Cardiac natriuretic peptides during exercise and training after heart transplantation

Endocrine heart after lung transplantation: increased brain natriuretic peptide is related to right ventricular function

Brain natriuretic peptide (BNP) increases in proportion to the extent of right ventricular dysfunction in pulmonary hypertension and after heart transplantation. No data are available after lung transplantation. Clinical, biological, respiratory, echocardiographic characteristics and circulating BNP and its second messenger cyclic guanosine monophosphate (cGMP) were determined in thirty matched subjects (10 lung-, 10 heart-transplant recipients (Ltx, Htx) and 10 healthy controls). Eventual correlations between these parameters were investigated. Heart rate and pulmonary arterial blood pressure were slightly increased after transplantation. Creatinine clearance was decreased. Mean of forced expiratory volume in 1 s was 76.6 +/- 5.3% and vital capacity was 85.3 +/- 6.4% of the predicted values in Ltx. BNP was similarly increased in Ltx and Htx, as compared with control values (54.1 +/- 14.2 and 45.6 +/- 9.2 vs. 6.2 +/- 1.8 pg/ml, respectively). Significant relationships were observed between plasma BNP and cGMP values (r = 0.62; P < 0.05 and r = 0.75; P < 0.01, in Ltx and Htx) and between BNP and right ventricular fractional shortening and tricuspid E/Ea ratio in Ltx (r = -0.75 and r = 0.93; P < 0.01, respectively). BNP is increased after lung transplantation, like after heart transplantation. The relationships observed suggest that the cardiac hormone might counterbalance possible deleterious effects of lung-transplantation on right functioning of patient's heart.

Time-dependent changes in B-type natriuretic peptide after heart transplantation: correlation with allograft rejection and function

Endomyocardial biopsy is the gold standard to diagnose cardiac allograft rejection, although a noninvasive modality such as brain natriuretic peptide (BNP) is attractive. The authors examined the correlation of BNP levels with rejection patterns and allograft function in cardiac allograft recipients followed up to 8 years. One hundred forty-four consecutive patients underwent endomyocardial biopsy, right heart catheterization, and blood sampling. BNP levels decreased during the first 6 months after transplant but then reached a plateau. Time-dependent correlations were made between BNP levels and allograft rejection, left ventricular ejection fraction, pulmonary capillary wedge pressure, right atrial pressure, and serum creatinine. BNP levels were not different between patients with any rejection pattern and no rejection prior to or after 6 months following transplant. BNP levels did not correlate with ejection fraction, pulmonary capillary wedge pressure, right atrial pressure, or creatinine in the first 6 months after transplant. Statistically significant correlations existed between BNP and these parameters after 6 months following transplant. In cardiac transplant recipients, BNP levels decrease in the first 6 months following transplant and then reach a plateau regardless of the presence, type, or severity of allograft rejection. BNP levels do predict allograft rejection but correlate with allograft function after 6 months following transplant.

Dysregulation of pulsatility in aging IV. Pulsatile signaling and cardiovascular aging: functions and regulation of natriuretic peptide signaling

Atrial and brain natriuretic peptides (ANP and BNP) are cardiac hormones connecting heart and kidney and playing a key role in hydromineral and hemodynamic homeostasis. In contrast with the renin-angiotensin-aldosterone system, circulating ANP and BNP are not temporally related with rapid eye movement (REM)-nonREM sleep cycles, autonomic activity, or blood pressure. Cardiac natriuretic peptides are secreted in a pulsatile manner, with short periods of 20-48min, in normal as well as in pathological conditions. The frequency of pulses seems to be unchanged with aging, whereas the absolute amplitude of the oscillations seems to increase, most likely as a result of an increase in the plasma hormone levels observed in elderly. Enhanced cardiac secretion and decreased degradation partly explain the higher ANP and BNP concentrations observed in elderly. Despite higher levels, the natriuretic system seems to loose efficiency at the renal site in elderly. This more probably relies on reduced target organ responsivity and not on deeply altered hormone secretion. Here we review the impact of aging on the renal effects of the natriuretic peptides, and point out the lack of knowledge on the precise interactions between the ultradian rhythms of the systems involved in salt and water balance in elderly. Additional studies focusing on potential age-induced alterations of the intracellular signaling pathway are now needed.

Does circulating BNP normalize after heart transplantation in patients with normal hemodynamic and right and left heart functions?

BACKGROUND

Increased brain natriuretic peptide (BNP) in cardiovascular disease is thought to be a compensatory protective mechanism allowing to delay the occurrence of terminal heart failure. Heart transplantation should normalize the neuroendocrine balance but BNP remains elevated in stable heart-transplant recipients (Htx). Such increase has been related to persistent endothelial and cardiac dysfunctions. The purpose of this study was to determine whether selected Htx, presenting with normal hemodynamic and cardiac systolic and diastolic functions on both side of the heart, show a normalization of their BNP plasma values.

METHODS

Of a cohort of well-being 26 Htx, we selected 12 patients with normal hemodynamics and left and right heart systolic and diastolic functions and compared their circulating BNP, cyclic guanosine monophosphate (cGMP) (the BNP second messenger) and endothelin-1 (ET) values with that of 12 age-, body mass index- and mean arterial pressure-matched controls. Cardiac function determination by echodoppler included cardiac filling pressures assessment using tissue Doppler imaging. Blood samples for biological and hormonal determinations were drawn at rest, within 15 min before echocardiography.

RESULTS

As selected, hemodynamic and left and right heart systolic and diastolic functions were located in the normal range in Htx. Plasma ET value was also similar in Htx and controls (20.7 +/- 0.9 vs. 19.6 +/- 0.9 fmol/mL). However, circulating BNP, like cGMP, was still significantly increased after heart transplantation, when compared with controls (33.8 +/- 8.5 vs. 4.0 +/- 0.9 pg/mL, p = 0.002 and 8.2 +/- 1.1 vs. 4.4 +/- 0.3 nmol/L, p = 0.003) for BNP and cGMP, respectively, in Htx and controls. Interestingly, the sole correlation observed was between BNP and cGMP (r = 0.85, p < 0.0001) after heart transplantation.

CONCLUSIONS

After heart transplantation, BNP remained increased despite the normalization of hemodynamic and cardiac systolic and diastolic functions. This suggests that such endocrine heart stimulation should not be viewed only as a hemodynamic marker in Htx. Further studies will be useful to investigate the role of pro-inflammatory cytokines and whether elevated BNP still possesses antifibrotic properties, further supporting the interest of enhancing its activity after heart transplantation.

Exercise limitation in trained heart and kidney transplant recipients: central and peripheral limitations

BACKGROUND

To evaluate the role of central and peripheral contributions to exercise limitation after transplantation, we compared, during exercise, 2 groups of very well-trained heart transplants recipients (HTRs) and kidney transplant recipients (KTRs) with a group of control subjects (CSs), matched for physical level.

METHODS

Nineteen male subjects, 7 HTRs, 6 KTRs and 6 CSs, participated in the study. All transplant patients were in sinus rhythm and were matched for immunosuppressive therapy, none of whom had therapy with chronotropic effects. Exercise capacities were evaluated using a symptom-limited treadmill test. Oxygen consumption (VO2) and heart rate (HR) were measured continuously. Heart rate reserve (HRR) was defined as peak HR minus resting HR; resting HR was the stabilized HR measured in the supine position before the treadmill test.

RESULTS

Functional capacities were evaluated for all HTRs, KTRs and CSs, according to maximal VO2 (41.5 +/- 4.0, 52.0 +/- 8.7 and 50.6 +/- 9.0 ml/kg per min, respectively), maximal treadmill speed (9.9 +/- 1.2, 12.7 +/- 1.9 and 15.5 +/- 1.5 km/h) and HRR (65 +/- 17, 101 +/- 12 and 110 +/- 11 beats per minute [bpm]), which were significantly lower in the HTR group (p < 0.05). Regardless of type of organ transplant, both HTR and KTR patients had a similar VO2/treadmill speed relationship, significantly higher than in the CS group. HRR correlated with maximal VO2 for HTRs (r = 0.72, p < 0.05).

CONCLUSIONS

Despite regular training, the decreased mechanical efficiency reflected by an increased VO2/treadmill speed relationship suggests a peripheral limitation in both heart and kidney transplant patients. Furthermore, exercise limitations in HTRs likely arose from both central and peripheral factors, in view of their specific HRR reduction. These factors probably contributed to the decreased speed and VO2 observed in the HTR group.

Effect of prolonged physical exercise on urinary proANP1-30 and proANP31-67

Dynamic exercise strongly affects atrial natriuretic peptides (ANP), in particular the mature bioactive alphaANP and the proANP fragments, namely proANP1-98, proANP1-30 and proANP31-67. The proANPs influence kidney functions and their plasma levels increase after physical exercise. We measured urinary proANP1-30 and proANP31-67 levels before and at the end of physical exercise in 28 well-trained male cyclists. For the first time, the proANP1-30 and proANP31-67 urinary levels in athletes before and at the end of a prolonged agonistic bicycle race were measured. Urinary creatinine and total proteins were also measured. The urinary proANP31-67, creatinine and total protein levels were significantly higher at the end of exercise than before. In contrast, proANP1-30/protein and proANP31-67/protein ratios decreased after exercise. Even proANP1-30/creatinine and proANP31-67/creatinine ratios were lower after exercise. A significant correlation between proANP1-30 and proANP31-67 urinary levels at the end of exercise was found. The proANP31-67/creatinine ratio before and after exercise also showed a significant correlation. The variation of urinary proANP fragments confirmed their possible role in physical exercise. In particular, it could be interpreted as a response of the body or kidney to renal impairment occurring during exercise.

Chronic But Not Acute Oral L-Arginine Supplementation Delays the Ventilatory Threshold During Exercise in Heart Failure Patients

The purpose of this study was to determine, in heart failure patients (HF), whether acute or chronic L-arginine supplementation (LAS) might delay the ventilatory threshold (VT) and whether chronic LAS might reduce exercise-induced plasma lactate increase. HF patients undertook 4 cardiopulmonary bicycle exercises tests. The first 3 were maximal without (EX1), after acute (EX2), or chronic (EX3) oral LAS (6 gm twice a day for 6 weeks). The 4th test (EX4), performed after chronic LAS, was similar to the first in order to investigate the effect of chronic LAS on circulating lactate levels. Results showed that acute LAS failed to improve both submaximal and maximal exercise capacities. Similarly, maximal exercise capacity remained unmodified after chronic LAS. Nevertheless, chronic LAS delayed significantly the patients' ventilatory threshold. Thus exercise duration prior to VT increased (mean ± SEM) from 6.04 ± 0.9 to 7.7 ± 1.03 min (p = 0.04), resulting in a significant increase in oxygen uptake (1.05 ± 0.08 to 1.24 ± 0.12 L•min−1; p = 0.03), CO2 release (0.94 ± 0.10 to 1.2 ± 0.12 L•min−1; p = 0.018), minute ventilation (29.31 ± 2.8 to 34.5 ± 2.7 L; p = 0.009), and workload (60.7 ± 9.8 to 78.5 ± 10.2 watts; p = 0.034). Furthermore, chronic LAS significantly reduced the exercise-induced increase in postexercise plasma lactate concentration (−21 ± 7%). In conclusion, unlike acute supplementation, chronic LAS significantly delays the ventilatory threshold, and chronic LAS reduces circulating plasma lactate in HF patients. These data suggest that chronic LAS might improve the ability of HF patients to perform their daily-life activities. Key words: maximal exercise, heart device, vasodilator

Improving exercise capacity, 6 wk training tends to reduce circulating endothelin after heart transplantation

Short-term survival is no longer the pivotal issue after heart transplantation but, most heart-transplant (Htx) patients still present with increased circulating endothelin-1 (ET) and reduced exercise capacity. ET-1 limits both exercise-induced vasodilation and blood flow redistribution toward acting muscles and might be accessible to training. This study was performed to investigate the effect of training on ET-1 and whether an eventual training-induced improvement in exercise capacity may be related to reduced baseline or exercise circulating ET-1 in Htx patients. Five Htx patients performed a maximal bicycle exercise test and an endurance exercise test before and after a training program of 18 exercises sessions during 6 wk. ET-1 was determined by radioimmunoassay at rest, end endurance exercise and 30 min recovery, before and after training. Training improved significantly Htx's maximal oxygen uptake (+13.1 +/- 4.8%; p < 0.05) and also reduced significantly the endurance exercise-induced heart rate increase. Resting ET-1 was increased in Htx (5.98 +/- 1.88 vs. 1.61 +/- 0.25 pmol/L in controls; p < 0.01) but although ET-1 modulation might participate in training-induced beneficial effects, training failed to modulate either resting or exercise ET-1 plasma level. Training-induced improvement in exercise capacity might not mainly due to decreased ET-1 after heart transplantation. Further supporting the usefulness of training, these preliminary data suggest that improved exercise capacity may not be mainly due to decreased ET-1 in Htx patients. Further, larger scale studies will be needed to investigate whether an impaired nitric oxide pathway stimulation might explain such results and whether a longer training program can reduce local ET-1, arising from working muscles after heart transplantation.

Reabilitação física no transplante de coração

Após o transplante cardíaco os pacientes melhoram a qualidade de vida. Porém, freqüentemente apresentam problemas clínicos pós-operatórios, como descondicionamento físico, atrofia e fraqueza muscular e menor capacidade aeróbia máxima, decorrentes em parte da inatividade pré-operatória e de fatores como diferença de superfície corpórea doador/receptor, denervação do coração, entre outros. A atividade física regular tem papel importante na terapêutica dos transplantados, devendo ser iniciada precocemente, se possível ainda na fase hospitalar, dando prosseguimento pós-alta hospitalar, para que possam retornar a um estilo de vida normal, próximo do que tinham antes da doença, permitindo um convívio social satisfatório, com retorno a uma vida ativa e produtiva.

Hormonal, renal, hemodynamic responses to acute neutral endopeptidase inhibition in heart transplant patients

We investigated the hemodynamic, renal, and hormonal responses to neutral endopeptidase (NEP) inhibition during a 6-h, double-blind, randomized, placebo-controlled study in seven chronic, stable heart transplant patients. Baseline characteristics were similar during both experiments, and no significant changes were observed after placebo. NEP inhibition increased circulating endothelin-1 (from 2.01 +/- 0.1 to 2.90 +/- 0.2 pmol/l; P < 0.01), atrial natriuretic peptide (ANP; from 21.5 +/- 2.7 to 29.6 +/- 3.7 pmol/l; P < 0.01), and the ANP second messenger cGMP. Noteworthy, systemic blood pressure did not increase. Renal plasma flow and glomerular filtration rate remained unmodified after NEP inhibition. Filtration fraction (33 +/- 13%), diuresis (196 +/- 62%), and natriuresis (315 +/- 105%) increased significantly in relation to ANP and cGMP. A strong inverse relationship was observed between excreted cGMP and sodium reabsorption (r = -0.71, P < 0.0001). Thus, despite significantly increasing endothelin-1, NEP inhibition did not adversely influence systemic or renal hemodynamics in transplant patients. ANP, possibly through a tubular action, enhances the natriuresis observed after NEP inhibition.