Relationship between brain natriuretic peptides and recurrence of atrial fibrillation after successful direct current cardioversion: a meta-analysis

Biomarkers associated with rhythm status after cardioversion in patients with atrial fibrillation

Biomarkers may help to improve our knowledge about the complex pathophysiology of atrial fibrillation (AF). In this study we sought to identify significant changes in biomarkers and clinical measures in patients with and without AF recurrence after electrical cardioversion. We measured 21 conventional and new biomarkers before and 30 days after electrical cardioversion and assessed the associations of changes in biomarker levels with rhythm status at follow-up. Significant between-group changes were observed for bone morphogenetic protein 10 (BMP10), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and total bilirubin. Their respective changes were − 10.4%, − 62.0% and − 25.6% in patients with sinus rhythm, and 3.1%, 1.1% and − 9.4% in patients with recurrent AF, for a between-group difference of − 13.5% (95% confidence interval [CI] − 19.3% to − 7.6%; P < 0.001), − 63.1% (95% CI − 76.6% to − 49.6%; P < 0.001) and − 16.3% (95% CI − 27.9% to − 4.7%; P = 0.007). In multivariable models, the reductions of BMP10 and NT-proBNP were significantly associated with follow-up rhythm status (β coefficient per 1 − SD decrease, − 3.85; 95% CI − 6.34 to − 1.35; P = 0.003 for BMP10 and − 5.84; 95% CI − 10.22 to − 1.47; P = 0.009 for NT-proBNP. In conclusion, changes in BMP10 und NT-proBNP levels were independently associated with rhythm status after cardioversion, suggesting that these markers may be dependent on the actual heart rhythm.

The Predictive Value of Tissue Doppler Indices for Early Recurrence of Atrial Fibrillation After Electrical Cardioversion

Purpose

Spectral tissue Doppler-derived E/e’ ratio has been proposed as the best parameter for prediction of atrial fibrillation (AF). Relaxation and contraction are equivalent parts of a continuous cardiac cycle, where systolic and diastolic abnormalities have a variable contribution to the left ventricle (LV) failure. The aim of this study was to investigate whether the E/(e’xs’) ratio is a better index than E/e‘ to predict AF recurrence and to determine the changes of spectral tissue Doppler indices 1 month after the electrical cardioversion (ECV).

Patients and Methods

The study included 77 persistent AF patients with restored sinus rhythm (SR) after ECV. Only patients with normal LV ejection fraction (EF) were included. Echocardiography and NT-proBNP laboratory findings were performed. A primary outcome was the early (within 1 month) recurrence of AF.

Results

After a 1 month follow-up period, 39 patients (50.6%) were in SR. E/e′ (HR=1.74, P=0.001) and E/(e’×s’) ratios (HR=8.17, P=0.01) were significant predictors of AF recurrence. E/(e’×s’) in combination with LV end-diastolic diameter >49.3 mm and NT-proBNP >2000 ng/L demonstrated a higher contribution in the model to predict AF recurrence compared to the E/e’ ratio (18.94, P=0.005 vs 1.95, P=0.001). On ROC analysis, E/(e’×s’) and E/e′ showed similar diagnostic accuracy (E/(e’×s’), AUC=0.71, P=0.002 and E/e′, AUC=0.75, P<0.0001). Average e‘ value significantly decreased after 1 month in SR (from 10.76±1.24 to 8.96±1.47 cm/s, P=0.01), E wave did not change significantly and E/e′ ratio tended to improve. A decrease of average e‘ and an increase of average s‘ values led to significant improvement of E/(e’xs’) ratio.

Conclusion

E/(e’xs’) and E/e’ ratios are comparable to predict early AF recurrence after ECV in patients with persistent AF. The e’ value decreased significantly after 1 month follow-up period after ECV for persistent AF patients.

The Expression of BNP, ET-1, and TGF-β1 in Myocardium of Rats with Ventricular Arrhythmias

Ventricular arrhythmia (VA) is a major component of sudden cardiac death (SCD). To investigate the expression of brain natriuretic peptide (BNP), endothelin-1 (ET-1), and transforming growth factor-beta 1 (TGF-β1) during VA, we established a rat model of VA induced by BaCl₂ solution through a microinjector pump. PD142893 (ET-1 receptor blocker) and SB431542 (TGF-β1 receptor type I blocker) were used to explore the effect of ET-1 and TGF-β1 on BNP expression in the myocardium after VA. BNP, ET-1, and TGF-β1 in rat myocardium were assayed by western blot and immunohistochemical staining for proteins, and real-time quantitative polymerase chain reaction for mRNAs. We found increased expression of BNP and ET-1 in rat myocardium that was associated with the duration of VA. However, TGF-β1 protein expression remained unchanged. Such early increases in BNP and ET-1 may be attributed to fatal arrhythmias associated with SCD, suggesting these may be novel biomarkers of this disease. After intraperitoneal injection of PD142893 and SB431542, respectively, BNP was downregulated in the myocardium of the left ventricle; however, this was abrogated by co-application of the two inhibitors. These results suggested that both ET-1 and TGF-β1, by specifically binding to their receptors, might be involved in the myocardial synthesis of BNP during VA in vivo.

B-type natriuretic peptide enhances fibrotic effects via matrix metalloproteinase-2 expression in the mouse atrium in vivo and in human atrial myofibroblasts in vitro

B-type natriuretic peptide (BNP) was approved by the US Food and Drug Administration in 2001 for the treatment of heart failure. However, the effects of BNP in clinical applications are controversial and uncertain. Recently, study indicated that high BNP levels are associated with an increased risk of developing atrial fibrillation. In this study, we investigated the direct effects of BNP on TNF-α-induced atrial fibrosis mice, as well as its effects on human atrial myofibroblasts. We found that injecting TNF-α-induced mice with recombinant human BNP enhanced atrial fibrosis via matrix metalloproteinase-2 (MMP-2) expression and collagen accumulation. Furthermore, we found that BNP stimulated MMP-2 expression in human atrial myofibroblasts. Treatment of human atrial myofibroblasts with cycloheximide had no effect on this outcome; however, treatment of cells with MG132 enhanced BNP-induced MMP-2 expression, indicating that protein stability and inhibition of proteasome-mediated protein degradation pathways are potentially involved. Inhibition of SIRT1 significantly decreased BNP-induced MMP-2 expression. Additionally, confocal and coimmunoprecipitation data indicated that BNP-regulated MMP-2 expression are likely to be mediated through direct interaction with SIRT1, which is thought to deacetylate MMP-2 and to increase its protein stability in human atrial myofibroblasts. Finally, we confirmed that SIRT1 is expressed and cytoplasmically redistributed as well as colocalized with MMP-2 in mouse fibrotic atrial tissue. We suggest a possible fibrosis-promoting role of BNP in the atrium, although the antifibrotic properties of BNP in the ventricle have been reported in previous studies, and that the coordination between MMP-2 and SIRT1 in BNP-induced atrial myofibroblasts participates in atrial fibrosis.

Relationship between Brain Natriuretic Peptide and Recurrence of Atrial Fibrillation after Successful Electrical Cardioversion: an Updated Meta-Analysis

Objective

To investigate the relationship between brain natriuretic peptide and recurrence of atrial fibrillation after successful electrical cardioversion.

Methods

Medline and Embase databases were used to identify publications evaluating BNP/N-Terminal (NT)-proBNP levels in association with atrial fibrillation recurrence after successful electrical cardioversion. Nineteen studies that fulfilled the specified criteria of our analysis were found.

Results

Baseline BNP/NT-proBNP levels of the atrial fibrillation recurrence group were significantly higher than those of the sinus rhythm maintaining group (SMD -0.70, CI [-0.82, -0.58]).

Conclusion

Our analysis suggests that low BNP/NT-proBNP levels are associated with sinus rhythm maintenance, and baseline BNP/NT-proBNP concentrations may be a predictor of atrial fibrillation recurrence after successful electrical cardioversion.

Advanced interatrial block is an electrocardiographic marker for recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND

Early recurrence of atrial fibrillation (AF) is common following a successful electrical cardioversion (ECV). The purpose of this study was to investigate the hypothesis that AF recurrence is related to atrial electrical inhomogeneity, which may influence the P wave characteristics.

METHODS

Two hundred ninety-one consecutive persistent AF patients who underwent ECV were enrolled, and evaluated for AF recurrences one month after the ECV. Patients with open-heart surgery, a history of catheter ablation, and an unsuccessful ECV were excluded. The P wave duration, dispersion and P wave morphology were evaluated by 12‑lead ECGs 30 min after the ECV.

RESULTS

In total, 141 patients were investigated. One month after the ECV, 60 (43%) patients maintained sinus rhythm. The advanced interatrial block (aIAB; P wave duration >120 ms and biphasic P waves in the inferior leads) (Hazard ratio [HR], 4.51; 95% confidence interval [CI] 1.45-14.01, P = 0.009), P wave dispersion (HR, 1.06; 95%CI 1.02-1.09, P = 0.001), and duration of AF per month (HR, 1.03; 95%CI 1.01-1.04, P = 0.004) were independent predictors of AF recurrence. An aIAB was not associated with structural parameters such as the left atrial volume index or right atrial area. There were no differences in the serum BNP level and frequency of administering anti-arrhythmic drugs between the patients with and without recurrence.

CONCLUSIONS

The risk of AF recurrence after the ECV can be predicted by the P wave characteristics. A longer P wave dispersion and the duration of AF also had a tendency for recurrence.

Lipidomic profiling reveals free fatty acid alterations in plasma from patients with atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its incidence is increasing worldwide. One method used to restore sinus rhythm is direct current cardioversion (DCCV). Despite the high success rate of DCCV, AF typically recurs within the first 2 weeks. However, our understanding of the pathophysiology of AF recurrence, incidence, and progression are highly limited. Lipidomic profiling was applied to identify altered lipids in plasma from patients with AF using ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry coupled with multivariate statistical analysis. Partial least-squares discriminant analysis revealed a clear separation between AF patients and healthy controls. The levels of several lipid species, including fatty acids and phospholipids, were different between AF patients and healthy controls, indicating that oxidative stress and inflammation are associated with the pathogenesis of AF. Similar patterns were also detected between recurrent and non-recurrent AF patients. These results suggest that the elevated saturated fatty acid and reduced polyunsaturated fatty acid levels in AF patients may be associated with enhanced inflammation and that free fatty acid levels may play a crucial role in the development and progression of AF.

Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis

Aims

The meta-analysis was aimed to search for candidate blood markers whose pre-ablation level was associated with atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA).

Methods and results

A systematic literature search of PubMed, EMBASE, Springer Link, Web of Science, Wiley-Cochrane library, and supplemented with Google scholar search engine was performed. Thirty-six studies covering 11 blood markers were qualified for this meta-analysis. Compared with the nonrecurrence group, the recurrence group had increased pre-ablation level of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-pro-BNP), interleukin-6 (IL-6), C-reactive protein, low density lipoprotein (LDL), and tissue inhibitor of metal loproteinase-2 (TIMP-2) [standardized mean difference (95% confidence interval): 0.37 (0.13-0.61), 0.77 (0.40-1.14), 1.25 (0.64-1.87), 0.37 (0.21-0.52), 0.35 (0.10-0.60), 0.24 (0.07-0.42), 0.17 (0.00-0.34), respectively], while no statistical difference of pre-ablation level of white blood cell, total cholesterol, triglyceride, and transforming growth factor-β1 was found. Subgroup analysis demonstrated that ANP was associated with AF recurrence in participants who had no concomitant structural heart diseases (SHD); however, not in participants who had SHD, C-reactive protein was associated with AF recurrence in Asian studies, whereas not in European studies.

Conclusion

Increased pre-ablation level of ANP, BNP, NT-pro-BNP, IL-6, C-reactive protein, LDL, and TIMP-2 was associated with greater risk of AF recurrence after RFCA.

Peak Early Diastolic Transmitral Velocity As A Surrogate Marker Of Short-Term Atrial Fibrillation Recurrence After Electrical Cardioversion

OBJECTIVES

The aim of this study was to assess if peak early diastolic transmitral velocity (E-wave) can be used as a surrogate marker of short-term atrial fibrillation (AF) recurrence.

METHODS

We prospectively studied 57 consecutive patients who underwent electrical cardioversion (ECV) for AF and successfully converted to sinus rhythm. N-terminal brain natriuretic peptide levels (BNP) before and after ECV was measured in all patients. The follow-up included physical examination and a 12-lead electrocardiogram 14 days and one month after the ECV.

RESULTS

In 42.1% patients AF recurred during one-month follow-up period. Gender, presence of mitral regurgitation, treatment with angiotensin II receptor blocker and left atrium diameter independently influenced E-wave velocity before ECV. E-wave velocity fell immediately after successful ECV (94.0±27 cm/s vs 79.7±23 cm/s, P<0.0001). E-wave velocity before ECV>94 cm/s and E-wave velocity after ECV >80 cm/s were predictors of one-month AF recurrence [(Hazard Ratio) HR=3.62 with 95% CI=1.49-8.78 and HR=3.76 with 95% CI=1.40-10.10, respectively]. E-wave velocity before and E-wave velocity after ECV remained predictors of AF recurrence but only in non-hypertensive patients (HR=1.01 with 95% C.I=1.01-1.03 and HR=1.03 with 95% C.I=1.01-1.06, respectively). Similarly, BNP levels before and after ECV were associated with an increased the risk of AF recurrence (HR=1.14 with 95% C.I 1.01-1.28 and HR= 1.16 with 95% C.I 1.03- 1.31, respectively). The addition of BNP levels to E-wave velocity before ECV appeared to have incremental value on short-term AF recurrence but at a marginally statistical significance (LR chi2=3.28, p=0.07).

CONCLUSIONS

E-wave velocity before and after ECV appears to be a marker of short-term recurrence of AF.

The changing circumstance of atrial fibrillation - progress towards precision medicine

The prevalence of atrial fibrillation (AF) in the general population is between 1% and 2% in the developed world and is higher in men than in women. The arrhythmia occurs much more commonly in the elderly, and the estimated lifetime risk of developing AF is one in four for men and women aged 40 years and above. Projected data from multiple population-based studies in the USA and Europe predict a two- to threefold increase in the number of AF patients by 2060. The high lifetime risk of AF and increased longevity underscore the important public health burden posed by this arrhythmia worldwide. AF has multiple aetiologies and a broad variety of presentations. The primary pathologies underlying or promoting the occurrence of AF vary more than for any other cardiac arrhythmia, ranging from autonomic imbalance to organic heart disease and metabolic disorders, such as diabetes mellitus, metabolic syndrome, hyperthyroidism and kidney disease, and lifestyle factors such as smoking, alcohol consumption and participation in endurance sports. Biomarkers are increasingly being investigated and, together with clinical and genetic factors, will eventually lead to a clinically valuable detailed classification of AF which will also incorporate pathophysiological determinants and mechanisms of the arrhythmia. In turn, this will allow the development and application of precision medicine to this troublesome arrhythmia.

Plasma B-type natriuretic peptide levels are poorly related to the occurrence of ischemia or ventricular arrhythmias during symptom-limited exercise in low-risk patients

INTRODUCTION

The usefulness of B-type natriuretic peptide (BNP) as a marker of ischemia is controversial. BNP levels have predicted arrhythmias in various settings, but it is unknown whether they are related to exercise-induced ischemic ventricular arrhythmias.

MATERIAL AND METHODS

We analyzed in 63 patients (64 ±14 years, 65% male, 62% with known coronary disease) undergoing exercise stress single-photon emission computed tomography (SPECT) the association between plasma BNP values (before and 15 min after exercise) and the occurrence of ischemia or ventricular arrhythmias during the test.

RESULTS

Exercise test (8.1 ±2.7 min, 7.4 ±8.1 metabolic equivalents, 82 ±12% of maximal predicted heart rate) induced reversible perfusion defects in 23 (36%) patients. Eight (13%) patients presented significant arrhythmias (≥ 7 ventricular premature complexes/min, couplets, or non-sustained ventricular tachycardia during exercise or in the first minute of recovery). Median baseline BNP levels were 17.5 (12.4-66.4) pg/ml in patients developing scintigraphic ischemia and 45.6 (13.2-107.4) pg/ml in those without ischemia (p = 0.137). The BNP levels increased after exercise (34.4 (15.3-65.4)% increment over baseline, p < 0.001), but the magnitude of this increase was not related to SPECT positivity (35.7 (18.8-65.4)% vs. 27.9 (5.6-64.0)% in patients with and without ischemia, respectively, p = 0.304). No significant association was found between BNP values (at baseline or their change during the test) and ventricular arrhythmias.

CONCLUSIONS

Plasma BNP values - at baseline or after exercise - were not associated with myocardial ischemia or with ventricular arrhythmia during exercise SPECT. These results highlight the limited usefulness of this biomarker to assess acute ischemia.