The Use of Brain Natriuretic Peptide in the Evaluation of Heart Failure in Geriatric Patients

The Impact of Metformin on BNP Levels: A Potential Cardioprotective Role in Type 2 Diabetes

Background/Objectives: Cardiovascular complications are the most common cause of mortality and morbidity in diabetic patients. Therefore, the aim of antidiabetic therapy should not only be to provide glucose regulation but also to protect patients from complications and related mortality. Brain natriuretic peptide (BNP) is a peptide secreted as a result of myocardial stress. BNP levels increase under conditions of increased myocardial stress, such as heart failure. It is an important marker not only at the time of diagnosis but also during follow-up. In our study, we aimed to evaluate BNP levels and thus, the factors affecting the risk of developing heart failure during the course of diabetes. Methods: This study was conducted at the diabetes outpatient clinic of the University of Health Sciences, Haseki Training and Research Hospital. A total of 252 patients met the inclusion criteria and were enrolled in the study. All study participants were patients with a confirmed diagnosis of type 2 diabetes. Laboratory parameters, including BNP values, comorbidities, and anamnesis data, were recorded. Results: The mean BNP levels were significantly lower in patients using metformin and pioglitazone. Other antidiabetic medications were not associated with BNP levels. BNP levels were positively correlated with age and diabetes duration and negatively correlated with hemoglobin levels. According to regression analysis, age, metformin use, and hemoglobin levels were found to independently affect BNP levels. Conclusions: Our findings suggest that metformin could potentially play a significant role in preventing the development of heart failure in diabetic patients currently not experiencing this complication owing to its favorable effects on myocardial stress. This suggests metformin's potential in preventing heart failure in type 2 diabetic patients.

Integrative bioinformatic analysis of prognostic biomarkers in heart failure: Insights from clinical trials

BACKGROUND

Heart failure (HF) remains a major cause of morbidity and mortality worldwide. Therefore, there is a need to identify robust biomarkers to improve early diagnosis, stratify disease severity and predict outcomes. Biomarkers such as galectin-3 (Gal-3), TIMP-1, BNP, NT-proBNP, CysC, CA125, ST2 and MMP9 have shown the potential to reflect the pathophysiology of HF. Despite their clinical potential, their integration into routine practice is still limited. The use of bioinformatics may help uncover critical associations between these biomarkers and the progression of HF, providing opportunities for personalized disease management.

METHODS

Following PRISMA guidelines, a systematic review of clinical studies was performed using databases with time constraints. The major proteins associated with HF were identified and their diagnostic and prognostic roles were analysed.

RESULTS

The study emphasizes that galectin-3 (Gal-3) and TIMP-1 serve as key indicators of fibrosis and inflammation, while BNP and NT-proBNP are reliable markers of cardiac stress. Cystatin C (CysC) reflects renal dysfunction, and CA125 correlates strongly with venous congestion. In addition, ST2 and MMP9 provide valuable insights into inflammation and tissue remodelling processes. These biomarkers are consistently elevated in patients with HF, emphasizing their critical role in detecting the systemic and cardiac manifestations of the disease.

CONCLUSION

Our results emphasize the importance of including biomarkers such as Gal-3, TIMP-1, BNP, NT-proBNP, CysC, CA125, ST2 and MMP9 in the diagnosis and treatment of HF. Their upregulation reflects the complex pathophysiological processes of HF and supports their use in the clinical setting to improve diagnostic accuracy, prognostic precision and personalized therapeutic strategies.

Action on elevated natriuretic peptide in primary care: a retrospective cohort study

BACKGROUND

Natriuretic peptides (NPs) are released by increased ventricular wall stress, most often caused by heart failure (HF). NP level measurement helps select patients clinically suspected of HF who need echocardiography. Yet, the diagnostic actions following NP testing in daily primary care are poorly studied.

AIM

To assess the diagnostic actions taken by GPs in patients with an elevated NP level.

DESIGN & SETTING

Retrospective observational study in general practices in The Netherlands.

METHOD

In patients with an elevated NP level between July 2017 and July 2022, diagnostic actions were collected during 3 months following NP testing. We compared patients with an elevated NP level referred for echocardiography with those not referred by univariable analyses.

RESULTS

Among 902 patients, 394 (43.7%) had an elevated NP level. Median age was 75.0 (interquartile range [IQR] 18.0) years; 68.8% were female. In total, 166 (42.1%) were referred for echocardiography and 114 (28.9%) underwent additional electrocardiogram (ECG) recording. In total, n = 30/166 (18.1%) referred patients were labelled HF by the cardiologist within 3 months after NP testing compared with n = 29/228 (12.7%) not referred. Referred patients were compared with those not referred and they were found to be younger (69.7 versus 74.1 years, P<0.001), were less often known to cardiologists (45.8% versus 62.3%, P = 0.002), and they had lower marginally elevated B-type natriuretic peptide (BNP) levels (35-50 pg/ml) (19.3% versus 36.6%, P<0.001).

CONCLUSION

Three out of five patients with an elevated NP level are not referred for echocardiography by GPs. Barriers to refer patients were older age, a marginally elevated BNP value, and already being under supervision of a cardiologist.

Heart Failure in Older Patients: An Update

Heart failure (HF) is a clinical syndrome with high incidence and prevalence and high morbidity and death rate, even in the short term, representing a serious public health issue, mainly in older people. It is a growing cause for hospital admission in this age group, being frequently associated with several comorbidities, further aggravating the disease's course. Moreover, older HF patients are usually affected by clinical conditions, like frailty, malnutrition, and cachexia, which significantly impact the overall management of HF and need to be properly identified and treated. Diagnosing and managing HF in older patients may be very complicated and challenging. Although specific data on treatment of both acute and chronic HF in older subjects are limited and mainly extrapolated from large-scale clinical trials, the standard pharmacological management may be considered well-tolerated and generally safe. In any case, a personalized and tailored approach is mandatory and is based on severity of comorbidities, overall status, and prognosis, above all in frailer and more comorbid subjects, due to the higher rate of drug interactions, side effects, and therapy discontinuation in this population. In this scenario, palliative care has become a fundamental part of HF management in the elderly in order to improve their care and the quality of life. Moreover, an increasing number of promising pharmacological options deserve further investigation in order to support clinicians in optimizing management of comorbid and frailer patients. In this work, we provide detailed and updated insight into clinical, therapeutic, and prognostic features of both acute and chronic HF in the older population.

NT-proBNP for Heart Failure Screening in Primary Care in an Eastern European Country: What We Know and Proposed Steps

Epidemiological studies indicate that heart failure (HF) prevalence and associated mortality are significantly higher among Eastern European countries as compared to their Western European counterparts. The significant financial burden on the healthcare system matches these sobering data. Thus, efficient programs for patients with HF have been called for. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) represents a widely used, cost-effective, and readily available test that can be used to evaluate HF risk. However, it should not be used as a universal assessment, given the existing variability in proposed cut-off scores for various subgroups of patients. Thus, the clinical context needs to always be considered, and alternative diagnoses need to be ruled out. Based upon evidence from the literature for the above assumptions, the advantages and limitations of using NT-proBNP in primary care settings, along with other HF diagnostic modalities, are discussed in this paper. Also, this paper argues that an effective primary care network, in collaboration with specialist providers, may avoid a delay in HF diagnoses, may help provide on-time treatments, and may ultimately cut unnecessary healthcare expenditures associated with HF hospitalizations. Therefore, the present paper proposes an algorithm for diagnosing HF in primary care settings and discusses specific knowledge and skills that family physicians should be well equipped with in order to successfully respond to the needs of their patients with HF.

Peptide Biomarkers - An Emerging Diagnostic Tool and Current Applicable Assay

In the past few decades, impressive progress achieved in technology development and improvement has accelerated the application of peptides as diagnostic biomarkers for various diseases. We outline the advantages of peptides as good diagnostic targets, since they serve as molecular surrogates of enzyme activities, much more specific biomarkers than proteins, and also play vital roles in many biological processes. On the basis of an extensive literature survey, peptide markers with high specificity and sensitivity that are currently applied in clinical tests, as well as recently identified, are summarized for the following four major categories of diseases: neurodegenerative disease, heart failure, infectious disease, and cancer. In addition, we summarize a few prevalent techniques used in peptide biomarker discovery and analysis, such as immunoassays, nanopore-based and nanoparticle-based peptide detection, and also MS-based peptide analysis techniques, and their pros and cons. Currently, there are plenty of analytical technologies available to achieve fast, sensitive and reliable peptide analyses, benefiting from the developments of hardware and instrumentation, as well as data analysis software and databases. Thus, with peptides emerging as sensitive, specific and reliable biomarkers for early detection of diseases, therapeutic monitoring, clinical treatment decisions and disease prognosis, the medical need for peptide biomarkers will increase strongly in the future.

Association between BNP and all-cause mortality in critically ill children: a cohort study

BACKGROUND

There is evidence that a high level of BNP is associated with poorer outcomes in patients with cardiac diseases, but few data are available concerning BNP and all-cause mortality in pediatric population.

METHODS

Using the 2010-2018 pediatric intensive care database, we conducted a retrospective study on patients aged 28 days to 18 years, analyzing post-admission BNP measurements. Through two-piecewise regression to identify inflection points, and multivariable logistic regression, we investigated BNP's association with all-cause mortality. We also developed a multivariable-adjusted restricted cubic spline model to explore BNP's non-linear correlation with mortality.

RESULTS

In a study of 3220 patients, the overall all-cause mortality rate was 6.7%, with rates across BNP quartiles (Q1-Q4) significantly differing, highlighting a notable increase in mortality at higher BNP levels (P < 0.001). Specifically, patients with BNP ≥ 10,170 pg/ml had an adjusted mortality odds ratio (OR) of 2.017 (95% CI 1.265-3.217; P = 0.0032). Analysis confirmed a non-linear relationship between BNP levels and mortality, with log2 BNP associated with increased risk (OR1.28, 95% CI 1.19-1.38; P < 0.001). Subgroup analyses further revealed that very high BNP levels, especially in infants, with lactate ≥2.0 mmol/L, or CKMB ≥ 45 μ/L.

CONCLUSIONS

BNP level was associated with all-cause mortality, especially for the patients with BNP ≥ 10,170 pg/ml.

IMPACT

This study explored the non-linear association between BNP levels and all-cause mortality in the PICU, finding a significant association among patients with BNP levels above 10,170 pg/ml. The study revealed that higher BNP levels are associated with increased mortality in critically ill children, including those with non-cardiac diseases. This research provides new data on a Southern Chinese population, previously unstudied, enriching the existing body of knowledge. While most studies have focused on adult cardiac patients, this research highlights the importance of BNP as a prognostic tool in the PICU, including non-cardiac cases, adding to the literature. This study furnishes novel clinical evidence supporting the monitoring of BNP concentrations within the PICU, aiding in prognostic predictions and the development of tailored treatment plans for patients.

Care manager role for older multimorbid heart failure patients' needs in relation to psychological distress and quality of life: a cross-sectional study

Background

There are few studies investigating patients' needs in healthcare focusing on disease severity and psychological characteristics of elderly heart failure (HF) patients with multimorbidity, specifically addressed by a care manager (CM).

Aims

To explore the role of a CM dealing with elderly multimorbid HF patients' needs/preferences according to NYHA class, ejection fraction, psychological/psychosomatic distress and quality of life (QoL), utilizing a Blended Collaborative Care (BCC) approach (ESCAPE; Grant agreement No 945377).

Methods

Cue cards, self-reported questionnaires, and a semi-structured interview were used to collect data.

Results

Twenty-five Italian patients (mean age ± SD = 77.5 ± 6.68) were enrolled between June 2021 and March 2022. The most relevant patients' needs to be addressed by a CM were: education (e.g., on medical comorbidities), individual treatment tailoring (e.g., higher number of appointments with cardiologists) and symptom monitoring.

Conclusion

The study highlights the importance of targeting HF patients' needs according to psychological characteristics, whose healthcare requires person-centered care with CM assistance. In view of ESCAPE BCC intervention, a CM should consider specific patients' needs of elderly multimorbid HF patients with psychological, psychosomatic distress, particularly somatization, and lower QoL to achieve a more personalized health care pathway.

Study registration

The «Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multi-morbid elderly patients» (ESCAPE) study has been registered at the University of Göttingen Medical Centre (UMG Reg. No 02853) and the German Clinical Trials Register (DRKS00025120).

Role of dietary inflammatory index in the association of NT-proBNP with all-cause and cardiovascular mortality in NHANES 1999-2004

N-terminal pro-Brain-type natriuretic peptide (NT-proBNP) has a predictive value of cardiovascular disease (CVD). Pro-inflammatory diet has been proven to be related to CVD. Our study investigated whether the association between NT-proBNP and mortality differed among general U.S. adults with different dietary inflammatory index (DII) scores. This study utilized the National Health and Nutrition Examination Surveys (NHANES) database from 1999 to 2004. Non-pregnant U.S. adults aged ≥ 20 years and without CVD were included. Cox regression model and restricted cubic splines were used to investigate the associations between NT-proBNP, DII, and mortality. A total of 9788 adults were included, and 2386 all-cause deaths with 668 CVD deaths occurred over 17.08 years of follow-up. NT-proBNP was positively associated with DII scores (P < 0.001). Among subjects without CVD, elevated NT-proBNP was positively associated with an increased risk of mortality, with per unit increase in log transformed NT-proBNP, the risk of all-cause and cardiovascular mortality increased by approximately 1.40 times (HR 2.397, 95%CI 1.966-2.922, P < 0.001) and 2.89 times (HR 3.889, 95%CI 2.756-5.490, P < 0.001) after adjusting for cardiovascular risk factors, similar results were observed after adjusting DII scores. Besides, significant interaction was found between lgNT-proBNP and DII on mortality (all P for interaction < 0.05). While as the DII quartiles increased, the association between lgNT-proBNP and mortality partially weakened. Our findings reveal that the association of NT-proBNP with all-cause and cardiovascular mortality differed with different DII scores among U.S. adults without CVD. A pro-inflammatory diet may partially explain the association between NT-proBNP and mortality and warrant further study.

Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty.

METHODS

From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607).

RESULTS

Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings.

CONCLUSIONS

Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.

A Set of Possible Markers for Monitoring Heart Failure and Cognitive Impairment Associated: A Review of Literature from the Past 5 Years

BACKGROUND

Heart failure is an epidemiologically relevant disease because of the aging population and widespread lifestyles that promote it. In addition to the acute event, it is possible for the disease to become chronic with periodic flare-ups. It is essential to study pathology from a diagnostic and prognostic point of view and to identify parameters for effective monitoring. In addition, heart failure is associated with multiple comorbidities, including cognitive impairment, which is monitored clinically but not through specific biomarkers in these patients. The purpose of this review is to gather the most recent scientific evidence on a few possible biomarkers previously identified for monitoring heart failure and associated cognitive impairment.

METHODS

We surveyed studies inherent to a set of previously identified markers, evaluating English-language articles from the past five years conducted in adult heart failure patient populations. We used the databases PubMed, Web of Sciences, and Cochrane Library for search studies, and we considered articles published in journals with an impact factor greater than five in the publication year.

RESULTS

Among the biomarkers evaluated, a concordant indication for serial measurements for heart failure monitoring emerged only for interleukin-6. For the other markers, there is still little evidence available, which is interesting but sometimes conflicting. Interesting studies have also emerged for biomarkers of cognitive decline assessed in patients with heart failure, confirming the hypotheses of the increasingly studied heart-brain correlation.

CONCLUSION

Certainly, further studies in large populations are needed to identify effective biomarkers for monitoring heart failure and associated cognitive impairment.

Supra-Normal Left Ventricular Function

Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.