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Millogo GRC, Thiam Tall A, Seghda TAA, Kambiré Y, Nongkouni E, Dabiré YE, Kagambéga LJ, Kologo JK, Yaméogo VN, Marcaggi X, Zabsonré P. [Contribution of the 6-minutes walking test and the plasma NT-proBNP at admission and discharge to the prognostic evaluation of patients with NYHA class II-III Heart Failure.]. Ann Cardiol Angeiol (Paris) 2023; 72:101639. [PMID: 37717311 DOI: 10.1016/j.ancard.2023.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To study the 6MWT and NT-proBNP contribution to the prognosis evaluation of patients with NYHA class II-III heart failure in the Yalgado Ouédraogo Teaching Hospital. METHODS We carried out a nine months prospective observational cohort from the 1st February to the 31st October 2020. Patients with NYHA class II-III HF who consented to participate were included in the study. We identified two variables of interest: death and readmission. RESULTS We included 50 patients with congestive heart failure representing 37.3% of heart failure. The average follow up time of patients was 154.58 ± 74.8 days. Twelve patients (24%) were readmited and 11 passed away with five during hospitalisation. On admission, The average distance on the 6MWT (194.6 ± 85.5 m) on admission and average NT-proBNP (5812.1±4729.4 ng/L) measured on admission and before discharge wasn't significantly correlated to the risk of death and re-hospitalisation. The average distance on the 6MWT before discharge (306.2±84.6) was significantly correlated to an increase risk of death and re-hospitalisation. Patients with an increase in NT-proBNP superior to 30% from measurement on admission to the one before discharge had a high risk of re-hospitalisation and death compare to those with a decrease of more than 30% with a moderate to good correlation coefficient of 0.6 between the two. CONCLUSION 6MWT and NT-proBNP variations from admission to discharge have been necessary to evaluate the prognosis of patients with CHF.
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Affiliation(s)
- G R C Millogo
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso.
| | - A Thiam Tall
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - T A A Seghda
- Service de cardiologie centre hospitalier Universitaire de Bogodogo, Ouagadougou, Burkina Faso
| | - Y Kambiré
- Service de cardiologie centre hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - E Nongkouni
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Y E Dabiré
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - L J Kagambéga
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - J K Kologo
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - V N Yaméogo
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | | | - P Zabsonré
- Service de cardiologie centre hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
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Zhang BF, Ren SB, Wang MX. The Predictive Value of Serum NT-proBNP on One-Year All-Cause Mortality in Geriatrics Hip Fracture: A Cohort Study. Cureus 2023; 15:e45398. [PMID: 37854739 PMCID: PMC10580863 DOI: 10.7759/cureus.45398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/20/2023] Open
Abstract
Objective This study evaluated the association between N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration and one-year mortality in geriatric patients with intertrochanteric and femoral neck fractures receiving the operative treatment. Methods Consecutive age ≥65 years patients with hip fractures were screened between January 2015 and September 2019. Demographic and clinical characteristics of the patients were collected. The multivariate logistic regression models were used to identify the association between preoperative NT-proBNP concentrations and mortality. All analyses were performed using EmpowerStats and the R software. Result One thousand two hundred nineteen patients were included in the study. The average age was 79.73±6.65 years (range 66-99 years). The mean NT-proBNP concentration was 616.09±1086.85 ng/L (median 313.40 ng/L, range 16.09-20123.00 ng/L). The follow-up was 35.39±15.09 months (median 35.78 months, range 0.10-80.14 months). One hundred and eleven (9.1%) patients died within one year. After adjusting for confounding factors, multivariate logistic regression models showed a curved association between preoperative NT-proBNP concentration and one-year mortality. When the NT-proBNP concentration was below 1099 ng/L, the mortality increased by 10% (OR=1.10, 95%CI: 1.03-1.17, P=0.0025) when NT-proBNP increased by 100 ng/L. When the NT-proBNP concentration was above 1099 ng/L, the mortality did not increase anymore when NT-proBNP increased (OR=1.00, 95%CI: 0.99-1.02, P=0. 7786). Thus, NT-proBNP was a valuable indicator to predict high one-year mortality in practice. Conclusion The NT-proBNP concentrations were nonlinearly associated with mortality in elderly hip fractures with a saturation effect, and NT-proBNP was a risk indicator of all-cause mortality. A well-designed controlled trial to show the role of mortality by decreasing the concentration of NT-proBNP is needed in the future.
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Affiliation(s)
- Bin-Fei Zhang
- School of Public Health, Xi'an Jiaotong University, Xi'an, CHN
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, CHN
| | - Shang-Bo Ren
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, CHN
| | - Ming-Xu Wang
- School of Public Health, Xi'an Jiaotong University, Xi'an, CHN
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3
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Sergi CM. Point of care with serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) for heart failure in patients with acute decompensation. An invited commentary. Contemp Clin Trials Commun 2022; 26:100889. [PMID: 36684692 PMCID: PMC9846449 DOI: 10.1016/j.conctc.2022.100889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/06/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
Point-of-care (POC) Testing (POCT) is a medical diagnostic approach carried out outside the clinical laboratory and close to the patient. The results are used for the immediate clinical decision to improve patient care. Accreditation Canada and Diagnostic Accreditation Programs regulatory standards and the College of the American Pathologists for POCT have implemented several guidelines and certifications. POC in heart failure (POC-HF) will demonstrate that it is helpful to develop a preliminary understanding of the value of serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements in the diagnostic and therapeutic process in patients hospitalized with acute decompensation of heart failure. In addition, POC-HF will hopefully answer questions on the workability of this approach in clinical routine and the usefulness and justification to perform larger-scale studies investigating this strategy.
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Affiliation(s)
- Consolato M. Sergi
- Anatomy Pathology Division, Children's Hospital of Eastern Ontario, University of Ottawa, ON, Canada,Departments of Pediatrics and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada,Stollery Children's Hospital, University Alberta Hospital, Edmonton, AB, Canada,Anatomy Pathology Division, Children's Hospital of Eastern Ontario, University of Ottawa, ON, Canada.
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Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
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Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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5
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Züsli S, Bierreth F, Boesing M, Haas P, Abig K, Maier S, Corridori G, Leuppi JD, Dieterle T. Point of care with serial NT-proBNP measurement in patients with acute decompensated heart failure as a therapy-monitoring during hospitalization (POC-HF): Study protocol of a prospective, unblinded, randomized, controlled pilot trial. Contemp Clin Trials Commun 2021; 23:100825. [PMID: 34485753 PMCID: PMC8403536 DOI: 10.1016/j.conctc.2021.100825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 07/20/2021] [Accepted: 07/24/2021] [Indexed: 12/11/2022] Open
Abstract
Despite important advances in diagnosis and medical therapy of heart failure (HF), disease monitoring and therapy guidance remains to be based on clinical signs and symptoms. NT-proBNP was repeatedly demonstrated to be a strong and independent predictor of morbidity and mortality in patients with HF. Only few – and conflicting – data are available on the efficacy of serial measurement of NT-proBNP as a tool for treatment monitoring in HF. These data are limited to the outpatient setting. Currently, no data are available on the effects of this approach in patients hospitalized for acute decompensated HF. The goal of this study is to explore whether the availability of serial NT-proBNP measurements may influence treatment decisions in patients with acute decompensated HF, and whether this leads to more rapid dose adjustments of prognostically beneficial medical therapies and earlier hospital discharge. In the intervention group, serial measurements of NT-proBNP every second business day are performed and made available to the treating physician, while no serial measurements are available in control group. HF therapy is left at the discretion of the treating physician. The primary endpoints are defined as the effects of monitoring NT-proBNP on medical HF therapy decisions, including type and dosing of medical therapies and the rapidity of adjustments, length of hospital stay, and evaluation of the changes in NT-proBNP values. Additional secondary endpoints include incidence of electrolyte imbalances and renal failure, changes in NYHA functional class, vital signs, body weight, quality of life, incidence of adverse events, transfer to Intensive Care Units, and mortality.
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Affiliation(s)
- Stephanie Züsli
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland
| | - Frederick Bierreth
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland
| | - Maria Boesing
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland
| | - Philippe Haas
- Synlab Suisse AG, Alpenquai 14, CH, 6002, Luzern, Switzerland
| | - Kristin Abig
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland
| | - Sabrina Maier
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland
| | - Giorgia Corridori
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland.,University of Basel, Faculty of Medicine, Klingelbergstrasse 61, CH, 4056, Basel, Switzerland
| | - Jörg D Leuppi
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland.,University of Basel, Faculty of Medicine, Klingelbergstrasse 61, CH, 4056, Basel, Switzerland
| | - Thomas Dieterle
- University Department of Medicine, Clinical Research, Cantonal Hospital Baselland, Rheinstrasse 26, CH, Liestal, Switzerland.,University of Basel, Faculty of Medicine, Klingelbergstrasse 61, CH, 4056, Basel, Switzerland
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Activity of the adrenomedullin system to personalise post-discharge diuretic treatment in acute heart failure. Clin Res Cardiol 2021; 111:627-637. [PMID: 34302189 PMCID: PMC9151518 DOI: 10.1007/s00392-021-01909-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Background Quantifying the activity of the adrenomedullin system might help to monitor and guide treatment in acute heart failure (AHF) patients. The aims were to (1) identify AHF patients with marked benefit or harm from specific treatments at hospital discharge and (2) predict mortality by quantifying the adrenomedullin system activity. Methods This was a prospective multicentre study. AHF diagnosis and phenotype were centrally adjudicated by two independent cardiologists among patients presenting to the emergency department with acute dyspnoea. Adrenomedullin system activity was quantified using the biologically active component, bioactive adrenomedullin (bio-ADM), and a prohormone fragment, midregional proadrenomedullin (MR-proADM). Bio-ADM and MR-proADM concentrations were measured in a blinded fashion at presentation and at discharge. Interaction with specific treatments at discharge and the utility of these biomarkers on predicting outcomes during 365-day follow-up were assessed. Results Among 1886 patients with adjudicated AHF, 514 patients (27.3%) died during 365-day follow-up. After adjusting for age, creatinine, and treatment at discharge, patients with bio-ADM plasma concentrations above the median (> 44.6 pg/mL) derived disproportional benefit if treated with diuretics (interaction p values < 0.001). These findings were confirmed when quantifying adrenomedullin system activity using MR-proADM (n = 764) (interaction p values < 0.001). Patients with bio-ADM plasma concentrations above the median were at increased risk of death (hazard ratio 1.87, 95% CI 1.57–2.24; p < 0.001). For predicting 365-day all-cause mortality, both biomarkers performed well, with MR-proADM presenting an even higher predictive accuracy compared to bio-ADM (p < 0.001). Conclusions Quantifying the adrenomedullin’s system activity may help to personalise post-discharge diuretic treatment and enable accurate risk-prediction in AHF. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01909-9.
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de Denus S, Leclair G, Dubé MP, St-Jean I, Zada YF, Oussaïd E, Jutras M, Givertz MM, Mentz RJ, Tang WHW, Ferreira JP, Rouleau J, Butler J, Kalogeropoulos AP. Spironolactone metabolite concentrations in decompensated heart failure: insights from the ATHENA-HF trial. Eur J Heart Fail 2020; 22:1451-1461. [PMID: 32237012 DOI: 10.1002/ejhf.1802] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/21/2020] [Accepted: 03/06/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS In Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF), high-dose spironolactone (100 mg daily) did not improve efficacy endpoints over usual care [placebo or continued low-dose spironolactone (25 mg daily) in patients already receiving spironolactone] in the treatment of acute heart failure (HF). We hypothesized that low concentrations of the long-acting active metabolites of spironolactone [canrenone and 7α-thiomethylspironolactone (7α-TMS)] in the high-dose group could have contributed to these neutral results. METHODS AND RESULTS In patients randomized to high-dose spironolactone not previously treated with spironolactone (high-dose-naïve, n = 112), concentrations of canrenone and 7α-TMS increased at 48 and 96 h compared to baseline, and between 48 and 96 h (all P < 0.005), indicating that steady-state concentrations had not been reached by 48 h. In patients previously on low-dose, high-dose spironolactone (high-dose-previous, n = 37), concentrations of canrenone increased at 48 and 96 h compared to baseline (both P < 0.0005), with a marginal increase between 48 and 96 h (P = 0.0507). At 48 h, both high-dose groups had higher concentrations of both metabolites than the low-dose spironolactone group (P < 0.0001). Moreover, concentrations of both metabolites were higher in high-dose-previous vs. high-dose-naïve patients (P < 0.01), indicating that previous spironolactone use was significant, and that steady-state has not been reached in high-dose-naïve patients at 48 h. We found limited and inconsistent evidence of correlation between metabolite concentrations and endpoints. CONCLUSIONS Lower-than-anticipated concentrations of spironolactone active metabolites were observed for at least 48 h in the high-dose spironolactone group and may have contributed to the absence of pharmacological effects of spironolactone in the ATHENA-HF trial.
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Affiliation(s)
- Simon de Denus
- Faculty of Pharmacy, Montreal, Canada.,Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | | | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada.,Medicine, Université de Montréal, Montreal, Canada
| | | | - Yassamin Feroz Zada
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Essaïd Oussaïd
- Montreal Heart Institute, Montreal, Canada.,Université de Montreal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | | | - Michael M Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Mentz
- Department of Medicine, Duke University, Durham, NC, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Jean Rouleau
- Montreal Heart Institute, Montreal, Canada.,Medicine, Université de Montréal, Montreal, Canada
| | - Javed Butler
- Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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A MULTI-MARKER MODEL FOR PREDICTING DECOMPENSATED HEART FAILURE IN PATIENTS WITH PRIOR ACUTE MYOCARDIAL INFARCTION. EUREKA: HEALTH SCIENCES 2020. [DOI: 10.21303/2504-5679.2020.001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the study was to assess the prognostic value of determining the plasma concentration of NT-proBNP and ST2 in the patients with decompensated HF and prior acute myocardial infarction and their combination in this category of patients.
Materials and methods. There were examined 120 patients with acute myocardial infarction and stage II A-B decompensated chronic HF according to the classification proposed by Vasylenko V. Kh. and Strazhesko M.D., NYHA functional class (FC) III-IV. The patients with Q-QS wave MI (60 individuals) and non Q MI (60 individuals) were divided into 4 groups depending on the treatment methods.
Study groups were homogenous by age, gender, disease severity, duration of the post-infarction period, clinical signs of decompensation, which served as a basis for inclusion of the patients in the study.
All the patients underwent the six-minute walk test in a quiet 30-50-m long hospital corridor in the morning. N-terminal pro-B-type brain natriuretic peptide (NT-proBNP) and ST-2 were analyzed in all patients.
Results. Promising biomarkers of HF decompensation in the post-infarction period were studied. In the patients with prior Q-QS MI and decompensated HF, NT-proBNP level was (950.38±3.15) pmol/l (p<0.05); in the patients with prior MI without signs of decompensated HF, it was (580.15±3.03) pmol/l (p˂0.05); in apparently healthy individuals, the level of NT-proBNP was found to be (111.20±3.47) pmol/l.
ST2 level was (14.80±1.61) ng/ml, (36.00±1.43) ng/ml and (49.22±1.40) ng/ml in the patients of Group 1, Group 2 and Group 3, respectively (p˂0.05).
Similar changes were found in patients with decompensated HF in postinfarction period after non Q MI.
Conclusions. The increase in plasma concentration of sST2 is associated with the activation of both neurohumoral and fibrous pathways and can help in detecting the patients with decompensated HF in the post-infarction period and predicting the risk of its development.
Our results confirmed the results of other multiple studies reporting ST2 in combination with NT-proBNP to be valuable tools for prognosing the development of decompensated HF in the patients with prior MI. ST2, alongside with NT-proBNP, is a promising biomarker to be included in the diagnostic panel for detecting acute HF and can provide additional information on risk stratification for such patients during hospitalization and at the time of discharge from the hospital.
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Russell FM, Ehrman RR, Ferre R, Gargani L, Noble V, Rupp J, Collins SP, Hunter B, Lane KA, Levy P, Li X, O'Connor C, Pang PS. Design and rationale of the B-lines lung ultrasound guided emergency department management of acute heart failure (BLUSHED-AHF) pilot trial. Heart Lung 2018; 48:186-192. [PMID: 30448355 DOI: 10.1016/j.hrtlng.2018.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/20/2018] [Accepted: 10/22/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30days post discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes. METHODS BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across five sites to, a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤15 B-lines on LUS or 6h post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 h of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198). CONCLUSION If successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Robinson Ferre
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Vicki Noble
- Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan Rupp
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benton Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Phillip Levy
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher O'Connor
- Division of Cardiology, INOVA Heart and Vascular Institute, Falls Church, VA, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis EMS, Indianapolis, IN, USA.
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10
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Prognostic Implications of Changes in N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Heart Failure. J Am Coll Cardiol 2017; 68:2425-2436. [PMID: 27908347 DOI: 10.1016/j.jacc.2016.09.931] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Natriuretic peptides (NP) have prognostic value in heart failure (HF), although the clinical importance of changes in NP from baseline is unclear. OBJECTIVES The authors assessed whether a reduction in N-terminal pro-B-type NP (NT-proBNP) was associated with a decrease in HF hospitalization and cardiovascular mortality (primary endpoint) in patients with HF and reduced ejection fraction, whether treatment with sacubitril/valsartan reduced NT-proBNP below specific partition values more than enalapril, and whether the relationship between changes in NT-proBNP and changes in the primary endpoint were dependent on assigned treatment. METHODS In PARADIGM-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial), baseline NT-proBNP was measured in 2,080 patients; 1,292 had baseline values >1,000 pg/ml and were reassessed at 1 and 8 months. We related change in NT-proBNP to outcomes. RESULTS One month after randomization, 24% of the baseline NT-proBNP levels >1,000 pg/ml had fallen to ≤1,000 pg/ml. Risk of the primary endpoint was 59% lower in patients with a fall in NT-proBNP to ≤1,000 pg/ml than in those without such a fall. In sacubitril/valsartan-treated patients, median NT-proBNP was significantly lower 1 month after randomization than in enalapril-treated patients, and it fell to ≤1,000 pg/ml in 31% versus 17% of patients treated with sacubitril/valsartan and enalapril, respectively. There was no significant interaction between treatment and the relationship between change in NT-proBNP and the subsequent risk of the primary endpoint. CONCLUSIONS Patients who attained a significant reduction in NT-proBNP had a lower subsequent rate of cardiovascular death or HF hospitalization independent of the treatment group. Treatment with sacubitril/valsartan was nearly twice as likely as enalapril to reduce NT-proBNP to values ≤1,000 pg/ml. (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) [PARADIGM-HF]; NCT01035255.).
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11
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Ferreira JP, Duarte K, Graves TL, Zile MR, Abraham WT, Weaver FA, Lindenfeld J, Zannad F. Natriuretic Peptides, 6-Min Walk Test, and Quality-of-Life Questionnaires as Clinically Meaningful Endpoints in HF Trials. J Am Coll Cardiol 2017; 68:2690-2707. [PMID: 27978953 DOI: 10.1016/j.jacc.2016.09.936] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/06/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
The Expedited Access for Premarket Approval and De Novo Medical Devices Intended for Unmet Medical Need for Life Threatening or Irreversibly Debilitating Diseases or Conditions document was issued as a guidance for industry and for the Food and Drug Administration. The Expedited Access Pathway was designed as a new program for medical devices that demonstrated the potential to address unmet medical needs for life threatening or irreversibly debilitating conditions. The Food and Drug Administration would consider assessments of a device's effect on intermediate endpoints that, when improving in a congruent fashion, are reasonably likely to predict clinical benefit. The purpose of this review is to provide evidence to support the use of 3 such intermediate endpoints: natriuretic peptides, such as N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptide, the 6-min walk test distance, and health-related quality of life in heart failure.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Kevin Duarte
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | | | - Michael R Zile
- Medical University of South Carolina and the RHJ Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | | | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, California
| | | | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
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Carubelli V, Lombardi C, Lazzarini V, Bonadei I, Castrini AI, Gorga E, Richards AM, Metra M. N-terminal pro-B-type natriuretic peptide-guided therapy in patients hospitalized for acute heart failure. J Cardiovasc Med (Hagerstown) 2016; 17:828-39. [DOI: 10.2459/jcm.0000000000000419] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Francis GS, Felker GM, Tang WHW. A Test in Context: Critical Evaluation of Natriuretic Peptide Testing in Heart Failure. J Am Coll Cardiol 2016; 67:330-7. [PMID: 26796399 DOI: 10.1016/j.jacc.2015.10.073] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/08/2015] [Accepted: 10/11/2015] [Indexed: 01/08/2023]
Abstract
Circulating natriuretic peptide measurements have been used extensively over the past 15 years to diagnose and monitor patients with heart failure. We are still learning how complex the dynamics of natriuretic peptides can be in the interpretation of test results in individual patients. Although natriuretic peptide measurements are widely used in practice, there are questions regarding why these peptides may not necessarily track with blood volume or invasive hemodynamic measurements in individual patients. Interpretation of natriuretic peptide measurements will depend on many factors, including special patient populations, obesity, renal function, the state of congestion or decongestion, and whether patients are receiving specific therapies. Natriuretic peptide measurements have clearly revolutionized clinical care for patients with heart failure, but further research should provide insights to help use these measurements to individualize patient care beyond the current guidelines.
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Affiliation(s)
| | | | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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