Dynamic risk stratification using serial measurements of plasma concentrations of natriuretic peptides in patients with heart failure

Long-Term Trajectories of Biomarkers, Functional, and Echocardiographic Parameters in Patients with Chronic Heart Failure from Dilated or Ischaemic Cardiomyopathy

INTRODUCTION

The long-term evolution of clinical, echocardiographic, and laboratory parameters of cardiac function in patients with chronic heart failure (HF) with either reduced (HFrEF) or mildly reduced (HFmrEF) left ventricular ejection fraction (LVEF) is incompletely characterised.

METHODS

We identified patients with chronic stable HF who presented at least twice to a university HF outpatient clinic between 1995 and 2021. Trajectories of NYHA functional class, LVEF, left ventricular internal end-diastolic diameter (LVIDD), NT-proBNP concentrations, and HF treatment over 10 years of follow-up were analysed using fractional polynomials. Analyses were repeated after stratifying patients according to aetiology (ischaemic vs. dilated) or HF category (HFrEF vs. HFmrEF).

RESULTS

A total of 2,132 patients were included, of whom 51% had ischaemic and 49% had dilated HF. Eighty six percent and 14% were classified as HFrEF and HFmrEF, respectively. Mean LVEF was 28 ± 10%, and median NT-proBNP and estimated glomerular filtration rate values were 1,170 (385-3,176) pmol/L and 81 (62-100) mL/min/1.73 m2, respectively. Median follow-up was 5.2 (2.6-9.2) years. Overall, NYHA functional class and LVIDD trajectories were U-shaped, whereas LVEF and NT-proBNP concentrations markedly improved during the first year and remained stable thereafter. However, the evolution of HF parameters significantly differed with respect to HF category and aetiology, with greater improvements seen in patients with HFrEF of non-ischaemic origin. Improvements in HF variables were associated with optimization of HF therapy, notably with initiation and up-titration of renin-angiotensin-system blockers.

CONCLUSION

This study provides insights into the natural history of HF in a large cohort of well-treated chronic HF outpatients with respect to subgroups of HF and different aetiologists.

Joint modelling of longitudinal processes and time-to-event outcomes in heart failure: systematic review and exemplar examining the relationship between serum digoxin levels and mortality

BACKGROUND

Joint modelling combines two or more statistical models to reduce bias and increase efficiency. As the use of joint modelling increases it is important to understand how and why it is being applied to heart failure research.

METHODS

A systematic review of major medical databases of studies which used joint modelling within heart failure alongside an exemplar; joint modelling repeat measurements of serum digoxin with all-cause mortality using data from the Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure (DIG) trial.

RESULTS

Overall, 28 studies were included that used joint models, 25 (89%) used data from cohort studies, the remaining 3 (11%) using data from clinical trials. 21 (75%) of the studies used biomarkers and the remaining studies used imaging parameters and functional parameters. The exemplar findings show that a per unit increase of square root serum digoxin is associated with the hazard of all-cause mortality increasing by 1.77 (1.34-2.33) times when adjusting for clinically relevant covariates.

CONCLUSION

Recently, there has been a rise in publications of joint modelling being applied to heart failure. Where appropriate, joint models should be preferred over traditional models allowing for the inclusion of repeated measures while accounting for the biological nature of biomarkers and measurement error.

Dynamic risk stratification using Markov chain modelling in patients with chronic heart failure

AIMS

Risk changes with the progression of disease and the impact of treatment. We developed a dynamic risk stratification Markov chain model using artificial intelligence in patients with chronic heart failure (CHF).

METHODS AND RESULTS

We described the pattern of behaviour among 7496 consecutive patients assessed for suspected HF. The following mutually exclusive health states were defined and assessed every 4 months: death, hospitalization, outpatient visit, no event, and leaving the service altogether (defined as no event at any point following assessment). The observed figures at the first transition (4 months) weres 427 (6%), 1559 (21%), 2254 (30%), 1414 (19%), and 1842 (25%), respectively. The probabilities derived from the first two transitions (i.e. from baseline to 4 months and from 4 to 8 months) were used to construct the model. An example of the model's prediction is that at cycle 4, the cumulative probability of death was 14%; leaving the system, 37%; being hospitalized between 12 and 16 months, 10%; having an outpatient visit, 8%; and having no event, 31%. The corresponding observed figures were 14%, 41%, 10%, 15%, and 21%, respectively. The model predicted that during the first 2 years, a patient had a probability of dying of 0.19, and the observed value was 0.18.

CONCLUSIONS

A model derived from the first 8 months of follow-up is strongly predictive of future events in a population of patients with chronic heart failure. The course of CHF is more linear than is commonly supposed, and thus more predictable.

Changes in BNP levels from discharge to 6-month visit predict subsequent outcomes in patients with acute heart failure

Background

This study aimed to investigate the association between changes in brain natriuretic peptide (BNP) from discharge to 6-month visit and subsequent clinical outcomes in patients with acute heart failure (AHF).

Methods

Among 1246 patients enrolled in the prospective longitudinal follow-up study nested from the Kyoto Congestive Heart Failure registry, this study population included 446 patients with available paired BNP data at discharge and 6-month index visit. This study population was classified into 3 groups by percent change in BNP from discharge to 6-month visit; the low tertile (≤-44%, N = 149), the middle tertile (>-44% and ≤22%, N = 149) and the high tertile (>22%, N = 148).

Findings

The cumulative 180-day incidence after the index visit of the primary outcome measure (a composite endpoint of all-cause death or hospitalization for HF) was significantly higher in the high and middle tertiles than in the low tertile (26.8% and 14.4% versus 6.9%, log-rank P<0.0001). The adjusted excess risk of the high tertile relative to the low tertile remained significant for the primary outcome measure (hazard ratio: 3.43, 95% confidence interval: 1.51–8.46, P = 0.003).

Conclusions

Percent change in BNP was associated with a subsequent risk for a composite of all-cause death and hospitalization for HF after adjustment of the absolute BNP values, suggesting that observing the change in BNP levels, in addition to absolute BNP levels themselves, helps us to manage patient with HF.

Apelin Improves Prognostic Value of HFSS (Heart Failure Survival Score) and MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) Scales in Ambulatory Patients with End-Stage Heart Failure

This prospective study aimed to determine the effect of adding apelin to the MAGGIC (Meta-Analysis Global Group In Chronic Heart Failure) and HFSS (Heart Failure Survival Score) scales for predicting one-year mortality in 240 ambulatory patients accepted for heart transplantation (HT) between 2015-2017. The study also investigated whether the combination of N-terminal pro-brain natriuretic peptide (NT-proBNP) with MAGGIC or HFSS improves the ability of these scales to effectively separate one-year survivors from non-survivors on the HT waiting list. The median age of the patients was 58.0 (51.50.0-64.0) years and 212 (88.3%) of them were male. Within a one year follow-up, 75 (31.2%) patients died. The area under the curves (AUC) for baseline parameters was as follows-0.7350 for HFSS, 0.7230 for MAGGIC, 0.7992 for apelin and 0.7028 for NT-proBNP. The HFSS-apelin score generated excellent power to predict the one-year survival, with the AUC of 0.8633 and a high sensitivity and specificity (80% and 78%, respectively). The predictive accuracy of MAGGIC-apelin score was also excellent (AUC: 0.8523, sensitivity of 75%, specificity of 79%). The addition of NT-proBNP to the HFSS model slightly improved the predictive power of this scale (AUC_{HFFSS-NT-proBNP}: 0.7665, sensitivity 83%, specificity 60%), while it did not affect the prognostic strength of MAGGIC (AUC_{MAGGIC-NT-proBNP}: 0.738, sensitivity 71%, specificity 69%). In conclusion, the addition of apelin to the HFSS and MAGGIC models significantly improved their ability to predict the one-year survival in patients with advanced HF. The MAGGIC-apelin and HFSS-apelin scores provide simple and powerful methods for risk stratification in end-stage HF patients. NT-proBNP slightly improved the prognostic power of HFSS, while it did not affect the predictive power of MAGGIC.

The therapeutic effect of B-type natriuretic peptides in acute decompensated heart failure

B-type natriuretic peptide (BNP) exhibits roles in natriuresis and diuresis, making it an ideal drug that may aid in diuresing a fluid-overloaded patient with poor or worsening renal function. Several randomized clinical trials have tested the hypothesis that infusions of pharmacological doses of BNP to acute heart failure (HF) patients may enhance decongestion and preserve renal function in this clinical setting. Unfortunately, none of these have demonstrated beneficial outcomes. The current challenge for BNP research in acute HF lies in addressing a failure of concept and a reluctance to abandon an ineffective research model. Future success will necessitate a detailed understanding of the mechanism of action of BNP, as well as better integration of basic and clinical science.

Chronic Obstructive Pulmonary Disease and Heart Failure: A Breathless Conspiracy

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are both common causes of breathlessness and often conspire to confound accurate diagnosis and optimal therapy. Risk factors (such as aging, smoking, and obesity) and clinical presentation (eg, cough and breathlessness on exertion) can be very similar, but the treatment and prognostic implications are very different. This review discusses the diagnostic challenges in individuals with exertional dyspnea. Also highlighted are the prevalence, clinical relevance, and therapeutic implications of a concurrent diagnosis of COPD and HF.

Longitudinal patterns of N-terminal pro B-type natriuretic peptide, troponin T, and C-reactive protein in relation to the dynamics of echocardiographic parameters in heart failure patients

Aims

To further elucidate the nature of the association between N-terminal pro-B type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-TnT), C-reactive protein (CRP), and clinical outcome, we examined the relationship between serial simultaneous measurements of echocardiographic parameters and these biomarkers in chronic heart failure (CHF) patients.

Methods and results

In 117 CHF patients with ejection fraction ≤50%, NT-proBNP, hs-TnT, and CRP were measured simultaneously with echocardiographic evaluation at 6-month intervals until the end of 30 months follow-up or until an adverse clinical event occurred. Linear mixed effects models were used for data-analysis. Median follow-up was 2.2 years (interquartile range 1.5–2.6). We performed up to six follow-up evaluations with 55% of patients having at least three evaluations performed. A model containing all three biomarkers revealed that doubling of NT-proBNP was associated with a decrease in left ventricular ejection fraction by 1.83 (95% confidence interval −2.63 to −1.03)%, P &lt; 0.0001; relative increase in mitral E/e′ ratio by 12 (6–18)%, P &lt; 0.0001; relative increase in mitral E/A ratio by 16 (9–23)%, P &lt; 0.0001; decrease in tricuspid annular plane systolic excursion by 0.66 (−1.27 to −0.05) mm, P = 0.03; rise in tricuspid regurgitation peak systolic gradient by 2.74 (1.43–4.05) mmHg, P = 0.001; and increase in left ventricular and atrial dimensions, P &lt; 0.05. Hs-TnT and CRP showed significant associations with some echocardiographic parameters after adjustment for clinical covariates, but after adjustment for the other biomarkers the associations were not significant.

Conclusion

Serum NT-proBNP independently reflects changes in echocardiographic parameters of systolic function, left ventricular filling pressures, estimated pulmonary pressure, and chamber dimensions. Our results support further studies on NT-proBNP as a surrogate marker for haemodynamic congestion and herewith support its potential value for therapy guidance.