N-terminal brain natriuretic peptide is a more powerful predictor of mortality than endothelin-1, adrenomedullin and tumour necrosis factor-alpha in patients referred for consideration of cardiac transplantation

Plasma endothelin-1-related peptides as the prognostic biomarkers for heart failure: A PRISMA-compliant meta-analysis

BACKGROUND

Most studies reported that high plasma endothelin-1 (ET-1), big ET-1, and C-terminal proET-1 (CT-proET-1) were correlated with poor prognosis of heart failure (HF). However, available evidence remains controversial. To help solve the debate, we collected all the available studies and performed a meta-analysis.

METHODS

We searched the databases covering Embase, PubMed, Ovid, and Web of Science on June 28, 2017. The hazard ratio (HR) or risk ratio (RR) and its 95% confidence intervals (CIs) were collected and calculated by use of a random-effect model. Heterogeneity was assessed by Cochran's Q test, and publication bias was assessed by funnel plots with Egger's and Begg's linear regression test.

RESULTS

Thirty-two studies with 18,497 patients were included in the analysis. Results showed that circulating ET-1, big ET-1, and CT-proET-1 were positively correlated with high risk of adverse outcomes, with pooled RRs (95% CIs) of 2.22 (1.82-2.71, P < .001), 2.47 (1.93-3.17, P < .001), and 2.27 (1.57-3.29, P < .001), respectively. In the subgroup of death as primary outcome, the pooled RRs (95% CIs) were 2.13 (1.68-2.70, P < .001), 2.55 (1.82-3.57, P < .001), and 2.02 (1.39-2.92, P < .001) for ET-1, big ET-1, and CT-proET-1, respectively. No significant publication bias was observed in this study.

CONCLUSION

Our meta-analysis provided evidence that increased plasma levels of ET-1, big ET-1, and CT-proET-1 were associated with poor prognosis or mortality for HF populations.

BNP and NT-proBNP as prognostic markers in persons with chronic stable heart failure

Prognosis permits clinicians to separate persons with heart failure (HF) into subgroups based on likely health outcomes. Treatment is partly guided by these likely outcomes. This systematic review explores whether brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) are independent predictors of prognosis in persons with chronic stable HF. We electronically searched Medline, Embase, AMED, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL for English-language articles published between 1989 and mid-2012. We utilized trained reviewers and standardized forms to screen articles for inclusion and extracted data from included articles. All included studies were summarized in narrative and tabular form. We used the Hayden criteria to assess the risk of bias. Sixteen BNP publications and 88 NT-proBNP publications were included in the systematic review. BNP was positively associated with all-cause and HF mortality. NT-proBNP was positively associated with all-cause and cardiovascular mortality. BNP and NT-proBNP levels are useful for estimating prognosis in persons with chronic stable HF. Further research is required to establish optimal cutpoints and to assess whether prognostic effects differ by age, sex, or time period.

The prognostic value of anemia, right-heart catheterization and neurohormones in chronic heart failure

Chronic heart failure is increasing in incidence and prevalence. Recent advances in medical therapy have improved prognosis such that, even in patients with chronic heart failure who are New York Heart Association Classes III and IV, annual mortality can be as low as 11.4%. Nevertheless, some patients remain at risk, despite optimal disease-modifying medical therapy, and it would seem appropriate that these patients are considered first for appropriate device therapy or for the scarce resource of cardiac transplantation. Many parameters have been assessed for their prognostic potential in patients with chronic heart failure. In this review, pertinent studies investigating anemia, right-heart hemodynamics and neurohormones as prognostic markers are discussed.

Amino-terminal pro-brain natriuretic peptide: a biomarker for diagnosis, prognosis and management of heart failure

There is a substantial need for a diagnostic tool to aid in the early diagnosis of heart failure and in the recognition of those at risk for its development, as well as in guidance of therapy. Testing for amino-terminal pro-brain natriuretic peptide (NT-proBNP) has been recognized to have utility in the diagnosis, prognosis and management of heart failure. In addition, numerous other applications for NT-proBNP testing are now recognized, such as evaluation of patients with heart disease in the absence of heart failure, as well as the diagnostic and prognostic evaluation of patients with acute coronary syndromes or pulmonary thromboembolism.

Novel biomarkers in chronic heart failure

Understanding of chronic heart failure (HF) has progressed from a syndrome of disordered hemodynamics caused by alterations in the structure of the heart to one that involves intertwined molecular pathways in disarray. Accordingly, the assessment and treatment of patients with chronic HF has shifted from a focus on hemodynamics to modification of maladaptive molecular processes. Accumulating evidence shows that molecular biomarkers of disease could provide a unique window into the pathophysiology of chronic HF, potentially improving our ability to predict adverse outcomes, provide novel drug targets, and even help gauge therapeutic efficacy. The more 'traditional' biomarkers such as cardiac troponin, natriuretic peptides, and C-reactive protein have been studied in large cohorts of patients with chronic HF and have relatively established clinical applications. In this Review, we summarize the properties, clinical data, and potential applications of some emerging biomarkers that could uniquely indicate the level of biomechanical stretch, inflammation, ventricular remodeling, myocardial injury, and renal dysfunction that occurs in chronic HF. We will also discuss the potential role for these biomarkers within a multimarker-based strategy that could, in the future, lead to better care for these patients.

Identification of chronic heart failure patients with a high 12-month mortality risk using biomarkers including plasma C-terminal pro-endothelin-1

OBJECTIVES

We hypothesised that assessment of plasma C-terminal pro-endothelin-1 (CT-proET-1), a stable endothelin-1 precursor fragment, is of prognostic value in patients with chronic heart failure (CHF), beyond other prognosticators, including N-terminal pro-B-type natriuretic peptide (NT-proBNP).

METHODS

We examined 491 patients with systolic CHF (age: 63±11 years, 91% men, New York Heart Association [NYHA] class [I/II/III/IV]: 9%/45%/38%/8%, 69% ischemic etiology). Plasma CT-proET-1 was detected using a chemiluminescence immunoassay.

RESULTS

Increasing CT-proET-1 was a predictor of increased cardiovascular mortality at 12-months of follow-up (standardized hazard ratio 1.42, 95% confidence interval [CI] 1.04-1.95, p = 0.03) after adjusting for NT-proBNP, left ventricular ejection fraction (LVEF), age, creatinine, NYHA class. In receiver operating characteristic curve analysis, areas under curve for 12-month follow-up were similar for CT-proET-1 and NT-proBNP (p = 0.40). Both NT-proBNP and CT-proET-1 added prognostic value to a base model that included LVEF, age, creatinine, and NYHA class. Adding CT-proET-1 to the base model had stronger prognostic power (p<0.01) than adding NT-proBNP (p<0.01). Adding CT-proET-1 to NT-proBNP in this model yielded further prognostic information (p = 0.02).

CONCLUSIONS

Plasma CT-proET-1 constitutes a novel predictor of increased 12-month cardiovascular mortality in patients with CHF. High CT-proET-1 together with high NT-proBNP enable to identify patients with CHF and particularly unfavourable outcomes.

N-terminal pro-brain natriuretic peptide and tumor necrosis factor-alpha both are increased in patients with Hepatitis C

Many patients with hepatitis C chronic infection (HCV+ patients) experience symptoms (fatigue, dyspnea) not proportional to the liver involvement and resemble symptoms of heart failure (HF). To our knowledge, no study evaluated at the same time serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and tumor necrosis factor alpha (TNF-alpha) in HCV+ patients. Circulating NT-proBNP and TNF-alpha were assayed in 60 HCV+ patients, and in 60 sex- and age-matched controls. HCV+ patients showed significantly higher mean NT-proBNP and TNF-alpha levels than controls (P < 0.003). By defining high NT-proBNP level as a value higher than 125 pg/mL (the single cutoff point for outpatients under 75 years of age), 28% of HCV+ and 7% controls had high NT-proBNP (chi-square; P < 0.002). With a cutoff point of 900 pg/mL (that should be used for ruling in HF in patients age 50-75; such as the patients in our study), 3% HCV+ and 0 controls had high NT-proBNP. In conclusion, the study demonstrates high levels of circulating NT-proBNP and TNF-alpha in HCV+ patients. The increase of NT-proBNP may indicate the presence of a subclinical cardiac dysfunction. Further prospective studies quantifying symptoms and correlating these with echocardiographic parameters are needed to confirm this association.

High circulating N-terminal pro-brain natriuretic peptide and tumor necrosis factor-α in mixed cryoglobulinemia

AIM: To evaluate serum levels of N-terminal pro-brain natriuretic peptide (NTproBNP) and tumor necrosis factor α (TNF-α) in a large series of patients with hepatitis C associated with mixed cryoglobulinemia (MC+HCV).

METHODS: Serum NTproBNP and TNF-α levels were assayed in 50 patients with MC+HCV, and in 50 sex- and age-matched controls.

RESULTS: Cryoglobulinemic patients showed significantly higher mean NTproBNP and TNF-α levels than controls (P < 0.001; Mann-Whitney U test). By defining high NTproBNP level as a value higher than 125 pg/mL (the single cut-off point for outpatients under 75 years of age), 30% of MC+HCV and 6% of controls had high NTproBNP (χ², P < 0.01). With a cut-off point of 300 pg/mL (used to rule out heart failure (HF) in patients under 75 years of age), 8% of MC+HCV and 0 controls had high NTproBNP (χ², P < 0.04). With a cut-off point of 900 pg/mL (used for ruling in HF in patients aged 50-75 years; such as the patients of our study), 6% of MC+HCV and 0 controls had high NTproBNP (χ², P = 0.08).

CONCLUSION: The study demonstrates high levels of circulating NTproBNP and TNF-α in MC+HCV patients. The increase of NTproBNP may indicate the presence of a subclinical cardiac dysfunction.

Prognostic value of plasma midregional pro-adrenomedullin and C-terminal-pro-endothelin-1 in chronic heart failure outpatients

AIMS

The identification of chronic heart failure (CHF) patients at high risk of adverse outcome remains a challenge. New peptides are emerging that may give additional information. In CHF patients, endothelin (ET) levels predict mortality risk. Adrenomedullin has been shown to predict mortality in ischaemic heart failure, but not in unselected or non-ischaemic CHF patients. Moreover, ADM and ET have never been assessed in one model. The aim of the present study was to assess the prognostic value of midregional-pro-adrenomedullin (MR-proADM) and C-terminal-pro-endothelin-1 (CT-proET-1) in outpatients with CHF.

METHODS AND RESULTS

We measured plasma MR-proADM and CT-proET-1 levels in 786 consecutive CHF outpatients and compared them with B-type natriuretic peptide (BNP) levels. At 24-month follow-up, 233 patients had died. A stepwise forward Cox regression model with age, sex, estimated glomerular filtration rate, NYHA > II, left ventricular ejection fraction (LVEF), MR-proADM, CT-proET-1, and BNP as possible predictors revealed that MR-proADM levels [hazard ratio (HR) = 1.77, P < 0.001] in addition to age (HR = 1.02, P = 0.004), ejection fraction (HR = 0.98, P = 0.004), and NYHA > II (HR = 1.86, P < 0.001) were predictors of death at 24 months. When the analysis was repeated dependent on NYHA-stage, MR-proADM (HR = 2.12, P < 0.001) and LVEF (HR = 0.96, P = 0.006) were significant markers, but only in patients with mild/moderate CHF.

CONCLUSION

Our data suggest that MR-proADM may be an important prognostic humoral marker, especially in mild/moderately symptomatic and non-ischaemic CHF patients.

B-type natriuretic Peptide: application in the community

Natriuretic peptide assessment has represented a significant advance in the management of heart failure. In a syndrome in which clinical symptoms and signs can be either nonspecific or absent, the presence of a reliable biomarker to aid diagnosis, assess prognosis, and potentially guide treatment and aid in prevention of this syndrome has represented a significant advance. The following review will outline established and potential new roles for natriuretic peptide assessment in the community.

Amino-terminal pro-B-type natriuretic peptides and prognosis in chronic heart failure

In patients with chronic heart failure (HF), amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels are among the strongest independent predictors of hazard, and their measurement is useful for prognostication across the entire spectrum of HF disease severity. In patients with chronic HF, repeated determinations of NT-proBNP levels appear to convey additional prognostic value for relevant adverse outcomes, including death or HF hospitalization. Although "hard targets" for NT-proBNP values are not entirely defined, morbidity and mortality in chronic HF appear to increase markedly with an NT-proBNP concentration >1,000 ng/L. Confounding factors (such as renal function or obesity) should be kept in mind when prognostically evaluating patients using NT-proBNP measurements; however, the value of NT-proBNP is retained in these patients. Thus, serial assessment of NT-proBNP is valuable for prognostication in chronic HF in outpatients, and, as such, a measurement at each patient visit or the following of changes in clinical stability is recommended.

Can we use B-type natriuretic peptides to monitor patients with heart failure?

The B-type natriuretic peptides (BNPs) now have a well-established role in the diagnosis of heart failure. There is also a wealth of evidence on their ability as prognostic markers in patients with heart failure. The other potential role of BNPs is in the arena of therapy monitoring, although much less is known regarding this putative application. This review summarizes what evidence there is both for and against using BNPs to monitor heart failure patients.

Nitric Oxide Metabolites Are Associated with Survival in Older Patients

OBJECTIVES

To assess the efficacy of various vascular endocrinological substances, such as plasma nitric oxide metabolites (NOx), as surrogate markers of survival in older patients.

DESIGN

Prospective cohort, observational.

SETTING

Nagoya University Hospital and related hospitals, Japan.

PARTICIPANTS

One hundred fifty patients aged 70 and older, recruited consecutively from the outpatient clinics of Nagoya University Hospital and related hospitals.

MEASUREMENT

Serum biochemical analyses such as albumin and total cholesterol, various prognostic markers, such as tumor necrosis factor (TNF)-alpha, NOx, activities of daily living (ADLs), and instrumental ADLs (IADLs) were evaluated on enrollment. ADLs, IADLs, and comorbidities, especially depression and impaired cognition, were evaluated on enrollment. The main outcome was survival rate over 2.75 years.

RESULTS

Forty-nine patients died during the follow-up period. Mann-Whitney U-test showed that hemoglobin, total protein, serum albumin, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high sensitive c-reactive protein, NOx, B-type natriuretic peptide, interleukin-6, and TNF-alpha levels; ADLs; cognitive impairment; and depressive status were significantly different for subjects who survived and those who died. Of the dependent variables in the Cox proportional hazards regression analyses, only ADLs, NOx, and albumin were significantly different. In the Kaplan-Meier analyses of mortality, the prognosis of patients in the third and fourth quartiles of NOx was significantly worse than that of patients in the first or second quartile. The prognosis of patients with impaired ADLs was worse than that of other patients for the overall period.

CONCLUSION

Lower levels of NOx may be associated with survival in older patients. It may be an effective marker, like ADLs, which is a well-known marker.

Prognostic importance of plasma NT-pro BNP in chronic heart failure in patients treated with a β-blocker: Results from the Carvedilol Or Metoprolol European Trial (COMET) trial

BACKGROUND

Plasma levels of N-terminal pro-brain natriuretic peptide (NT-pro BNP) are increased in patients with chronic heart failure (CHF). Beta-blockers (BB) may influence these levels but it is unclear whether changes in NT-pro BNP reflect concomitant changes in prognosis.

OBJECTIVES

To assess the prognostic importance of NT-pro BNP at baseline and during follow-up, in patients in whom beta-blocker therapy is initiated.

METHODS

In COMET, 3029 patients with CHF in NYHA class II-IV and EF<35% were randomised to carvedilol or metoprolol tartrate and were followed for an average of 58 months. Blood samples were collected for the measurement of NT-pro BNP at baseline (n=1559) and during follow-up (n=309).

RESULTS

Baseline plasma concentrations of NT-pro BNP above the median (1242 pg/ml) were associated with higher all-cause mortality (RR 2.77; 95% CI 2.33-3.3, p<0.001). Patients who achieved NT-pro BNP levels<400 pg/ml during follow-up had a lower subsequent mortality (RR 0.32; 95% CI 0.15-0.69, p=0.004).

CONCLUSIONS

The plasma concentration of NT-pro BNP is a powerful predictor of mortality in patients with CHF. Patients who achieve an NT-pro BNP of <400 pg/ml subsequent to treatment with a beta-blocker have a favourable prognosis.

B-type natriuretic peptides in heart failure

There is increasing interest in the B-type natriuretic peptides in many clinical settings, with most research centered on patients with heart failure. These peptides have a strong negative predictive value in patients suspected of having this diagnosis, but are also known to be powerfully predictive of an adverse outcome. This latter property is particularly important in patients with advanced heart failure, allowing the selection of at-risk individuals for therapies that are in scarce resource. There is also ongoing research into B-type natriuretic peptide as a treatment for decompensated heart failure, as well as in other clinical contexts. This review aims to summarize the contemporary and established data on the B-type natriuretic peptides, with particular emphasis in the context of advanced heart failure.

Emerging role of the apelin system in cardiovascular homeostasis

The angiotensin receptor-like 1 (APJ) and its novel ligand, apelin, share similarities in structure and anatomical distribution with that of angiotensin II and the angiotensin II type 1 receptor. However, apelin has positive inotropic, vasodilatory and diuretic properties. Differential expression and synthesis of apelin and the APJ receptor in normal and failing hearts suggest that the apelin system may contribute to the pathophysiology of human heart failure and has potential therapeutic use in treatment of heart failure.

Cardiovascular risk with cyclooxygenase inhibitors: general problem with substance specific differences?

Randomised clinical trials and observational studies have shown an increased risk of myocardial infarction, stroke, hypertension and heart failure during treatment with cyclooxygenase inhibitors. Adverse cardiovascular effects occurred mainly, but not exclusively, in patients with concomitant risk factors. Cyclooxygenase inhibitors cause complex changes in renal, vascular and cardiac prostanoid profiles thereby increasing vascular resistance and fluid retention. The incidence of cardiovascular adverse events tends to increase with the daily dose and total exposure time. A comparison of individual selective and unselective cyclooxygenase inhibitors suggests substance-specific differences, which may depend on differences in pharmacokinetic parameters or inhibitory potency and may be contributed by prostaglandin-independent effects. Diagnostic markers such as N-terminal pro brain natriuretic peptide (NT-proBNP) or high-sensitive C-reactive protein might help in the early identification of patients at risk, thus avoiding the occurrence of serious cardiovascular toxicity.

Plasma concentrations of the novel peptide apelin are decreased in patients with chronic heart failure

BACKGROUND

Apelin, the novel endogenous ligand for the G-protein-coupled receptor APJ, has shown positive inotropic, vasodilatory and diuretic properties in animal studies. Differential expression and synthesis of apelin and APJ receptors have been observed in normal and failing human hearts, suggesting a possible role in cardiovascular homeostasis. Changes in plasma apelin concentrations in relation to heart failure have been described in small studies with conflicting results. Our aim was to evaluate plasma apelin concentrations in a large cohort of patients with chronic heart failure (CHF) across a broad spectrum of disease severity.

METHOD AND RESULTS

Plasma apelin concentrations were measured in 202 patients with CHF secondary to left ventricular systolic dysfunction and 22 age-matched controls. Plasma apelin concentrations were significantly lower in patients with CHF, irrespective of NYHA class, ejection fraction or aetiology when compared to age-matched controls (0.85 [0.53-2.04] versus 3.76 [0.85-5.13] ng/ml, p<0.001). Apelin concentrations were correlated with peak VO(2) and right ventricular ejection fraction, but not with age, sex, body mass index, renal function or NT-proBNP concentrations.

CONCLUSIONS

Plasma apelin concentrations are decreased in patients with CHF. The Apelin-APJ signaling pathway may be a potentially important mediator in the pathophysiological processes of heart failure and may therefore have potential therapeutic implications.

N-Terminal Brain Natriuretic Peptide, But Not Anemia, Is a Powerful Predictor of Mortality in Advanced Heart Failure

BACKGROUND

Anemia is prevalent in patients with chronic heart failure, the proportion of which increases with deteriorating New York Heart Association functional class. Anemia is also associated with increased symptoms, more frequent hospitalizations, and, in some studies, with an increased mortality rate. We have demonstrated that N-terminal brain natriuretic peptide (NT-proBNP) is a powerful predictor of death in advanced heart failure and is superior to the traditional markers of chronic heart failure (CHF) severity. However, to date, there are no published data that compare the prognostic ability of NT-proBNP with that of hemoglobin and hematocrit in patients with advanced heart failure who are referred for consideration of cardiac transplantation at a time when erythropoietin is under investigation as a treatment option in such a population.

METHODS AND RESULTS

We prospectively studied 182 consecutive patients with advanced CHF who had been referred for consideration of cardiac transplantation. Blood samples were taken at recruitment for routine investigation and for NT-proBNP analysis; the patients' condition was followed for a median of 554 days. The primary end point of all-cause death was reached in 30 patients, and the secondary end point of all-cause death or urgent cardiac transplantation was reached in 34 patients. The mean hemoglobin level was 13.9 +/- 2.2 g/dL, and the median concentration of NT-proBNP was 1505 pg/mL (interquartile range, 517-4015). The only multivariate predictor of all-cause death (chi 2 = 14.2; P < .001) or the secondary end point of all-cause death or urgent transplantation (chi 2 = 21.8; P < .001) was an NT-proBNP concentration above the median value.

CONCLUSION

A single measurement of NT-proBNP in patients with advanced CHF can help to identify patients who are at a higher risk of death and is a better prognostic marker than anemia.