How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review

Association between NT-proBNP changes and clinical outcomes in paediatric patients with heart failure: Insights from PANORAMA-HF and PARADIGM-HF

AIMS

The PANORAMA-HF trial demonstrated significant N-terminal pro-B-type natriuretic peptide (NT-proBNP) reductions in paediatric patients with left ventricular systolic dysfunction with sacubitril/valsartan or enalapril treatment over 52 weeks. This post hoc analysis aims to correlate changes in NT-proBNP levels with clinical outcomes in PANORAMA-HF patients receiving either sacubitril/valsartan or enalapril. Additionally, NT-proBNP reductions in the paediatric population were compared with a subset of adult heart failure with reduced ejection fraction (HFrEF) patients from the PARADIGM-HF trial.

METHODS AND RESULTS

This post hoc analysis utilized data from Part 2 of the PANORAMA-HF trial. Associations between baseline NT-proBNP levels, changes post-baseline and the risk of HF clinical events in paediatric patients on sacubitril/valsartan or enalapril were assessed. The paediatric HF population from PANORAMA-HF was categorized into age groups (AG): AG1 (aged 6 to <18 years), AG2a (aged 2 to <6 years) and AG3a (aged 1 month to <2 years). The Cox proportional hazard model evaluated the relationship between NT-proBNP and clinical outcomes. Analysis of 361 paediatric patients (sacubitril/valsartan, n = 179; enalapril, n = 182) demonstrated overall higher baseline NT-proBNP levels in younger AGs. At Week 52, both treatment groups exhibited reduced NT-proBNP levels across all AGs. Reductions were comparable between sacubitril/valsartan and enalapril, with a numerically greater reduction observed in adult patients versus children. Strong associations between NT-proBNP levels and HF clinical outcomes were observed in paediatric populations in PANORAMA-HF and in adult DCM patients with HFrEF in PARADIGM-HF. Doubling of NT-proBNP levels was associated with a ≥1.7-fold increased risk of HF clinical events, while halving of the levels correlated with a 52% reduction in the risk of clinical events.

CONCLUSIONS

This is the first prospective, randomized large-scale study to demonstrate a strong correlation between NT-proBNP levels and risks of HF clinical events in paediatric patients with HF.

Development and validation of a risk prediction model for adverse outcomes in patients with suspected coronary artery disease and no significant stenosis on angiography: a retrospective cohort study

OBJECTIVES

To develop and validate a risk prediction model for adverse outcomes in patients with angina with non-obstructive coronary arteries (ANOCA) confirmed by invasive coronary angiography.

DESIGN

Retrospective cohort study.

SETTING

A tertiary cardiovascular care centre in China.

PARTICIPANTS

From 17 816 consecutive patients undergoing coronary angiography for suspected coronary artery disease, 5934 met ANOCA criteria after rigorous exclusion: (1) significant stenosis (≥50% luminal narrowing), (2) established coronary artery disease history, (3) incomplete baseline/follow-up data, (4) non-cardiovascular life-limiting conditions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a composite of all-cause death, non-fatal myocardial infarction (MI), stroke and repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The secondary outcome was major adverse cardiovascular events, defined as cardiac-related death, non-fatal MI, non-fatal stroke, repeat PCI and CABG.

RESULTS

The derivation cohort (n=4452) and validation cohort (n=1482) demonstrated comparable baseline characteristics. The nomogram incorporated eight prognosticators: age, haemoglobin, serum urea, serum sodium, alanine aminotransferase/aspartate aminotransferase ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), left atrial diameter and left ventricular ejection fraction. The prediction model showed robust discrimination for primary endpoint, achieving area under the curve (AUC) values of 0.82 (1 year), 0.90 (2 years) and 0.89 (3 years) in the derivation cohort, with corresponding validation cohort AUCs of 0.75, 0.77 and 0.78. Calibration plots revealed close alignment between predicted and actual event-free survival probabilities in both cohorts. Risk stratification identified two distinct prognostic groups with significant survival differences (log-rank p<0.0001).

CONCLUSIONS

This predictive model integrates routinely available clinical parameters to accurately stratify mortality and cardiovascular risk in ANOCA patients, providing a potential valuable decision-support tool for personalised therapeutic strategies.

Acoustic features are independently associated with heart failure and pulmonary hypertension

INTRODUCTION

Acoustic analysis of speech has discriminated decompensated acute heart failure (HF). Speech rate (SR) and cepstral peak prominence (CPP) variation are among features previously evaluated. However, the association between SR and CPP and chronic stable HF with and without pulmonary hypertension (PH) as well as PH alone have not been previously studied.

METHODS

Patients evaluated for HF and/or PH in the outpatient setting recorded a standardized text read out loud from which a sentence was extracted and analysed to extract pre-specified acoustic features including SR and CPP calculated for voiced speech (CPP-V) and in all speech (CPP-All). Patients were grouped depending on the presence or absence of disease (HF and/or PH) and symptoms. Linear regression models were fitted to determine the association between each acoustic feature and disease status.

RESULTS

In total, 2153 patients were included: age 65.32 ± 17.18 years; male n = 1246 (57.9%); 879 had HF (40.8%), 542 had PH (25.2%) and 777 had no disease and no symptoms (36.1%). After adjustment for age and sex, SR was significantly lower in patients with PH only [estimated coefficient, 95% confidence interval (CI): -0.14, -0.21 to -0.06, P = 0.0006], HF only (-0.11, -0.17 to -0.05, P = 0.0002) and HF with PH (-0.17, -0.24 to -0.10, P < 0.0001) compared with no disease. CPP-V differed in patients with PH only (0.37, 0.16-0.57, P = 0.0004) and CPP-All differed significantly compared with patients without disease (0.23, 0.08-0.38, P = 0.0025).

CONCLUSIONS

SR is significantly slower in patients with HF alone, PH alone and HF and PH combined compared with patients without disease. CPP also differs significantly in patients with PH compared with controls. These findings suggest that acoustic analysis may be useful in discriminating chronic stable HF and PH, offering promise for the development of non-invasive screening methods for HF and PH.

Molecular and cellular neurocardiology in heart disease

This paper updates and builds on a previous White Paper in this journal that some of us contributed to concerning the molecular and cellular basis of cardiac neurobiology of heart disease. Here we focus on recent findings that underpin cardiac autonomic development, novel intracellular pathways and neuroplasticity. Throughout we highlight unanswered questions and areas of controversy. Whilst some neurochemical pathways are already demonstrating prognostic viability in patients with heart failure, we also discuss the opportunity to better understand sympathetic impairment by using patient specific stem cells that provides pathophysiological contextualization to study 'disease in a dish'. Novel imaging techniques and spatial transcriptomics are also facilitating a road map for target discovery of molecular pathways that may form a therapeutic opportunity to treat cardiac dysautonomia.

The prognostic value of NT-proBNP in 28-day mortality and post-discharge survival in pneumonia: a retrospective cohort study from Taiwan

BACKGROUND

NT-proBNP, traditionally used to assess heart failure, is increasingly recognized for its prognostic value in other diseases. This study evaluates its value in pneumonia.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of adult patients hospitalized for pneumonia at Wan Fang Hospital (2017-2021) to investigate whether elevated NT-proBNP levels predicted poorer outcomes. Logistic regression identified risk factors for 28-day mortality, while the Cox regression model identified predictors of post-discharge survival.

RESULTS

Among 2,805 patients (79.6 ± 13.4 years, female 45%), the 28-day mortality rate was 18.2%, and the median post-discharge follow-up time was 359 days. Moderately (increased but < 10000 pg/mL) and severely (>10000 pg/mL) elevated NT-proBNP levels had higher 28-day mortality compared to normal NT-proBNP; adjusted odds ratios: 2.24 (1.34-3.75, p = 0.002) and 3.57 (2.03-6.27, p < 0.001). Moderately and severely elevated NT-proBNP levels related to shorter survival time than normal NT-proBNP levels; adjusted hazard ratios 1.60 (1.28-2.00, p < 0.001) and 2.03 (1.56-2.63, p < 0.001). All ratios were adjusted with comorbidities, sex, age, and clinical and laboratory tests.

CONCLUSIONS

Elevated NT-proBNP levels predict higher 28-day mortality and shorter survival time in patients with pneumonia across most subpopulations. This marker holds potential as a prognostic biomarker for pneumonia, especially in high-risk patients.

Fibulin 1 and 2 Levels in Patients with Heart Failure: Comparison of Different Heart Failure Stages and Exploring the Temporal Changes During Acute Exacerbation

Background

Fibulin 1 and Fibulin 2 are members of the extracellular matrix (ECM) glycoprotein family. ECMs drive prognosis through remodeling, a key step in the pathogenesis of heart failure (HF). We aimed to compare Fibulin 1 and 2 levels in different stages of HF and to investigate their relationship with other prognostic factors of HF.

Methods

Patients with HF were divided into two groups according to left ventricular ejection fraction (LVEF): reduced and non-reduced LVEF. The control and patient groups consisted of individuals with Stages A and B HF, Stages C and D HF, respectively. Fibulin levels were measured at different stages of HF and in the control group. Additionally, Fibulin levels were measured at admission, discharge, and in the first month in patients who were hospitalized due to decompensated HF.

Results

Serum Fibulin 1 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were significantly higher in the patient group than in the control group. Serum Fibulin 2 levels were similar between the groups. Although serum Fibulin 2 levels were similar at repeated measurements, serum Fibulin 1 and NT-proBNP levels significantly decreased at discharge and remained similar at 1 month compared with admission. There was a significant positive correlation between Fibulin 1 and NT-proBNP levels and a significant negative correlation between Fibulin 1 levels and LVEF. Fibulin 2 levels were not correlated with LVEF and NT-proBNP.

Conclusions

Our study demonstrated that serum Fibulin 1 levels differ among different HF stages and have a similar temporal change as observed for NT-proBNP levels. A similar association was not observed for Fibulin 2 in our study.

Survival and predictors of mortality in patients with heart failure in the cardiology department of the Center Hospitalier Basse Terre in Guadeloupe: historical cohort study

BACKGROUND

Despite the progress made in recent years in the treatment of Acute Heart Failure (AHF), its prognosis remains poor in the developing country. The objective of this study is to analyze the survival and predictors of mortality of patients with acute heart failure in the cardiology department of the Basse Terre Hospital Center in Guadeloupe.

METHODS

this was a historical cohort study carried out over a period from June 2021 to June 2022, targeting all acute heart failure patients undergoing cardiac monitoring in the cardiology department of the Basse Terre Hospital Center in Guadeloupe. Sociodemographic, clinical, biological characteristics and outcome (recovery or death) were studied. Survival was described using the Kaplan Meier method α = 5%.

RESULTS

this study involved 242 acute heart failure patients whose median age was 75 years and the majority were male (sex ratio 2 M/1F). Among these patients, 14.9% died, the most common cause of death was cardiogenic shock (52.8%). After adjustment, tobacco consumption (aHR: 2.90; 95% CI: 1.36-8.09), Chronic Kidney Disease (aHR: 2.52; 95% CI: 1.22-5.20), infection (aHR: 2.14; 95CI %: 1.99-4.58), hyponatremia (aHR: 1.90; 95% CI: 1.10-2.86), mitral regurgitation (aHR: 3.04; 95% CI: 1.98-9.47) and N-terminal pro Brain Natriuretic Peptide > 10000ng/ml (aHR: 2.57; 95% CI: 1.21-5.49) were independently associated with the risk of death in heart failure patients.

CONCLUSION

Acute heart failure leads to high mortality, mainly due to cardiogenic shock and factors of multiple organ failure.

The Role of Natriuretic Peptides in the Management of Heart Failure with a Focus on the Patient with Diabetes

Natriuretic peptides (NPs) are polypeptide hormones involved in the homeostasis of the cardiovascular system. They are produced by cardiomyocytes and regulate circulating blood volume and sodium concentration. Clinically, measurements of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are recommended by international guidelines as evidence is accumulating on their usefulness. They have a high negative predictive value, and in the setting of low NPs, a diagnosis of heart failure (HF) can be safely excluded in both emergency (BNP < 100 pg/mL, NT-proBNP < 300 pg/mL) and outpatient settings (BNP < 35 pg/mL and NT-proBNP < 125 pg/mL). Moreover, the 2023 consensus from the European Society of Cardiology suggests threshold values for inclusion diagnosis. These values are also associated with increased risks of major cardiovascular events, cardiovascular mortality, and all-cause mortality whether measured in inpatient or outpatient settings. Among patients without known HF, but at high risk of developing it (e.g., in the setting of diabetes mellitus, hypertension, or atherosclerotic cardiovascular disease), NPs may be useful in stratifying cardiovascular risk, optimizing therapy, and reducing the risk of developing overt HF. In the diabetes setting, risk stratification with the use of these peptides can guide the physician to a more informed and appropriate therapeutic choice as recommended by guidelines. Notably, NP levels should be carefully interpreted in light of certain conditions that may affect their reliability, such as chronic kidney disease and obesity, as well as demographic variables, including age and sex. In conclusion, NPs are useful in the diagnosis and prognosis of HF, but they also offer advantages in the primary prevention setting.

Depressive symptoms are associated with clinical outcomes in heart failure with reduced ejection fraction

AIMS

The objective of this study was to examine associations between elevated depressive symptoms and increased risk of adverse clinical events patients with heart failure and reduced ejection fraction (HFrEF), as well as the potential contribution of health behaviours.

METHODS AND RESULTS

One hundred forty-two men and women with HFrEF were enrolled through heart failure (HF) clinics and followed over time. At baseline and 6 months, depressive symptoms were assessed by the Beck Depression Inventory-II (BDI-II) and HFrEF disease activity by B-type natriuretic peptide (BNP). The Self-Care of Heart Failure Index (SCHFI) was used to assess HF self-care behaviours. Proportional hazards regression models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization. Over a median follow-up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10-point higher baseline BDI-II score was associated with a 35% greater risk of death or cardiovascular hospitalization. Higher baseline BDI-II scores were associated with poorer HF self-care maintenance behaviours (R = -0.30, P < 0.001) and fewer daily steps (R = -0.19, P = 0.04), suggesting that elevated depressive symptoms may diminish important health behaviours. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI-II and plasma BNP over 6 months were positively related (R = 0.25, P = 0.004).

CONCLUSIONS

This study confirms that elevated depressive symptoms are associated with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Poor health behaviours may contribute to the adverse association of elevated depressive symptoms with the increased hazard of adverse clinical outcomes.

Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea Overlap Syndrome: An Update on the Epidemiology, Pathophysiology, and Management

This review provides an up-to-date summary of the prevalence, pathophysiology, diagnosis, and treatment of the chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) overlap syndrome (OVS). The presence of OVS is high in patients with COPD and in patients with OSA and is associated with profound nocturnal oxygen desaturation and systemic inflammation. There is a high prevalence of cardiovascular disease among patients with OVS and this likely contributes to increased mortality. Observational studies suggest that positive airway pressure therapy improves survival and reduces COPD exacerbations; however, randomized controlled trials will be required to confirm these findings.

Plasma B-type natriuretic peptide is independently associated with cardiovascular events and mortality in patients with chronic kidney disease

The association between B-type natriuretic peptide (BNP) and cardiovascular (CV) events and mortality has not been well characterized in patients with chronic kidney disease (CKD). We prospectively investigated whether BNP was associated with CV events or mortality beyond cardiac alterations in 1078 patients with CKD. Participants were divided into the following 3 groups according to circulating BNP concentration: < 40 pg/mL, low; 40-100 pg/mL, middle; and > 100 pg/mL, high. Primary outcome was fatal or nonfatal CV events, and alternative outcome was a composite of fatal or nonfatal CV events, or non-CV deaths. During a median follow-up of 2.6 years, CV and composite events occurred in 158 and 248 participants, respectively. Cox analyses after adjustment for covariates, including cardiac parameters, showed that the hazard ratios (HRs) (95% confidence intervals [CIs]) for CV events of middle and high groups were 1.00 (0.63, 1.58) and 1.72 (1.06, 2.79), respectively, compared with low group. Additionally, similar results were obtained for composite events; the HRs (95% CIs) of middle and high groups were 1.10 (0.77, 1.57) and 1.54 (1.04, 2.27), respectively, compared with low group. Thus, in CKD, high BNP concentrations were independently associated with CV events and mortality, independent of cardiac alterations.

Novel Biomarkers in Early Detection of Heart Failure: A Narrative Review

Heart failure (HF) represents a significant global health challenge, characterized by a variety of symptoms resulting from cardiac dysfunction. This dysfunction often leads to systemic and pulmonary congestion. The pathophysiology of HF is complex, involving stimulation of the sympathetic nervous system, which is insufficiently balanced by the release of natriuretic peptide. This imbalance leads to progressive hypertrophy and dilatation of the heart's chambers, impairing its pumping efficiency and increasing the risk of arrhythmias and conduction disorders. The prevalence of HF is exceptionally high in industrialized nations and is expected to increase owing to an aging population and advancements in diagnostic methods. This study emphasizes the critical role of early diagnosis in reducing morbidity and mortality associated with HF, focusing specifically on the evolving importance of biomarkers in managing this condition. Biomarkers have played a key role in transforming the diagnosis and treatment of HF. Traditional biomarkers such as b-type natriuretic peptide and N-terminal pro-b-type natriuretic peptide have been widely adopted for their cost-effectiveness and ease of access. However, the rise of novel biomarkers such as growth differentiation factor 15 and adrenomedullin has shown promising results, offering superior sensitivity and specificity. These new biomarkers enhance diagnostic accuracy, risk stratification, and prognostic evaluation in HF patients. Despite these advancements, challenges remain, such as limited availability, high costs, and the need for further validation in diverse patient populations. Through a comprehensive literature review across databases such as PubMed, Google Scholar, and the Cochrane Library, this study compiles and analyzes data from 18 relevant studies, offering a detailed understanding of the current state of HF biomarkers. The study examines both traditional and emerging biomarkers such as galectin-3 and soluble suppression of tumorigenicity 2 in HF, exploring their clinical roles and impact on patient outcomes.

High-sensitive troponin T and N-terminal pro-B-type natriuretic peptide independently predict survival and cardiac-related events in adults with congenital heart disease

AIMS

High-sensitive troponin T (hs-TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) are established prognostic biomarkers for cardiovascular (CV) morbidity and mortality and frequently used in symptomatic and/or hospitalized adults with congenital heart disease (ACHD). Their prognostic value in clinically stable ACHD has not yet been well established. This study investigates the predictive value of hs-TnT, NT-proBNP, and CRP for survival and CV events in stable ACHD.

METHODS AND RESULTS

In this prospective cohort study, 495 outpatient ACHD (43.9 ± 10.0 years, 49.1% female) underwent venous blood sampling including hs-TnT, NT-proBNP, and CRP. Patients were followed up for survival status and the occurrence of CV events. Survival analyses were performed with Cox proportional hazards regression analysis and Kaplan-Meier curves. During a mean follow-up of 2.8 ± 1.0 years, 53 patients (10.7%) died or reached a cardiac-related endpoint including sustained ventricular tachycardia, hospitalization with cardiac decompensation, ablation, interventional catheterization, pacer implantation, or cardiac surgery. Multivariable Cox regression revealed hs-TnT (P = 0.005) and NT-proBNP (P = 0.018) as independent predictors of death or cardiac-related events in stable ACHD, whilst the prognostic value of CRP vanished after multivariable adjustment (P = 0.057). Receiver-operator characteristic curve analysis identified cut-off values for event-free survival of hs-TnT ≤9 ng/L and NT-proBNP ≤200 ng/L. Patients with both increased biomarkers had a 7.7-fold (confidence interval 3.57-16.40, P < 0.001) higher risk for death and cardiac-related events compared with patients without elevated blood values.

CONCLUSION

Subclinical values of hs-TnT and NT-proBNP are a useful, simple, and independent prognostic tool for adverse cardiac events and survival in stable outpatient ACHD.

REGISTRATION

German Clinical Trial Registry DRKS00015248.

Preoperative B-Type Natriuretic Peptides to Predict Postoperative Atrial Fibrillation in Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Post-operative atrial fibrillation (AF) is the most common complication following cardiac surgery. There has been extensive exploration of clinical variables, imaging, and biomarkers to predict its occurrence after cardiac surgery. In this study, we examine the emerging biomarkers B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) to assess their pre-operative values and correlations with the occurrence of post-operative AF in patients undergoing cardiac surgery.

METHODS

A comprehensive literature search was conducted using PubMed, EMBASE, MEDLINE via Ovid, ClinicalTrials.Gov, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies published until March 2023. The studies were included if they reported pre-operative BNP or NT-proBNP values and the development of post-operative AF in cardiac surgery patients. Subsequently, data were extracted, and a meta-analysis was performed using Review Manager 5.4 4 (The Cochrane Collaboration, 2020) and SPSS version 28 (IBM Corp, Armonk, NY, USA) to assess the difference between pre-operative BNP and NT-proBNP levels between patients with post-operative AF (AF group) and those without (No-AF group) using a random-effect model. Further analysis was performed in three subgroups: isolated coronary artery bypass grafting, isolated valve, and combined/mixed surgery group.

RESULT

A total of 20 studies, including 9,079 participants were identified and included in the systematic review and meta-analysis. Pre-operative BNP levels were reported in 11 studies, and NT-proBNP levels were reported in 10 studies, of which one study reported both BNP and NT-proBNP levels. There is an overall significant difference between pre-operative levels of BNP (p=0.03, I2=95%) and NT-proBNP (p<0.001, I2=65%) when compared between AF and No-AF groups. Nonetheless, subgroup analysis showed there is no significant difference in pre-operative BNP levels, except in isolated valve surgery (p<0.001), whereas all subgroups showed significantly different pre-operative levels of NT-proBNP.

CONCLUSIONS

Elevated levels of both BNP and NT-proBNP were observed in patients who developed post-operative AF after undergoing cardiac surgery. In particular, pre-operative NT-proBNP levels were elevated in all patients irrespective of the type of surgical procedure, but elevated pre-operative BNP was only seen in valve surgery patients. These findings suggest the potential usefulness of NT-proBNP as a promising biomarker for predicting the occurrence of post-operative AF following cardiac surgery.

Timing of Surgery for Asymptomatic Primary Mitral Regurgitation: Possible Value of Early, Serial Measurements of Left Ventricular Sphericity

Asymptomatic primary mitral regurgitation due to myxomatous degeneration of the mitral valve leaflets may remain so for long periods, even as left ventricular function progresses to a decompensated stage. During the early compensated stage, the ventricle's initial response to the volume overload is an asymmetric increase in the diastolic short axis dimension, accomplished by a diastolic shift of the interventricular septum into the right ventricular cavity, creating a more spherical left ventricular diastolic shape, increasing diastolic filling and stroke volume. Early valve repair is recommended to reduce postoperative left ventricular dysfunction. Early serial measurements of left ventricular sphericity index [LV-Si]. during the compensated stage of mitral regurgitation might identify subtle changes in left ventricular shape and assist in determining the optimal earliest timing for surgical intervention.

Role of Pro-BNP in predicting outcome in acute heart failure patient presenting to a medical emergency: An observational study from North India

Background

Acute heart failure (AHF) is a clinical syndrome defined as the new onset or acutely decompensated heart failure (ADHF) leading to signs and symptoms of heart failure (HF). The critical cut-off values for these biomarkers that suggest high mortality are not clearly defined in previous studies. More studies are required to better understand the correlation of Pro- BNP and its association with HF. The primary objective is to study the role of Pro-BNP and critical factors in predicting outcomes in AHF patients presenting to a medical emergency.

Materials and Methods

The data from the patients presented with symptoms of HF in the Department of Medical Emergency at our hospital were recorded and analysed. AHF is a clinical syndrome defined as the new onset or ADHF leading to signs and symptoms of HF, as based on the European Society of Cardiology.

Results

The present study highlights the various risk factors of AHF in patients and their association with mortality. In the present study, mortality in patients with very high Pro-BNP levels ≥2000 pg/ml was significantly higher than in patients with moderately elevated Pro-BNP. The patients who survived after 5 days of hospitalization had Pro-BNP levels ≤2000 pg/ml, suggesting that very high Pro-BNP levels ≥2000 pg/ml are associated with fatal outcomes.

Conclusion

To conclude, diabetes and sepsis are critical factors for the hospitalization and mortality of patients with AHF in northern India. Very high Pro-BNP levels ≥2000 pg/ml in patients with AHF requiring hospitalization and associated with fatal outcomes.

Association of Depression Symptoms and Biomarkers of Risk on Clinical Outcomes in HFrEF

BACKGROUND

Prior studies have demonstrated an association of depression with adverse clinical outcomes in patients with HFrEF, but the possible mechanisms responsible for the association are not unserstood.

METHODS

142 men and women with HFrEF were enrolled through HF clinics and followed over time. At baseline and 6-months, depression was assessed by the Beck Depression Inventory (BDI-II) and disease activity by B-type natriuretic peptide (BNP). Proportional Hazards Regression Models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization.

RESULTS

Over a median follow-up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10-point higher baseline BDI-II score was associated with a 35% higher hazard of death or cardiovascular hospitalization. Greater baseline BDI-II scores were associated with poorer HF self-care maintenance (R=-0.30, p<0.001) and fewer daily steps (R=-0.19, p=0.04), suggesting that depression may adversely affect important health behaviors. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI-II score and plasma BNP over 6 months were positively correlated (R=0.25, p=0.004).

CONCLUSIONS

This study underscores the importance of elevated depression symptoms and their association with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Health behaviors may play a greater role than direct biobehavioral pathways in the adverse effects of depression on the HF disease trajectory and resultant clinical outcomes.

Heart Failure Management Capability and Exacerbation of Heart Failure - A 6-Month Prospective Cohort Study

Background: In households with older individuals, where a patient is experiencing heart failure (HF), effective cooperation between patients and caregivers is crucial for disease management. However, there is limited evidence regarding the impact of cooperative HF management on the incidence of exacerbation. Therefore, the aim of this 6-month prospective cohort study was to investigate the association between HF management capability and exacerbations. Methods and Results: The study enrolled outpatients (age ≥65 years) with chronic HF from a cardiology clinic and their caregivers. Self-care capabilities among patients and caregivers were evaluated using the Self-Care of Heart Failure Index (SCHFI) and Caregiver Contribution-SCHFI, respectively. Total scores were calculated using the highest score for each item. During the follow-up period, 31 patients experienced worsening HF. The analysis revealed no significant association between the total HF management score and HF exacerbation among all eligible patients. However, in patients with preserved left ventricular ejection fraction (LVEF), high HF management capability of the family unit was associated with a reduced risk of HF exacerbation, even after adjusting for the severity of HF. Conclusions: In older patients with HF and preserved LVEF, effective HF management may contribute to a lower risk of exacerbations.

Opportunistic screening for asymptomatic left ventricular dysfunction in type 2 diabetes mellitus

BACKGROUND

International guidelines recommend natriuretic peptide biomarker-based screening for patients at high heart failure (HF) risk to allow early detection. There have been few reports about the incorporation of screening procedure to existing clinical practice.

OBJECTIVE

To implement screening of left ventricular dysfunction in patients with type 2 diabetes mellitus (DM).

METHOD

A prospective screening study at the DM complication screening centre was performed.

RESULTS

Between 2018 and 2019, 1043 patients (age: 63.7±12.4 years; male: 56.3%) with mean glycated haemoglobin of 7.25%±1.34% were recruited. 81.8% patients had concomitant hypertension, 31.1% had coronary artery disease, 8.0% had previous stroke, 5.5% had peripheral artery disease and 30.7% had chronic kidney disease (CKD) stages 3-5. 43 patients (4.1%) had an elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration above the age-specific diagnostic thresholds for HF, and 43 patients (4.1%) had newly detected atrial fibrillation (AF). The prevalence of elevated NT-proBNP increased with age from 0.85% in patients aged <50 years to 7.14% in those aged 70-79 years and worsening kidney function from 0.43% in patients with CKD stage 1 to 42.86% in CKD stage 5. In multivariate logistic regression, male gender (OR: 3.67 (1.47-9.16), p = 0.005*), prior stroke (OR: 3.26 (1.38-7.69), p = 0.007*), CKD (p<0.001*) and newly detected AF (OR: 7.02 (2.65-18.57), p<0.001*) were significantly associated with elevated NT-proBNP. Among patients with elevated NT-proBNP, their mean left ventricular ejection fraction (LVEF) was 51.4%±14.7%, and 45% patients had an LVEF <50%.

CONCLUSION

NT-proBNP and ECG screening could be implemented with relative ease to facilitate early detection of cardiovascular complication and improve long-term outcomes.

Use of Preoperative Natriuretic Peptide in Predicting Mortality After Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis

The objective of this systematic review was to evaluate the current evidence on the utility of preoperative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide (NT-proBNP) in predicting short-term and long-term mortality after coronary artery bypass grafting (CABG). OVID MEDLINE, EMBASE, SCOPUS, and PUBMED were searched from 1946 to August 2022 using the following terms: "coronary artery bypass grafting" and "BNP" and "outcomes." Eligible studies included observational studies reporting the association between preoperative BNP and NT-proBNP levels and short- and long-term mortality after CABG. Articles were selected systematically, assessed for bias, and, when possible, meta-analyzed using a random effect model. After retrieving 53 articles, 11 were included for qualitative synthesis and 4 for quantitative meta-analysis. Studies included in this review showed that elevated preoperative natriuretic peptide levels, despite variable cut-offs, have been consistently shown to be associated with short- and long-term mortality after CABG. The median BNP cut-off value was 145.5 pg/mL (25th-75th percentile 95-324.25 pg/mL), and the mean NT-proBNP value was 765 ± 372 pg/mL. Compared to patients with normal natriuretic peptide levels, patients with elevated BNP and NT-proBNP presented higher mortality rates after CABG (odds ratio 3.96, 95% confidence interval 2.41-6.52; p < 0.00001). Preoperative BNP level is a powerful predictor of mortality in patients undergoing CABG. The measurement of BNP can add significant value to these patients' risk stratification and therapeutic decision-making.

Recent advancements of nanomodified electrodes - Towards point-of-care detection of cardiac biomarkers

The increasing number of deaths from cardiovascular diseases has become a substantial concern in both developed and underdeveloped countries. Rapid and on-site monitoring of this disease is urgently important to control, prevent and make awareness of public health. Recently, a lot of focus has been placed on nanomaterials and modify these nanomaterials have been explored to detect cardiac biomarkers. By implementing biosensors that are modified with novel recognition elements and more stable nanomaterials, the use of electrochemistry for point-of-care devices is more realistic every day. This review focuses on the current state of nanomaterials conjugated biorecognition elements (enzyme integrated with nanomaterials, antibody conjugated nanomaterials and aptamer conjugated nanomaterials) for electrochemical cardiovascular disease detection. Specifically, a lot of attention has been given to the trends toward more stable biosensors that have increased the potential to be used as point-of-care devices for the detection of cardiac biomarkers due to their high stability and specificity. Moreover, the recent progress on biomolecule-free electrochemical nanosensors for cardiovascular disease detection has been considered. At last, the possibility and drawbacks of some of these techniques for point-of-care cardiac device development in the future have been discussed.

A Prognostic Model Based on Clinical Biomarkers for Heart Failure in Adult Patients Following Allogeneic Hematopoietic Stem Cell Transplantation

Heart failure (HF) is an uncommon but serious cardiovascular complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Unfortunately, knowledge about early mortality prognostic factors in patients with HF after allo-HSCT is limited, and an easy-to-use prognostic model is not available. This study aimed to develop and validate a clinical-biomarker prognostic model capable of predicting HF mortality following allo-HSCT that uses a combination of variables readily available in clinical practice. To investigate this issue, we conducted a retrospective analysis at our center with 154 HF patients who underwent allo-HSCT between 2008 and 2021. The patients were separated according to the time of transplantation, with 100 patients composing the derivation cohort and the other 54 patients composing the external validation cohort. We first calculated the univariable association for each variable with 2-month mortality in the derivation cohort. We then included the variables with a P value <.1 in univariate analysis as candidate predictors in the multivariate analysis using a backward stepwise logistic regression model. Variables remaining in the final model were identified as independent prognostic factors. To predict the prognosis of HF, a scoring system was established, and scores were assigned to the prognostic factors based on the regression coefficient. Finally, 4 strongly significant independent prognostic factors for 2-month mortality from HF were identified using multivariable logistic regression methods with stepwise variable selection: pulmonary infection (P = .005), grade III to IV acute graft-versus-host disease (severe aGVHD; P = .033), lactate dehydrogenase (LDH) >426 U/L (P = .049), and brain natriuretic peptide (BNP) >1799 pg/mL (P = .026). A risk grading model termed the BLIPS score (for BNP, LDH, cardiac troponin I, pulmonary infection, and severe aGVHD) was constructed according to the regression coefficients. The validated internal C-statistic was .870 (95% confidence interval [CI], .798 to .942), and the external C-statistic was .882 (95% CI, .791-.973). According to the calibration plots, the model-predicted probability correlated well with the actual observed frequencies. The clinical use of the prognostic model, according to decision curve analysis, could benefit HF patients. The BLIPS model in our study can serve to identify HF patients at higher risk for mortality early, which might aid designing timely targeted therapies and eventually improving patients' survival and prognosis.

The role of serial cardiac biomarkers in prognostication and risk prediction of chronic heart failure: additional scientific insights with hemodynamic feedback

INTRODUCTION

Heart failure (HF) is considered as a chronic long-term and lethal disease and will continue to be a major public health problem. Studying (circulating) biomarkers is a promising field of research and could be the first step toward HF tailored prognostic strategies as well as understanding the response to HF drugs in CHF patients.

AREAS COVERED

In literature, there has been considerable research on elevated biomarker levels that are related to a poor prognosis for HF. Since biomarker levels change over time, it is important to study serial (repeated) biomarker measurements which may help us better understand the dynamic course of HF illness. However, the majority of research focuses predominantly on baseline values of biomarkers. Additionally, remote monitoring devices, like sensors, can be used to link hemodynamic information to freshen biomarker data in order to further ameliorate the management of HF.

EXPERT OPINION

Novel biomarkers and additional scientific insights with hemodynamic feedback strongly aid in the prognostication and risk prediction of chronic HF.

Duchenne muscular dystrophy patients: troponin leak in asymptomatic and implications for drug toxicity studies

BACKGROUND

Cardiomyopathy is the leading cause of death in Duchenne muscular dystrophy (DMD), but studies suggest heart failure biomarkers correlate poorly with cardiomyopathy severity. DMD clinical trials have used troponin I (cTnI) as a biomarker of toxicity, but it is unclear if asymptomatic DMD patients have elevated cTnI. We longitudinally evaluated cTnI, brain natriuretic peptide (BNP), and N-terminal pro-BNP (NT-proBNP) in a DMD cohort.

METHODS

DMD patients were prospectively enrolled and followed for 3 years. Serum was drawn at the time of cardiac magnetic resonance (CMR). Normal biomarker values were derived from healthy subjects. Biomarkers were correlated with CMR markers.

RESULTS

All subjects were asymptomatic at the time of enrollment. Several DMD subjects had transiently elevated cTnI. Those with elevated cTnI were more likely to have late gadolinium enhancement on baseline CMR. NT-proBNP correlated with indexed left ventricular end diastolic and maximum left atrial volumes. Otherwise, standard cardiac biomarkers did not correlate with CMR markers of cardiomyopathy.

CONCLUSIONS

CTnI, BNP, and NT-proBNP do not correlate with CMR assessment of cardiomyopathy progression. A subset of DMD patients have asymptomatic cTnI leak of uncertain clinical significance, though of critical importance if cTnI is used to assess for cardiac toxicity in future drug trials.

IMPACT

Asymptomatic patients with Duchenne muscular dystrophy (DMD) exhibit transient troponin I leak. NT-proBNP correlated with indexed left ventricular end diastolic volume and indexed maximum left atrial volume. Other cardiac biomarkers did not correlate with cardiac magnetic resonance (CMR) markers of cardiomyopathy.

Effects of ANP and BNP on the generation of respiratory rhythms in brainstem-spinal cord preparation isolated from newborn rats

Natriuretic peptides (NPs) are a family of peptide hormones produced in cardiac muscle cells and consist mainly of three types: atrial NP (ANP), B-type (or brain) NP (BNP), and C-type NP. We herein report the effects of ANP and BNP on central respiratory activity in brainstem-spinal cord preparation isolated from newborn rats. Bath application of these peptides (100 nM) induced a weak transient depression of the respiratory rhythm followed by recovery. Respiratory-related neurons in the rostral ventrolateral medulla showed a tendency for transient hyperpolarization followed by recovery during the application of ANP or BNP. The application of a membrane-permeable cGMP, 8-Br-cGMP (10 or 20 μM), did not induce significant effects on respiratory rhythm, suggesting no involvement of guanylyl cyclase in effects of ANP or BNP. We also examined effects of BNP on respiratory depression induced by the sedative dexmedetomidine, which exerts an inhibitory influence on respiratory rhythm. When pretreated with 50 nM BNP, the inhibitory effect of 100 nM dexmedetomidine was significantly reduced. Our findings suggest that ANP and BNP act as mild excitatory agents with sustained effects on respiratory rhythm after an initial transient depression.

Biomarkers in heart failure: Relevance in the clinical practice

Early detection and risk stratification of patients with heart failure (HF) are crucial to improve outcomes. Given the complexity of the pathophysiological processes of HF and the involvement of multi-organ systems in different stages of HF, clinical prognostication of HF can be challenging. In this regard, several biomarkers have been investigated for diagnosis, screening, and risk stratification of HF patients. These biomarkers can be classified as biomarkers of myocardial stretch such as B-type natriuretic peptide, biomarkers of neurohormonal activation, biomarkers of inflammation and oxidative stress and biomarkers of cardiac hypertrophy, fibrosis and remodeling. In this paper, we summarize current evidence supporting the use of selected biomarkers in HF. We review their diagnostic, prognostic and therapeutic role in the management of HF. We also discuss potential factors limiting the use of these novel biomarkers in the clinical practice and highlight the challenges of adopting a multi-biomarker strategy.

Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure

Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.

Using Echocardiography and Biomarkers to Determine Prognosis in Peripartum Cardiomyopathy: A Systematic Review

Peripartum cardiomyopathy (PPCM) is a rare but debilitating form of heart failure that affects pregnant women. Although PPCM has a high rate of complete resolution, some patients often have a progressive disease and develop significant morbidity and mortality. Making an accurate prediction of outcomes and identifying those patients at the highest risk has proven difficult over the years. This study aimed to establish if we can use echocardiographic parameters and biomarkers as reliable indicators of prognosis. A predetermined systematic search strategy was employed in four databases: PubMed, Google Scholar, Science Direct, and Cochrane Library to include articles from the last 15 years (January 2007 to January 2022). Data from 12 studies were synthesized and included in this study. Although no parameter proved consistent in all the studies, echocardiographic parameters, including strain profiles and biomarkers, proved significant in the prognostication of patients with PPCM in the various studies evaluated. Therefore, a holistic approach is still needed in the risk stratification of patients with PPCM. Future studies should evaluate these parameters as well as clinical characteristics in a larger cohort study with a long follow-up period of more than one year in order to potentially develop prognostic score criteria that can be used to accurately identify those patients at the highest risk of developing severe disease or death to allow for timely and targeted therapies to improve outcomes in these patients.

The Effects of Exercise Training on Cardiopulmonary Exercise Testing and Cardiac Biomarkers in Adult Patients with Hypoplastic Left Heart Syndrome and Fontan Circulation

Background: Several studies have shown that adult patients with Hypoplastic Left Heart Syndrome (HLHS) and Fontan circulation have a reduced exercise tolerance that affects daily life. Recent studies have investigated the effects of aerobic exercise training in patients with univentricular heart; however, this research topic is still poorly studied. The aim of this study was to evaluate the effects of an aerobic exercise training program on cardiopulmonary exercise testing parameters and cardiac biomarkers in patients with HLHS. Methods: We enrolled 12 patients with a mean age of 24 ± 2.5 years (range 22−27 years), 50% male, with HLHS at Bambino Gesù Children’s Hospital IRCCS. All patients underwent a cardiopulmonary test and blood sampling before (T0) and after (T1) a 4-week aerobic exercise program. Cardiac biomarkers hs-cTnT, NT-proBNP, ST2, GDF-15 were studied. Results: Data analysis demonstrated an increase in cardiorespiratory performance after 4 weeks of aerobic exercise training activity. In particular, the data showed a significant improvement in test duration (p < 0.05), heart rate at rest (p < 0.05), heart rate recovery 1 min (p < 0.05), VO2 max (p < 0.01) and oxygen uptake efficiency slope (p < 0.05). At the same time, the data showed a significant reduction in NT-proBNP and ST2 values (p < 0.01 and p < 0.05, respectively) and a significant increase in GDF-15 (p < 0.01). No significant changes were found between the hs-cTnT values. Conclusions: Our study demonstrated the 4-week efficacy of an aerobic training program in improving cardiorespiratory performance and cardiac biomarker values in adult patients with HLHS and Fontan circulation. More studies with larger numbers of patients will be needed to confirm these data.

Cardiovascular Biomarkers: Lessons of the Past and Prospects for the Future

Cardiovascular diseases (CVDs) are a major healthcare burden on the population worldwide. Early detection of this disease is important in prevention and treatment to minimise morbidity and mortality. Biomarkers are a critical tool to either diagnose, screen, or provide prognostic information for pathological conditions. This review discusses the historical cardiac biomarkers used to detect these conditions, discussing their application and their limitations. Identification of new biomarkers have since replaced these and are now in use in routine clinical practice, but still do not detect all disease. Future cardiac biomarkers are showing promise in early studies, but further studies are required to show their value in improving detection of CVD above the current biomarkers. Additionally, the analytical platforms that would allow them to be adopted in healthcare are yet to be established. There is also the need to identify whether these biomarkers can be used for diagnostic, prognostic, or screening purposes, which will impact their implementation in routine clinical practice.

Dissecting the correlates of N-terminal prohormone brain natriuretic peptide in acute infective endocarditis

Purpose

To explore the prognostic value and the correlates of NT-proBNP in patients with acute infective endocarditis, a life-threatening disease, with an often unpredictable outcome given by the lack of reliable prognostic parameters.

Methods

We retrospectively studied 337 patients admitted to our centre between January 1, 2006 and September 30, 2020 with available NT-proBNP level at admission. Our analyses were performed considering NT-proBNP as both a categorical variable, using the median value as the cut-off level, and numerical variable. Study end points were in-hospital mortality, cardiac surgery and 1 year survival.

Results

NT-proBNP was an independent predictor of in-hospital mortality (OR 14.9 [95%C.I. 2.46–90.9]; P = .003). Levels below 2926 pg/mL were highly predictive of a favorable in-hospital outcome (negative predictive value 96.6%). Patients with higher NT-proBNP levels showed a significantly lower survival rate at 1 year follow-up (log-rank P = .005). NT-proBNP was strongly associated with chronic kidney disease (P < .001) and significantly higher in patients with prior chronic heart failure (P = .001). NT-proBNP was tightly related to staphylococcal IE (P = .001) as well as with higher CRP and hs-troponin I (P = 0.023, P < .001, respectively).

Conclusion

Our results confirm the remarkable prognostic role of NT-proBNP in patients with IE and provide novel evidences of its multifaceted correlates in this unique clinical setting. Our data strongly support the incorporation of NT-proBNP into the current diagnostic work-up of IE.

Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department

Background

Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management.

Objective

Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED.

Methods

This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED-HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30-day cardiovascular death and/or heart failure-related events.

Results

Of the 491 subjects included in the GUIDED-HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54-70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval,  0.49-2.01, P = 0.994).

Conclusion

If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

Analysis of the B-Type Natriuretic Peptide and the Aminoterminal-Pro-B-Type Natriuretic Peptide in Different Parrot, Raptor and Owl Species

The B-type natriuretic peptide (BNP), a member of the natriuretic peptide family and a cardiac hormone, is produced mainly in the ventricular myocytes and released into the circulation due to mechanical stimuli during an increasing cardiac wall stretch. BNP has a significant role in the regulation of the cardiovascular system and body fluid. The concentration of this hormone and of the biologically inactive amino-terminal-prohormone in the blood plasma is a helpful diagnostic tool for detecting cardiovascular diseases in human medicine and can be used as a prognostic marker for the risk of mortality, whilst such a tool does not exist for avian medicine. To date, the amino acid sequence of BNP is not known for many of the species commonly presented in avian consultation. In this study, the amino acid sequence of BNP and the prepropeptide was described for 12 parrot species as well as 3 raptor and 3 owl species by polymerase chain reaction (PCR) after RNA isolation from the heart. The results showed a high similarity between the amino acid sequences in the mature peptide region of the BNP. The prepropeptide showed several differences between the examined species, some of them shared by closely related species.

Role of confirmed and potential predictors of an unfavorable outcome in heart failure in everyday clinical practice

Heart failure (HF) is the only cardiovascular disease with an ever increasing incidence. HF, through reduced functional capacity, frequent exacerbations of disease, and repeated hospitalizations, results in poorer quality of life, decreased work productivity, and significantly increased costs of the public health system. The main challenge in the treatment of HF is the availability of reliable prognostic models that would allow patients and doctors to develop realistic expectations about the prognosis and to choose the appropriate therapy and monitoring method. At this moment, there is a lack of universal parameters or scales on the basis of which we could easily capture the moment of deterioration of HF patients' condition. Hence, it is crucial to identify such factors which at the same time will be widely available, cheap, and easy to use. We can find many studies showing different predictors of unfavorable outcome in HF patients: thorough assessment with echocardiography imaging, exercise testing (e.g., 6-min walk test, cardiopulmonary exercise testing), and biomarkers (e.g., N-terminal pro-brain type natriuretic peptide, high-sensitivity troponin T, galectin-3, high-sensitivity C-reactive protein). Some of them are very promising, but more research is needed to create a specific panel on the basis of which we will be able to assess HF patients. At this moment despite identification of many markers of adverse outcomes, clinical decision-making in HF is still predominantly based on a few basic parameters, such as the presence of HF symptoms (NYHA class), left ventricular ejection fraction, and QRS complex duration and morphology.

Emerging therapies: The potential roles SGLT2 inhibitors, GLP1 agonists, and ARNI therapy for ARNI pulmonary hypertension

Pulmonary hypertension (PH) is a highly morbid condition. PH due to left heart disease (PH-LHD) has no specific therapies and pulmonary arterial hypertension (PAH) has substantial residual risk despite several approved therapies. Multiple lines of experimental evidence link metabolic dysfunction to the pathogenesis and outcomes in PH-LHD and PAH, and novel metabolic agents hold promise to improve outcomes in these populations. The antidiabetic sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) agonists targeting metabolic dysfunction and improve outcomes in patients with LHD but have not been tested specifically in patients with PH. The angiotensin receptor/neprilysin inhibitors (ARNIs) produce significant improvements in cardiac hemodynamics and may improve metabolic dysfunction that could benefit the pulmonary circulation and right ventricle function. On the basis of promising preclinical work with these medications and clinical rationale, we explore the potential of SGLT2 inhibitors, GLP1 agonists, and ARNIs as therapies for both PH-LHD and PAH.

Corticotropin releasing hormone receptor 2 antagonist, RQ-00490721, for the prevention of pressure overload-induced cardiac dysfunction

BACKGROUND

G protein-coupled receptors (GPCRs) regulate the pathological and physiological functions of the heart. GPCR antagonists are widely used in the treatment of chronic heart failure. Despite therapeutic advances in the treatments for cardiovascular diseases, heart failure is a major clinical health problem, with significant mortality and morbidity. Corticotropin releasing hormone receptor 2 (CRHR2) is highly expressed in cardiomyocytes, and cardiomyocyte-specific deletion of the genes encoding CRHR2 suppresses pressure overload-induced cardiac dysfunction. This suggests that the negative modulation of CRHR2 may prevent the progression of heart failure. However, there are no systemic drugs against CRHR2.

FINDINGS

We developed a novel, oral, small molecule antagonist of CRHR2, RQ-00490721, to investigate the inhibition of CRHR2 as a potential therapeutic approach for the treatment of heart failure. In vitro, RQ-00490721 decreased CRHR2 agonist-induced 3', 5'-cyclic adenosine monophosphate (cAMP) production. In vivo, RQ-00490721 showed sufficient oral absorption and better distribution to peripheral organs than to the central nervous system. Oral administration of RQ-00490721 inhibited the CRHR2 agonist-induced phosphorylation of cAMP-response element binding protein (CREB) in the heart, which regulates a transcription activator involved in heart failure. RQ-00490721 administration was not found to affect basal heart function in mice but protected them from pressure overload-induced cardiac dysfunction.

INTERPRETATION

Our results suggest that RQ-00490721 is a promising agent for use in the treatment of chronic heart failure.

Clinical significance of the N-terminal pro-brain natriuretic peptide and B-type natriuretic peptide ratio in the acute phase of acute heart failure

AIMS

Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels are rarely evaluated simultaneously in the acute phase of acute heart failure (AHF).

METHOD AND RESULTS

A total of 1207 AHF patients were enrolled, and 1002 patients were analysed. Blood samples were collected within 15 min of admission. Patients were divided into two groups according to the median value of the NT-proBNP/BNP ratio [low-NT-proBNP/BNP group (Group L) vs. high-NT-proBNP/BNP group (Group H)]. A multivariate logistic regression model showed that the C-reactive protein level (per 1-mg/dL increase), Controlling Nutrition Status score (per 1-point increase), and estimated glomerular filtration rate (eGFR, per 10-mL/min/1.73 m2 increase) were independently associated with Group H [odds ratio (OR) 1.049, 95% confidence interval (CI) 1.009-1.090, OR 1.219, 95% CI 1.140-1.304, and OR 1.543, 95% CI 1.401-1.698, respectively]. A Kaplan-Meier curve analysis showed that the prognosis was significantly poorer in Group H than in Group L, and a multivariate Cox regression model revealed Group H to be an independent predictor of 180-day mortality [hazard ratio (HR) 3.084, 95% CI 1.838-5.175] and HF events (HR 1.963, 95% CI 1.340-2.876). The same trend in the prognostic impact was significantly observed in the low-BNP (<810 pg/mL, n = 501), high-BNP (≥810 pg/mL, n = 501), and low-eGFR (<60 mL/min/1.73 m2, n = 765) cohorts, and tended to be observed in normal-eGFR (≥60 mL/min/1.73 m2, n = 237) cohort.

CONCLUSION

A high NT-proBNP/BNP ratio was associated with a non-cardiac condition (e.g. inflammatory reaction, nutritional status, and renal dysfunction) and is independently associated with adverse outcomes in AHF.

Evaluation of a multimarker panel in chronic heart failure: a 10-year follow-up

Aim: We assessed the 10-year prognostic role of 11 biomarkers with different pathophysiological backgrounds. Materials & methods/results: Blood samples from 144 patients with heart failure were analyzed. After 10 years of follow-up (median follow-up was 104 months), data regarding all-cause mortality were acquired. Regarding Kaplan-Meier analysis, all markers, except TIMP-1 and GDF-15, were significant predictors for all-cause mortality. We created a multimarker model with nt-proBNP, hs-TnT and IGF-BP7 and found that patients in whom all three markers were elevated had a significantly worse long-time prognosis than patients without elevated markers. Conclusion: In a 10-year follow-up, a combination of three biomarkers (NT-proBNP, hs-TnT, IGF-BP7) identified patients with a high risk of mortality.

Effect of Topiroxostat on Brain Natriuretic Peptide Level in Patients with Heart Failure with Preserved Ejection Fraction: A Pilot Study

BACKGROUND

Various optimal medical therapies have been established to treat heart failure (HF) with reduced ejection fraction (HFrEF). Both HFrEF and HF with preserved ejection fraction (HFpEF) are associated with poor outcomes. We investigated the effect of topiroxostat, an oral xanthine oxidoreductase inhibitor, for HFpEF patients with hyperuricemia or gout.

METHODS

In this nonrandomized, open-label, single-arm trial, we administered topiroxostat 40-160 mg/day to HFpEF patients with hyperuricemia or gout to achieve a target uric acid level of 6.0 mg/dL. The primary outcome was rate of change in log-transformed brain natriuretic peptide (BNP) level from baseline to 24 weeks after topiroxostat treatment. The secondary outcomes included amount of change in BNP level, uric acid evaluation values, and oxidative stress marker levels after 24 weeks of topiroxostat treatment. Thirty-six patients were enrolled; three were excluded before study initiation.

RESULTS

Change in log-transformed BNP level was -3.4 ± 8.9% (p = 0.043) after 24 weeks of topiroxostat treatment. The rate of change for the decrease in BNP level was -18.0 (-57.7, 4.0 pg/mL; p = 0.041). Levels of uric acid and 8-hydroxy-2'-deoxyguanosine/creatinine, an oxidative stress marker, also significantly decreased (-2.8 ± 1.6 mg/dL, p < 0.001, and -2.3 ± 3.7 ng/mgCr, p = 0.009, respectively).

CONCLUSIONS

BNP level was significantly lower in HFpEF patients with hyperuricemia or gout after topiroxostat administration; however, the rate of decrease was low. Further trials are needed to confirm our findings.

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic heart failure in primary care (PREFER): a real-world study

Objective

To assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from PC to a cardiologist could improve care, defined as adherence to European Society of Cardiology (ESC) guideline-recommended pharmacotherapy.

Methods

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic HF in PC (PREFER) study enrolled HFrEF patients from PC considered clinically stable and those with NT-pro-BNP ≥600 pg/mL were referred to a cardiologist for optimisation of HF treatment. The primary outcome of adherence to ESC HF guidelines after referral to specialist was assessed at the second visit within 4 weeks of cardiologist’s referral and no later than 6 months after the baseline visit. Based on futility interim analysis, the study was terminated early.

Results

In total, 1415 HFrEF patients from 223 PCs from 18 countries in Europe were enrolled. Of these, 1324 (96.9%) were considered clinically stable and 920 (65.0%) had NT-pro-BNP ≥600 pg/mL (mean: 2631 pg/mL). In total, 861 (60.8%) patients fulfilled both criteria and were referred to a cardiologist. Before cardiologist consultation, 10.1% of patients were on ESC guideline-recommended HFrEF medications and 2.7% were on recommended dosages of HFrEF medication (defined as ≥50% of ESC guideline-recommended dose). Postreferral, prescribed HFrEF drugs remained largely unchanged except for an increase in diuretics (+4.6%) and mineralocorticoid receptor antagonists (+7.9%). No significant increase in patients’ adherence to guideline-defined drug combinations (11.2% post-referral vs 10.1% baseline) or drug combinations and dosages (3.3% postreferral vs 2.7% baseline) was observed after cardiologist consultation.

Conclusions

PREFER demonstrates substantial suboptimal treatment of HFrEF patients in the real world. Referral of patients with elevated NT-pro-BNP levels from PC to cardiologist did not result in meaningful treatment optimisation for treatments with known mortality and morbidity benefit.

Association of treatment-resistant hypertension defined by home blood pressure monitoring with cardiovascular outcome

In diagnosis of treatment-resistant hypertension (TRH), guidelines recommend out-of-office blood pressure (BP) measurements, ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM). Although evidence of an association between ABPM-evaluated TRH and cardiovascular disease (CVD) prognosis has accumulated, data are sparse regarding HBPM-evaluated TRH. We investigated this issue using data from the nationwide practice-based J-HOP (Japan Morning-Surge Home BP) study, which recruited 4,261 outpatients (mean age 64.9 years; 46.8% men; 91.5% hypertensives) who underwent morning and evening HBPM for 14 days. During 6.2 ± 3.8 years (26,418 person-years) follow-up, 270 total CVDs (stroke, coronary artery disease, aortic dissection, and heart failure) occurred. The adjusted hazard ratio (HR) (95% CIs) of uncontrolled TRH, i.e., uncontrolled BP using 3 classes of medications including diuretics or ≥4 classes of medications, for total CVD risk compared to controlled BP using <3 classes were 2.02 (1.38-2.94) and 1.81 (1.23-2.65) in home BP of 135/85 mmHg and 130/80 mmHg, respectively. Additionally, patients with TRH defined by guidelines, i.e., uncontrolled BP using 3 classes of medications including diuretics or controlled/uncontrolled BP using ≥4 classes of medications, also had higher total CVD risk compared to non-TRH under all home BP criteria. Moreover, in patients with uncontrolled apparent-TRH, i.e., TRH defined by office BP, uncontrolled home BP (≥135/85 mmHg) was still associated with atherosclerotic CVD (CVDs except heart failure) risk (adjusted HR [95% CI], 2.38 [1.09-5.19]). This is the first study to demonstrate an independent association between TRH evaluated by HBPM and CVD outcomes.

Prognostic value of an echocardiographic index reflecting right ventricular operating stiffness in patients with heart failure

PURPOSE

We recently reported a noninvasive method for the assessment of right ventricular (RV) operating stiffness that is obtained by dividing the atrial-systolic descent of the pulmonary artery-RV pressure gradient (PRPGD_AC) derived from the pulmonary regurgitant velocity by the tricuspid annular plane movement during atrial contraction (TAPM_AC). Here, we investigated whether this parameter of RV operating stiffness, PRPGD_AC/TAPM_AC, is useful for predicting the prognosis of patients with heart failure (HF).

METHODS

We retrospectively included 127 hospitalized patients with HF who underwent an echocardiographic examination immediately pre-discharge. The PRPGD_AC/TAPM_AC was measured in addition to standard echocardiographic parameters. Patients were followed until 2 years post-discharge. The endpoint was the composite of cardiac death, readmission for acute decompensation, and increased diuretic dose due to worsening HF.

RESULTS

58 patients (46%) experienced the endpoint during follow-up. Univariable and multivariable Cox regression analyses demonstrated that the PRPGD_AC/TAPM_AC was associated with the endpoint. In a Kaplan-Meier analysis, the event rate of the greater PRPGD_AC/TAPM_AC group was significantly higher than that of the lesser PRPGD_AC/TAPM_AC group. In a sequential Cox analysis for predicting the endpoint's occurrence, the addition of PRPGD_AC/TAPM_AC to the model including age, sex, NYHA functional classification, brain natriuretic peptide level, and several echocardiographic parameters including tricuspid annular plane systolic excursion significantly improved the predictive power for prognosis.

CONCLUSION

A completely noninvasive index of RV operating stiffness, PRPGD_AC/TAPM_AC, was useful for predicting prognoses in patients with HF, and it showed an incremental prognostic value over RV systolic function.

Prognostic role of hypothyroidism and low free-triiodothyronine levels in patients hospitalized with acute heart failure

Low thyroid function has been widely recognized as a potential cause of heart failure (HF), but the evidence about a possible association with in-hospital, all-cause mortality in patients with acute HF (AHF) is not consistent. This study sought to investigate the prevalence and prognostic role of hypothyroidism, overt and subclinical, and of low free-triiodothyronine (fT3) levels in patients hospitalized with AHF. We retrospectively analyzed consecutive 1018 patients who were hospitalized for AHF in a single academic medical center [Fondazione Policlinico A.Gemelli IRCCS, Rome, Italy] between January 1st 2016, and December 31st 2018. Patients were divided into three groups: normal thyroid function (n = 798), subclinical hypothyroidism (n = 105), and overt hypothyroidism (n = 115). The outcome was in-hospital, all-cause mortality. Patients were 81 years of age, 55% were females and nearly two-thirds of the patients were on New York Heart Association functional class III. The three most common cardiovascular comorbidities were coronary artery disease, hypertension, and atrial fibrillation with no differences across the three groups. Overall, 138 patients (14%) died during the hospital stay. The mortality rate was 27% among patients with overt hypothyroid, 17% among those with subclinical hypothyroidism, and 11% among euthyroid patients (p < 0.001). At a multivariate Cox regression model, overt hypothyroidism (HR 2.1, 95% CI 1.4-3.2) and fT3 levels < 1.8 pg/mL (HR 3.4, 95% CI 2.3-5.1) were associated with an increased likelihood of in-hospital death. No association was found with subclinical hypothyroidism. Among patients hospitalized with AHF, overt hypothyroidism and low fT3 levels are independent predictors of all-cause mortality during the hospital stay.

Molecular Signaling Mechanisms and Function of Natriuretic Peptide Receptor-A in the Pathophysiology of Cardiovascular Homeostasis

The discovery of atrial, brain, and C-type natriuretic peptides (ANP, BNP, and CNP) and their cognate receptors has greatly increased our knowledge of the control of hypertension and cardiovascular homeostasis. ANP and BNP are potent endogenous hypotensive hormones that elicit natriuretic, diuretic, vasorelaxant, antihypertrophic, antiproliferative, and antiinflammatory effects, largely directed toward the reduction of blood pressure (BP) and cardiovascular diseases (CVDs). The principal receptor involved in the regulatory actions of ANP and BNP is guanylyl cyclase/natriuretic peptide receptor-A (GC-A/NPRA), which produces the intracellular second messenger cGMP. Cellular, biochemical, molecular, genetic, and clinical studies have facilitated understanding of the functional roles of natriuretic peptides (NPs), as well as the functions of their receptors, and signaling mechanisms in CVDs. Transgenic and gene-targeting (gene-knockout and gene-duplication) strategies have produced genetically altered novel mouse models and have advanced our knowledge of the importance of NPs and their receptors at physiological and pathophysiological levels in both normal and disease states. The current review describes the past and recent research on the cellular, molecular, genetic mechanisms and functional roles of the ANP-BNP/NPRA system in the physiology and pathophysiology of cardiovascular homeostasis as well as clinical and diagnostic markers of cardiac disorders and heart failure. However, the therapeutic potentials of NPs and their receptors for the diagnosis and treatment of cardiovascular diseases, including hypertension, heart failure, and stroke have just begun to be expanded. More in-depth investigations are needed in this field to extend the therapeutic use of NPs and their receptors to treat and prevent CVDs.

Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme

Background

Long-term monitoring is important in chronic condition management. Despite considerable costs of monitoring, there is no or poor evidence on how, what and when to monitor. The aim of this study was to improve understanding, methods, evidence base and practice of clinical monitoring in primary care, focusing on two areas: chronic kidney disease and chronic heart failure.

Objectives

The research questions were as follows: does the choice of test affect better care while being affordable to the NHS? Can the number of tests used to manage individuals with early-stage kidney disease, and hence the costs, be reduced? Is it possible to monitor heart failure using a simple blood test? Can this be done using a rapid test in a general practitioner consultation? Would changes in the management of these conditions be acceptable to patients and carers?

Design

Various study designs were employed, including cohort, feasibility study, Clinical Practice Research Datalink analysis, seven systematic reviews, two qualitative studies, one cost-effectiveness analysis and one cost recommendation.

Setting

This study was set in UK primary care.

Data sources

Data were collected from study participants and sourced from UK general practice and hospital electronic health records, and worldwide literature.

Participants

The participants were NHS patients (Clinical Practice Research Datalink: 4.5 million patients), chronic kidney disease and chronic heart failure patients managed in primary care (including 750 participants in the cohort study) and primary care health professionals.

Interventions

The interventions were monitoring with blood and urine tests (for chronic kidney disease) and monitoring with blood tests and weight measurement (for chronic heart failure).

Main outcome measures

The main outcomes were the frequency, accuracy, utility, acceptability, costs and cost-effectiveness of monitoring.

Results

Chronic kidney disease: serum creatinine testing has increased steadily since 1997, with most results being normal (83% in 2013). Increases in tests of creatinine and proteinuria correspond to their introduction as indicators in the Quality and Outcomes Framework. The Chronic Kidney Disease Epidemiology Collaboration equation had 2.7% greater accuracy (95% confidence interval 1.6% to 3.8%) than the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate. Estimated annual transition rates to the next chronic kidney disease stage are ≈ 2% for people with normal urine albumin, 3–5% for people with microalbuminuria (3–30 mg/mmol) and 3–12% for people with macroalbuminuria (> 30 mg/mmol). Variability in estimated glomerular filtration rate-creatinine leads to misclassification of chronic kidney disease stage in 12–15% of tests in primary care. Glycaemic-control and lipid-modifying drugs are associated with a 6% (95% confidence interval 2% to 10%) and 4% (95% confidence interval 0% to 8%) improvement in renal function, respectively. Neither estimated glomerular filtration rate-creatinine nor estimated glomerular filtration rate-Cystatin C have utility in predicting rate of kidney function change. Patients viewed phrases such as ‘kidney damage’ or ‘kidney failure’ as frightening, and the term ‘chronic’ was misinterpreted as serious. Diagnosis of asymptomatic conditions (chronic kidney disease) was difficult to understand, and primary care professionals often did not use ‘chronic kidney disease’ when managing patients at early stages. General practitioners relied on Clinical Commissioning Group or Quality and Outcomes Framework alerts rather than National Institute for Health and Care Excellence guidance for information. Cost-effectiveness modelling did not demonstrate a tangible benefit of monitoring kidney function to guide preventative treatments, except for individuals with an estimated glomerular filtration rate of 60–90 ml/minute/1.73 m2, aged < 70 years and without cardiovascular disease, where monitoring every 3–4 years to guide cardiovascular prevention may be cost-effective. Chronic heart failure: natriuretic peptide-guided treatment could reduce all-cause mortality by 13% and heart failure admission by 20%. Implementing natriuretic peptide-guided treatment is likely to require predefined protocols, stringent natriuretic peptide targets, relative targets and being located in a specialist heart failure setting. Remote monitoring can reduce all-cause mortality and heart failure hospitalisation, and could improve quality of life. Diagnostic accuracy of point-of-care N-terminal prohormone of B-type natriuretic peptide (sensitivity, 0.99; specificity, 0.60) was better than point-of-care B-type natriuretic peptide (sensitivity, 0.95; specificity, 0.57). Within-person variation estimates for B-type natriuretic peptide and weight were as follows: coefficient of variation, 46% and coefficient of variation, 1.2%, respectively. Point-of-care N-terminal prohormone of B-type natriuretic peptide within-person variability over 12 months was 881 pg/ml (95% confidence interval 380 to 1382 pg/ml), whereas between-person variability was 1972 pg/ml (95% confidence interval 1525 to 2791 pg/ml). For individuals, monitoring provided reassurance; future changes, such as increased testing, would be acceptable. Point-of-care testing in general practice surgeries was perceived positively, reducing waiting time and anxiety. Community heart failure nurses had greater knowledge of National Institute for Health and Care Excellence guidance than general practitioners and practice nurses. Health-care professionals believed that the cost of natriuretic peptide tests in routine monitoring would outweigh potential benefits. The review of cost-effectiveness studies suggests that natriuretic peptide-guided treatment is cost-effective in specialist settings, but with no evidence for its value in primary care settings.

Limitations

No randomised controlled trial evidence was generated. The pathways to the benefit of monitoring chronic kidney disease were unclear.

Conclusions

It is difficult to ascribe quantifiable benefits to monitoring chronic kidney disease, because monitoring is unlikely to change treatment, especially in chronic kidney disease stages G3 and G4. New approaches to monitoring chronic heart failure, such as point-of-care natriuretic peptide tests in general practice, show promise if high within-test variability can be overcome.

Future work

The following future work is recommended: improve general practitioner–patient communication of early-stage renal function decline, and identify strategies to reduce the variability of natriuretic peptide.

Study registration

This study is registered as PROSPERO CRD42015017501, CRD42019134922 and CRD42016046902.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.

Current Use of Cardiac Biomarkers in Various Heart Conditions

Biomarkers are increasingly recognized to have significant clinical value in early identification and progression of various cardiovascular diseases. There are many heart conditions, such as congestive heart failure (CHF), ischemic heart diseases (IHD), and diabetic cardiomyopathy (DCM), and cardiac remodeling, in which the severity of the cardiac pathology can be mirrored through these cardiac biomarkers. From the emergency department (ED) evaluation of acute coronary syndromes (ACS) or suspected acute myocardial infarction (AMI) with cardiac marker Troponin to the diagnosis of chronic conditions like Heart Failure (HF) with natriuretic peptides, like B-type natriuretic peptide (BNP), N-terminal pro-B- type natriuretic peptide (Nt-proBNP) and mid regional pro-atrial natriuretic peptide (MR- proANP), their use is continuously increasing. Their clinical importance has led to the discovery of newer biomarkers, such as the soluble source of tumorigenicity 2 (sST2), galectin-3 (Gal-3), growth differentiation factor-15 (GDF-15), and various micro ribonucleic acids (miRNAs). Since cardiac pathophysiology involves a complex interplay between inflammatory, genetic, neurohormonal, and biochemical levels, these biomarkers could be enzymes, hormones, and biologic substances showing cardiac injury, stress, and malfunction. Therefore, multi-marker approaches with different combinations of novel cardiac biomarkers, and continual assessment of cardiac biomarkers are likely to improve cardiac risk prediction, stratification, and overall patient wellbeing. On the other hand, these biomarkers may reflect coexisting or isolated disease processes in different organ systems other than the cardiovascular system. Therefore, knowledge of cardiac biomarkers is imperative. In this article, we have reviewed the role of cardiac biomarkers and their use in the diagnosis and prognosis of various cardiovascular diseases from different investigations conducted in recent years.

Prognostic Value of Natriuretic Peptides for All-Cause Mortality, Right Ventricular Failure, Major Adverse Events, and Myocardial Recovery in Advanced Heart Failure Patients Receiving a Left Ventricular Assist Device: A Systematic Review

Aims: Major adverse event (MAE) rates during left ventricular assist device (LVAD) therapy in advanced heart failure (HF) patients are high, and impair quality of life and survival. Prediction and risk stratification of MAEs in order to improve patient selection and thereby outcome during LVAD therapy is therefore warranted. Circulating natriuretic peptides (NPs) are strong predictors of MAEs and mortality in chronic HF patients. However, whether NPs can identify patients who are at risk of MAEs and mortality or tend toward myocardial recovery after LVAD implantation is unclear. The aim of this systematic review is to analyze the prognostic value of circulating NP levels before LVAD implantation for all-cause mortality, MAEs and myocardial recovery after LVAD implantation.

Methods and Results: Electronic databases were searched for studies analyzing circulating NP in adults with advanced HF before LVAD implantation in relation to mortality, MAEs, or myocardial recovery after LVAD implantation. Twenty-four studies published between 2008 and 2021 were included. Follow-up duration ranged from 48 hours to 5 years. Study sample size ranged from 14 to 15,138 patients. Natriuretic peptide levels were not predictive of all-cause mortality. However, NPs were predictive of right ventricular failure (RVF) and MAEs such as ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization. No relation between NPs and myocardial recovery was found.

Conclusion: This systematic review found that NP levels before LVAD implantation are not predictive of all-cause mortality after LVAD implantation. Thus, NP levels may be of limited value in patient selection for LVAD therapy. However, NPs help in risk stratification of MAEs and may be used to identify patients who are at risk for RVF, ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization after LVAD implantation.

Prognostic value of natriuretic peptides in heart failure: systematic review and meta-analysis

Risk models, informing optimal long-term medical management, seldom use natriuretic peptides (NP) in ascertaining the absolute risk of outcomes for HF patients. Individual studies evaluating the prognostic value of NPs in HF patients have reported varying effects, arriving at best estimates requires a systematic review. We systematically summarized the best evidence regarding the prognostic value of brain natriuretic peptide (BNP) and NT-proBNP in predicting mortality and hospitalizations in ambulatory heart failure (HF) patients. We searched bibliographic databases from 2005 to 2018 and included studies evaluating the association of BNP or NT-proBNP with mortality or hospitalization using multivariable Cox proportional hazard models. We pooled hazard ratios using random-effect models, explored heterogeneity using pre-specified subgroup analyses, and evaluated the certainty of evidence using the Grading of Recommendations and Development Evaluation framework. We identified 67 eligible studies reporting on 76,178 ambulatory HF patients with a median BNP of 407 pg/mL (261-574 pg/mL). Moderate to high-quality evidence showed that a 100-pg/mL increase in BNP was associated with a 14% increased hazard of mortality (HR 1.14, 95% CI 1.06-1.22); a 1-log-unit increase was associated with a 51% increased hazard of mortality (HR 1.51, 95% CI 1.41-1.61) and 48% increased hazard of mortality or hospitalization (HR 1.48, 95% CI 1.29-1.69). With moderate to high certainty, we observed a 14% independent relative increase in mortality, translating to a clinically meaningful increase in absolute risk even for low-risk patients. The observed associations may help in developing more accurate risk models that incorporate NPs and accurately prognosticate HF patients.