in CSS patients with cardiac involvement. (123)I-MIBG scintigraphy was useful in detecting cardiac involvement and in predicting cardiac events.

Comparison between immunoradiometric and fluorimetric brain natriuretic peptide determination in patients with congestive heart failure

This study compared two different methods, namely the immunoradiometric (IRMA) and fluorimetric (FIA), in order to determine plasma brain natriuretic peptide (BNP) in congestive heart failure (CHF) patients.

METHODS

CHF in-patients underwent echocardiography and plasma BNP determination using both two methods. The echocardiograms analysed left ventricular end-systolic (LVESV) and end-diastolic (LVEDV) volumes and systolic dysfunction [left ventricular ejection fraction (LVEF) <50%].

RESULTS

Seventy-three (71% males, age 67 ± 9.6 yr) patients were enrolled, 31.5% affected by valvular heart disease. The mean LVEF was 39.8 ± 14.1%; in 26 (35%) a hypertensive etiology emerged. The immunoradiometric assay (IRMA) BNP was found to be significantly lower than the FIA determination 116.5 ± 149 pg/ml vs 267.3 ± 285.6 pg/ml; p=0.0001) and the two methods were closely correlated (r=0.89; p=0.00001). Logistic regression demonstrated a significant correlation between BNP, LVEF, and LVESV/LVEDV (r=-0.45, p=0.0003; r=-0.48, p=0.00001; r=0.22 p=0.003; r=0.34 p=0.0001; r=0.13 p=0.02; r=0.28 p=0.001 IRMA and FIA, respectively). IRMA BNP and FIA BNP significantly increased according to the worsening functional class [from 34.3 ± 60.2 pg/ml in NYHA (New York Heart Association) I to 555.5 ± 273.1 pg/ml in NYHA IV; from 86.1 ± 162.1 pg/ml in NYHA I to 1070 ± 42.2 pg/ml in NYHA IV, respectively]. In severe systolic dysfunction (LVEF<30%), receiver operating characteristic analysis revealed a satisfactorily sensitivity and specificity using a cut-off point of 50.6 pg/ml with IRMA and 243 pg/ml with FIA. In mild systolic dysfunction (LVEF<50%), a good sensitivity and specificity using a cut-off point of 42 pg/ml with IRMA and 182 pg/ml with FIA emerged.

CONCLUSIONS

In CHF patients both BNP methods correlated with NYHA class, LVEF, and ventricular volumes.

Baseline plasma NT-proBNP and clinical characteristics: results from the irbesartan in heart failure with preserved ejection fraction trial

BACKGROUND

N-terminal B type natriuretic peptide (NT-proBNP) is usually elevated in heart failure (HF) patients with reduced ejection fraction (EF). Less is known about NT-proBNP in HF with preserved EF (HF-PEF). We measured baseline NT-proBNP in 3562 HF-PEF enrolled patients in the Irbesartan in Heart Failure with Preserved Ejection Fraction trial.

METHODS AND RESULTS

Patients with EF >or=45%, age >or=60 years, and either New York Heart Association (NYHA) II-IV symptoms with HF hospitalization (HFH) within 6 months or NYHA III-IV symptoms with corroborative evidence of HF or structural changes associated with HF-PEF. NT-proBNP (pg/mL) measured centrally using the Elecsys proBNP assay (Roche). Mean age 72 +/- 7 years, 60% were women, the investigator indicated HF etiology was hypertension in 64%; the majority were in NYHA III. Medications included diuretics in 82%, angiotensin-converting enzyme inhibitor in 26%, beta-blocker in 59%, and spironolactone in 15%. Median NT-proBNP was 341 pg/mL (interquartile range 135 to 974 pg/mL) and geometric mean was 354 pg/mL. In multivariate analysis, the baseline characteristics most strongly associated with higher NT-proBNP levels were atrial fibrillation (ratio of geometric mean 2.59, P < .001), NYHA IV symptoms (1.52, P < .001), lower estimated glomerular filtration rate (1.44, P < .001), and HFH hospitalization within 6 months (1.37, P < .001).

CONCLUSIONS

Most HF-PEF patients have elevated NT-proBNP levels. The NT-proBNP concentrations were related to baseline characteristics generally associated with worse outcomes for HF patients.

How often we need to measure brain natriuretic peptide (BNP) blood levels in patients admitted to the hospital for acute severe heart failure? Role of serial measurements to improve short-term prognostic stratification

BACKGROUND

Brain natriuretic peptide (BNP) is increasingly used in the management of patients with heart failure (HF). It is still unclear how to use serial BNP measurement in HF.

AIM

To evaluate the usefulness of three consecutive measurements of BNP in patients (pts) hospitalized for acute HF.

METHODS

Clinical evaluation, BNP levels and echocardiography were assessed in 150 pts (67% males, age: 69+/-12 years; left ventricular ejection fraction: 34+/-14%) admitted for severe HF (NYHA class III-IV: 146/150). BNP measurements were obtained: at admission (basal, T0), at discharge (T1) and at first ambulatory control (T2), after optimization of medical therapy in those with discharge BNP level >250 pg/mL. End-points were death and hospital readmission during 6-month follow-up.

RESULTS

According to BNP levels 3 groups of patients were identified: Group 1 (62 pts, 41%), in whom discharge (T1) BNP was high and persisted elevated at T2 despite aggressive medical therapy; at 6-month follow-up 72% died or were hospitalized for HF. Group 2 (36 pts, 24%), in whom discharge (T1) BNP was high but decreased after medical therapy (T2); death and HF-readmission were observed in 8 pts (26%). Group 3 (52 pts, 35%), in whom discharge (T1) BNP levels were <250 pg/mL and persisted below this value at T2; death and HF-hospital readmission were observed in 6 pts (12%). Event rate differences among groups were statistically significant (p<0.001). At Cox-analysis discharge BNP cutoff of 250 pg/mL was the only parameter predictive of a worse outcome.

CONCLUSION

These data suggest that 3 BNP measurements, at admission, at discharge and few weeks later can allow to identify HF pts whom, despite a further potentiation of medical therapy, will present a worsening or even will die during short-term follow-up.

Inpatient monitoring and prognostic importance of B-type natriuretic peptide

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in many industrialized countries. Despite a consistent body of data demonstrating the benefits of drug therapy, the prognosis of patients admitted with ADHF remains dismal, as it is associated with high readmission and mortality rates within 6 months of admission. ADHF is a largely hemodynamic disorder; 90% of hospitalized patients present with volume overload. Neurohormonal activation characterizes the disease; the B-type natriuretic peptide (BNP) and N-terminal prohormone brain natriuretic peptide are natriuretic and vasodilating peptides released from the cardiac ventricles as a response to ventricular volume expansion and relate to outcome. While BNP levels obtained on admission provide independent prognostic information of in-hospital mortality, BNP levels during and at the completion of hospitalization can help to achieve euvolemia and may reflect adequacy of treatment. Once euvolemia is reached, BNP level correlated with functional class and prognosis. Studies using natriuretic peptides have suggested that predischarge BNP level appeared to be the strongest predictor for identifying subsequent death or hospital admission at 6 months. The addition of predischarge BNP levels to a clinical/instrumental decisional score for discharge decision should make possible the detection of high-risk patients who need reinforced treatment or follow-up.

Treatment of hypertension in heart failure with preserved ejection fraction: role of the kidney

Heart failure can present clinically as primarily diastolic or systolic dysfunction or both. There is an increasing awareness that heart failure can occur in the presence of a normal left ventricular ejection fraction. Heart failure with normal left ventricular ejection fraction is frequently referred to as diastolic heart failure because of the presence of diastolic left ventricular dysfunction evident from impaired left ventricular relaxation. This article focuses on the treatment of hypertension and the role the kidney plays in selecting appropriate agents.

Urinary B-Type Natriuretic Peptide Levels in the Diagnosis and Prognosis of Heart Failure

BACKGROUND

Plasma B-type natriuretic peptide (BNP) is a useful biomarker for diagnosis and prognosis of heart failure (HF); however, urine BNP has never been calculated. We sought to compare urinary and plasma BNP levels and to investigate the potential diagnostic and prognostic value of this peptide in HF.

METHODS AND RESULTS

Urine and plasma BNP levels were measured in 92 HF patients and 30 control subjects. Urinary BNP levels were higher in HF patients than in control subjects (P < .0001), correlating with plasma BNP levels (r = 0.64, P < .0001). Urine BNP was a good tool for the diagnosis of HF, the area under the curve (AUC) being 0.91 +/- 0.06 (P < .0001). Urinary BNP levels had prognostic power for cardiac events (cardiac admissions + mortality) with an odds ratio of 6.6 (P < .05). To determine the prognostic power of urinary BNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.76 +/- 0.6 (P = .014).

CONCLUSIONS

The data suggest that urine BNP is a new candidate marker for diagnosis and prognosis of HF mortality and cardiac events. This raises the possibility of using this relatively simple noninvasive test in primary care settings or in specific conditions where the collection of blood samples could be difficult.

Relation of brain natriuretic peptide to myocardial performance index in adults with congenital heart disease

Myocardial performance index (MPI) is an echocardiographic Doppler-derived measure of ventricular function previously validated in patients with congenital heart disease. It may be preferred over conventional noninvasive measures of ventricular function in patients with complex anatomy because it is dependent on neither geometric shape nor heart rate. Brain natriuretic peptide (BNP) is a predictor of systolic and diastolic dysfunction in anatomically correct hearts. The correlation of BNP to MPI in patients with congenital heart disease was determined. Fifty-four adults with congenital heart disease were evaluated. BNP was measured using standardized assays. Doppler echocardiography was performed within 6 months of BNP assay. There were no changes in clinical status during this interval. An experienced observer was blinded and evaluated all echocardiographic images, and MPI and ejection fraction (EF) were determined. Left ventricular (LV) or univentricular MPI was calculated in 34 patients and right ventricular (RV) MPI was calculated in 23 patients. Pearson's correlation coefficient test showed that BNP significantly correlated with LV/univentricular MPI (r = 0.461, p = 0.006) and RV MPI (r = 0.748, p <0.0001), whereas LV/univentricular EF and RVEF had no significant correlation with BNP (r = -0.189, p = 0.172; r = 0.066, p = 0.729, respectively). In patients with congenital heart disease, BNP correlated significantly with MPI, but not with LV, RV, or univentricular EF. This is particularly true in patients with geometrically variable right ventricles in which EF may be more difficult to assess. In conclusion, these findings emphasize the unique ability of both BNP and MPI to assess global ventricular function in geometrically complex hearts.

Prognosis of decompensated heart failure patients with preserved systolic function is predicted by NT-proBNP variations during hospitalization

BACKGROUND

Almost half of heart failure (HF) patients have preserved left ventricular systolic function (LVSF). Although morbidity is similar in patients with preserved and depressed LVSF, clinicians have limited information on prognostic factors of patients with preserved LVSF. We aimed to evaluate the prognostic value of NT-proBNP in patients with decompensated HF regardless of LVSF.

METHODS

Patients hospitalised due to decompensated HF were followed for 6 months. The primary endpoint was death or hospital readmission. We evaluated 224 patients with NT-proBNP measured at admission and discharge and an echocardiogram performed. NT-proBNP decreased on average during hospitalization in patients with preserved LVSF (n=63) and in patients with depressed LVSF (n=161). The morbidity was not different between patients with preserved and depressed LVSF. Among patients with preserved LVSF, predictors of adverse events were serum creatinine, haemoglobin, NT-proBNP levels at discharge and the variation in NT-proBNP during hospitalisation. Among patients with depressed LVSF, predictors of adverse events were female gender, atrial fibrillation, non-prescription of ACE-inhibitor at discharge, NT-proBNP levels at discharge and the variation in NT-proBNP during hospitalisation.

CONCLUSIONS

These results suggest that, in HF patients with preserved LVSF as in patients with depressed LVSF, NT-proBNP can play a role as a tool to identify patients at risk of an adverse outcome.

Accuracy of bedside tissue Doppler echocardiography for the prediction of in-hospital mortality in elderly patients with acute heart failure with preserved left ventricular systolic function. comparison with B-type natriuretic peptide measurement

According to recent studies, tissue Doppler echocardiography used as a non-invasive surrogate for left ventricular diastolic pressures regardless of rhythm is likely to offer additional information beyond the clinical judgment and the B-type natriuretic peptide (BNP) assay in the emergency diagnosis of acute heart failure with preserved left ventricular systolic function (HFPSF). The present study attempted to determine the usefulness of bedside tissue Doppler echocardiography as compared with BNP, both obtained at presentation before unloading therapy, for the prediction of in-hospital outcome in 75 consecutive elderly patients with acute HFPSF, of whom 16 died during their in-hospital stay. Unlike BNP (p=0.002), the spectral tissue Doppler-derived E/Ea ratio was not able to provide prognostic information in such patients before tailored therapy (p=0.9).

Prognostic role of B-type natriuretic peptide in patients with diabetes and acute decompensated heart failure

BACKGROUND

Several studies have reported the prognostic value of natriuretic peptides, but their predictive value in patients with diabetes mellitus is unknown. The aim of the study was to test the hypothesis that measurement of brain natriuretic peptide (BNP) levels in ambulatory patients with congestive heart failure (CHF) and diabetes can predict the occurrence of cardiovascular events at 6-month follow-up.

METHODS

We enrolled 145 consecutive patient with diabetes [age 72 +/- 9 years, hypertension (21%), ischaemic heart disease (52%), atrial fibrillation (22%), preserved left ventricular function (29%)] seen in the outpatient heart failure clinic after an acute episode of cardiac failure.

RESULTS

The median (25th/75th interquartile range) BNP concentrations at discharge were 186 (75-348) pg/ml. At 6-month clinical follow-up 10/145 (7%) subjects had died and 31/145 (21%) had been readmitted because of cardiac decompensation. BNP values of 200 and 500 pg/ml were found to have the best compromise between sensitivity (88 and 46%, respectively) and specificity (71 and 89%, respectively) for predicting events at 6 months. Multivariate Cox regression analysis identified only two parameters as predictors of events: serum creatinine [hazard ratio (HR) = 3.3; P = 0.02], and BNP plasma level BNP cut-off values (HR = 3.8; P = 0.03 for 201-499 pg/ml and HR = 7.7; P = 0.001 for > or = 500 pg/ml).

CONCLUSION

These results suggest that BNP and serum creatinine are strong predictors of clinical events in patients with diabetes and CHF. In these patients, clinical outcome might be stratified by plasma BNP levels.

B-type natriuretic peptide predicts postdischarge prognosis in elderly patients admitted due to cardiogenic pulmonary edema

To examine the prognostic role of predischarge B-type natriuretic peptide (BNP) levels in elderly patients admitted to the hospital due to cardiogenic pulmonary edema, 203 patients consecutively admitted to the Heart Failure Unit of the Cardiology Department were retrospectively evaluated. The primary clinical end point selected was a combination of: 1) deaths; plus 2) readmissions to the hospital for heart failure in the 6 months after discharge. Thirty-one deaths (15.3%) and 44 readmissions for heart failure (21.7%) were recorded. Cox multivariate regression analysis confirmed that BNP cutoff values (identified on receiver-operated curve analysis) are the most accurate predictor of events. Hazard ratios (HRs) increased from the lowest, for BNP < or = 200 pg/mL (HR=1), through BNP 201-499 pg/mL (HR=2.3200; p=0.0174), to the highest, for BNP > or = 500 pg/mL (HR=3.6233; p=0.0009). This study demonstrates that BNP is useful in predischarge risk stratification of elderly patients with cardiogenic pulmonary edema.

B-type natriuretic peptide predicts adverse cardiovascular events in pediatric outpatients with chronic left ventricular systolic dysfunction

BACKGROUND

Plasma B-type natriuretic peptide (BNP) levels are elevated in adults with heart failure and correlate with functional classification and prognosis. The range and predictive power of BNP concentrations in children with chronic heart failure, however, are not known.

METHODS AND RESULTS

Whole blood BNP concentrations were measured in 53 consecutive patients with chronic left ventricular (LV) systolic dysfunction (biventricular hearts, ejection fraction < 50%, > 3 months since diagnosis). Children who had been hospitalized within 3 months before potential enrollment and those < 2 months or > 21 years of age were excluded. BNP concentrations were measured with the Triage assay (Biosite Diagnostics, Inc, San Diego, Calif). Echocardiographers and clinicians were blinded to BNP levels. An adverse cardiovascular event was defined as cardiac death, cardiac-related hospitalization, or listing for cardiac transplantation. The median age of patients with LV dysfunction was 9.3 years (interquartile range [IQR], 2.7 to 15.1 years). BNP levels were elevated in children with LV dysfunction compared with healthy controls (median, 78 pg/mL [IQR, 22 to 551 pg/mL] versus median, 7 pg/mL [IQR, 5 to 11 pg/mL]; P < 0.0001). Whole blood BNP concentrations were increased in patients who had a 90-day adverse cardiovascular event compared with those who did not (median, 735 pg/mL [IQR, 685 to 1510 pg/mL] versus median, 37 pg/mL [IQR, 14 to 92 pg/mL]; P < 0.001). Patients with a BNP concentration > or = 300 pg/mL were at increased risk of death, hospitalization, or listing for cardiac transplantation (adjusted hazard ratio, 63.6; P < 0.0001).

CONCLUSIONS

BNP concentrations are elevated in children with chronic LV systolic dysfunction and predict the 90-day composite end point of death, hospitalization, or listing for cardiac transplantation.

Evaluation of cardiac laboratory markers in patients with systemic sclerosis

OBJECTIVES

Myocardial involvement is frequent in systemic sclerosis, but symptoms are usually delayed and non-specific, thus often misrecognized. The aim of this study was the evaluation of the early subclinical cardiac involvement in patients with systemic sclerosis by means of non-invasive laboratory cardiac markers.

DESIGN AND METHODS

Cardiac troponin T (cTnT), ischemia modified albumin (IMA) and NT-prohormone-brain natriuretic peptide (NT-proBNP) were measured in 40 female patients with systemic sclerosis and in 40 matched healthy controls.

RESULTS

Patients with systemic sclerosis displayed significantly increased concentrations of serum IMA (106 versus 93.5 kunits/l, P < 0.0001) and NT-proBNP (89 versus 37 pg/ml, P < 0.0001), whereas no significant differences could be observed in both IMA and NT-proBNP values in limited versus diffuse pattern of disease.

CONCLUSIONS

The increased levels of NT-proBNP and IMA could be considered a sign of early myocardial involvement, warranting further heart examination and a regular follow-up.