The Role of N-terminal PRO-Brain Natriuretic Peptide and Echocardiography for Screening Asymptomatic Left Ventricular Dysfunction in a Population at High Risk for Heart Failure. The PROBE-HF Study

Association between left ventricular dysfunction, anemia, and chronic renal failure. Analysis of the Heart Failure Prevalence and Predictors in Turkey (HAPPY) cohort

BACKGROUND

Anemia and chronic renal failure (CRF) are frequent comorbidities in patients with heart failure (HF), and they have been reported to be associated with increased mortality and hospitalization rates. HF, anemia, and CRF have been reported to interact with each other forming a vicious cycle termed cardio-renal-anemia syndrome. The aim of the present study was to evaluate the association of HF, anemia, and CRF using data from the large-scale"Heart Failure Prevalence and Predictors in Turkey (HAPPY)" study.

PATIENTS AND METHODS

Among the HAPPY cohort, 3,369 subjects who had either left ventricular dysfunction (LVD) or normal left ventricular function on echocardiography or normal serum NT-proBNP levels were included in this analysis.

RESULTS

The prevalence of anemia and CRF was significantly higher in patients with LVD compared with subjects with normal ventricular function (20.7 % vs. 4.0 % and 19.0 % vs. 3.7 %, respectively; p < 0.001 for each). Binary logistic regression analyses for the presence of LVD, anemia, and CRF demonstrated that each one was an independent predictor for the presence of the others.

CONCLUSION

These findings point to the presence of cardio-renal-anemia syndrome and the necessity of treating these comorbidities in patients with HF.

Body mass index, gender, and clinical outcome among hypertensive and diabetic patients with stage A/B heart failure

OBJECTIVE

The existence of an "obesity paradox" in asymptomatic patients with preclinical heart failure (HF) has not been investigated. The prognostic value of BMI in a cohort of hypertensive and diabetic patients with stage A/B HF enrolled in the PROBE-HF study was explored.

DESIGN AND METHODS

BMI was measured in 1003 asymptomatic subjects (age 66.4 ± 7.8 years, 48% males) with hypertension and/or type 2 diabetes and no clinical evidence of HF. Predefined endpoints were all-cause mortality and a composite of death and hospitalization for cardiac causes.

RESULTS

During a follow-up of 38.5 ± 4.1 months, 33 deaths were observed. Mortality in the normal BMI group (1.6 deaths per 100 patient-years) did not differ to that in the overweight group (1.1 per 100 patient-years, p = 0.31), but was higher than that in the obese group (0.4 per 100 patient-years, p = 0.0089). In multivariable analysis, obesity (hazard ratio [HR] 0.27 [0.09-0.85], p = 0.025) but not overweight (HR 0.68 [0.32-1.45], p = 0.32) was associated with lower risk of death. Obesity was also independently associated with reduced risk of the composite endpoint (HR 0.54 [0.28-0.99], p = 0.047).

CONCLUSION

In asymptomatic hypertensive and diabetic patients with preclinical HF, obesity is associated with better survival and reduced risk of events.

Diffuse myocardial fibrosis in the systemic right ventricle of patients late after Mustard or Senning surgery: an equilibrium contrast cardiovascular magnetic resonance study

AIMS

After atrial redirection surgery (Mustard-Senning operations) for transposition of the great arteries (TGA), the systemic right ventricle (RV) suffers from late systolic failure with high morbidity and mortality. Mechanisms of late RV failure are poorly characterized. We hypothesized that diffuse interstitial expansion representing diffuse fibrosis is greater in systemic RVs of patients following Mustard-Senning surgery and that it would be associated with other markers of heart failure and disease severity.

METHODS AND RESULTS

We used equilibrium contrast cardiovascular magnetic resonance (CMR) imaging to quantify extracellular volume (ECV) in the septum and RV free wall of 14 adults presenting to a specialist clinic late after surgery for TGA (8 Mustard, 6 female, median age 33). These were compared with 14 age-and sex-matched healthy volunteers. Patients were assessed with a standardized CMR protocol, NT-brain natriuretic peptide (NT-proBNP), and cardiopulmonary exercise (CPEX) testing. The mean septal ECV was significantly higher in patients than controls (0.254 ± 0.036 vs. 0.230 ± 0.032; P = 0.03). NT-proBNP positively related to septal ECV (P = 0.04; r = 0.55). The chronotropic index (CI) during CPEX testing negatively related to the ECV (P = 0.04; r = -0.58). No relationship was seen with other CMR or CPEX parameters. R.V free wall ECV was difficult to measure (heavy trabeculation, sternal wires, blood pool in regions of interest) with high and poor inter-observer reproducibility: this analysis was abandoned.

CONCLUSION

Septal interstitial expansion is seen in adults late after atrial redirection surgery for TGA. It correlates well with NT-proBNP and CI and may have a role in the development of RV systolic impairment. Measuring interstitial expansion in the RV free wall is difficult using this methodology.

Association of N-terminal pro-B-type natriuretic peptide with left ventricular structure and function in chronic kidney disease (from the Chronic Renal Insufficiency Cohort [CRIC])

We evaluated the cross-sectional associations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) with cardiac structural and functional abnormalities in a cohort of patients with chronic kidney disease without clinical heart failure, the Chronic Renal Insufficiency Cohort (n = 3,232). The associations of NT-proBNP with echocardiographically determined left ventricular (LV) mass and LV systolic and diastolic function were evaluated using multivariate logistic and linear regression models. Reclassification of participants' predicted risk of LV hypertrophy (LVH), systolic and diastolic dysfunction was performed using a category-free net reclassification improvement index that compared a clinical model with and without NT-proBNP. The median NT-proBNP was 126.6 pg/ml (interquartile range 55.5 to 303.7). The greatest quartile of NT-proBNP was associated with a nearly threefold odds of LVH (odds ratio 2.7, 95% confidence interval [CI] 1.8 to 4.0) and LV systolic dysfunction (odds ratio 2.7, 95% CI 1.7 to 4.5) and a twofold odds of diastolic dysfunction (odds ratio 2.0, 95% CI 1.3 to 2.9) in the fully adjusted models. When evaluated alone as a screening test, NT-proBNP functioned modestly for the detection of LVH (area under the curve 0.66) and LV systolic dysfunction (area under the curve 0.62) and poorly for the detection of diastolic dysfunction (area under the curve 0.51). However, when added to the clinical model, NT-proBNP significantly reclassified participants' likelihood of having LVH (net reclassification improvement 0.14, 95% CI 0.13-0.15; p <0.001) and LV systolic dysfunction (net reclassification improvement 0.28, 95% CI 0.27 to 0.30; p <0.001) but not diastolic dysfunction (net reclassification improvement 0.10, 95% CI 0.10 to 0.11; p = 0.07). In conclusion, in this large chronic kidney disease cohort without heart failure, NT-proBNP had strong associations with prevalent LVH and LV systolic dysfunction.

N-terminal B-type natriuretic peptide and the association with left ventricular diastolic function in a population at high risk of incident heart failure: results of the SCReening Evaluationof the Evolution of New-Heart Failure Study (SCREEN-HF)

AIMS

Impaired diastolic function is associated with increased morbidity and mortality, but antecedents and predictors of progression to heart failure (HF) are not well understood. We examined associations between NT-proBNP, HF risk factors, and diastolic function in a population at high risk for incident HF.

METHODS AND RESULTS

A total of 3550 subjects at high risk for incident HF (≥60 years plus ≥1 HF risk factor), but without pre-existing HF or LV dysfunction were recruited. Participants at highest risk (n = 664) (NT-proBNP in the highest quintile >254 pg/mL) underwent echocardiography. Moderate or severe diastolic dysfunction was observed in 25% [95% confidence interval (CI) 21-29%] of participants. Age (P = 0.001), male gender (P = 0.03), diabetes (P = 0.03), and NT-proBNP (P = 0.002) were associated with severity of diastolic dysfunction after adjustment for HF risk factors and LVEF. In regression analysis, log-transformed NT-proBNP was also associated with LV mass index (P = 0.05), left atrial size (P < 0.0001), and Doppler ratio of the mitral valve E/e' (P = 0.001). Multiple HF risk factors were present in the majority of participants (>70%), but no association was observed between diastolic dysfunction and the number of risk factors reported (P = 0.3).

CONCLUSION

Diastolic dysfunction was observed in one in four of these high risk subjects (≥ 60 years, HF risk factor, NT-proBNP >254 pg/mL). NT-proBNP, age and diabetes were strongly associated with severity of diastolic dysfunction, whereas other HF risk factors and LVEF were not. More targeted surveillance using a combination of risk factors and biomarkers may improve identification of those at great risk of incident HF.

Using NT-proBNP to Detect Chronic Heart Failure in Elderly Patients with Chronic Obstructive Pulmonary Disease

Objective. To detect chronic heart failure in elderly patients with a registered diagnosis of chronic obstructive pulmonary disease (COPD) treated in Swedish primary health care using natriuretic peptide NT-proBNP. Design. A cross-sectional study. Setting. Two primary health care centres in southeastern Sweden each with about 9000 listed patients. Subjects. Patients aged 65 years and older with a registered diagnosis of COPD. Main Outcome Measures. Percentage of patients with elevated NT-proBNP, percentage of patients with abnormal left ventricular function assessed by echocardiography, and association between elevated NT-proBNP and symptoms, signs, and electrocardiography. Results. Using NT-proBNP threshold of 1200 pg/mL, we could detect and confirm chronic heart failure in 5.6% of the study population with concurrent COPD. An elevated level of NT-proBNP was only associated with nocturia and abnormal electrocardiography. Conclusions. We found considerably fewer cases of heart failure in patients with COPD than could be expected from the results of previous studies. Our study shows the need for developing improved strategies to enhance the validity of a suspected heart failure diagnosis in patients with COPD.

Brain natriuretic Peptide production and secretion in inflammation

Gene expression and secretion of the cardiac polypeptide hormones atrial natriuretic factor (ANF) and brain natriuretic peptide (BNP) are simultaneously upregulated in various cardiac disorders such as congestive heart failure, ischemic heart disease, and hypertensive heart disease, in which hemodynamic or neuroendocrine changes are key components in the progression of disease. However, during acute cardiac allograft rejection, plasma BNP levels are increased but not those of ANF. Successful treatment of the rejection episode decreases the elevated plasma BNP to prerejection values suggesting that substances related to inflammation may selectively influence BNP gene expression. Indeed, cytokines such as TNFα and IL-1β selectively stimulate cardiac BNP at the transcriptional and translational levels in cardiomyocyte cultures without affecting ANF. This selective BNP increase is seen in vivo, in addition to acute cardiac allograft rejection, in several circumstances where inflammation significantly contributes to the pathogenesis of disease such as in sepsis and in acute myocarditis.

Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department

STUDY OBJECTIVE

We examine the point prevalence of subclinical hypertensive heart disease in a cohort of urban emergency department (ED) patients with elevated blood pressure.

METHODS

A convenience sample of hypertensive (blood pressure ≥ 140/90 mm Hg on 2 measurements) patients aged 35 years or older with no history of cardiac or renal disease who presented to a single urban ED and were asymptomatic from a cardiovascular perspective (ie, no symptoms of dyspnea or chest pain) were enrolled. All patients underwent a standardized evaluation (including echocardiography), and subclinical hypertensive heart disease was defined by the presence of one or more of the following criterion-based echocardiographic [corrected] findings: left-ventricular hypertrophy, systolic dysfunction, or diastolic dysfunction.

RESULTS

A total of 161 patients were included. Mean age was 49.8 years (SD 8.3 years), 93.8% were black, and 51.6% were men. Nearly all (93.8%) had a history of hypertension, and many (68.3%) were receiving antihypertensive therapy at baseline. Mean systolic and diastolic blood pressures were 183.9 mm Hg (SD 25.1 mm Hg) and 109.5 mm Hg (SD 14.4 mm Hg), respectively. Subclinical hypertensive heart disease was found in 146 patients (90.7%; 95% confidence interval [CI] 85.2% to 94.3%), with most (n=131) displaying evidence of diastolic dysfunction (89.7%; 95% CI 83.7% to 93.7%). Left-ventricular hypertrophy was also common (n=89; 61.0%; 95% CI 52.9% to 68.5%) and was often (but not exclusively) present in those with diastolic filling abnormalities (n=75; 57.3%; 95% CI 48.7% to 65.4%).

CONCLUSION

In our largely black cohort of ED patients with elevated blood pressure, subclinical hypertensive heart disease was highly prevalent, suggesting the need for coordinated efforts to reduce cardiac consequences of hypertension in such inner-city communities.

Update on diabetic cardiomyopathy: inches forward, miles to go

Diabetes causes cardiomyopathy, both directly and by potentiating the effect of its common comorbidities, coronary artery disease and hypertension, on its development. With the common and growing prevalence of diabetes worldwide, diabetic cardiomyopathy is a significant public health problem. Recent research identifies both mitochondrial dysfunction and epigenetic effects as newly recognized factors in the complex pathogenesis of diabetic cardiomyopathy. Diagnostically, specialized echocardiography techniques, cardiac magnetic resonance imaging, and serologic biomarkers all appear to have promise in detecting the early stages of diabetic cardiomyopathy. Research into treatments includes both traditional diabetes and heart failure therapies, but also explores the potential of newer metabolic and anti-inflammatory agents. These recent insights provide important additions to our knowledge about diabetic cardiomyopathy, but much remains unknown.

Cardiac biomarkers: new tools for heart failure management

The last decade has seen exciting advances in the field of biomarkers used in managing patients with heart failure (HF). Biomarker research has broadened our knowledge base, shedding more light on the underlying pathophysiological mechanisms occurring in patients with both acute and chronic HF. The criterion required by an ideal cardiovascular biomarker has been progressively changing to an era of sensitive assays that can be used to guide treatment. Recent technological advances have made it possible to rapidly measure even minute amounts of these proteins by means of higher sensitivity assays. With a high prevalence of comorbidities associated with HF, an integrated approach utilizing multiple biomarkers have shown promise in predicting mortality, better risk stratification and reducing re-hospitalizations, thus lowering health-care costs. This review provides a brief insight into recent advances in the field of biomarkers currently used in the diagnosis and prognosis of patients with acute and chronic HF.

Association of left ventricular diastolic dysfunction with elevated NT-proBNP in type 2 diabetes mellitus patients with preserved ejection fraction: the supplemantary role of tissue doppler imaging parameters and NT-proBNP levels

BACKGROUND

Early diagnosis of cardiovascular disease in diabetic patients may be important to introduce treatment early. Echocardiography is a method used to show the ventricular functions. A ventricular hormone, BNP is used to identify the changes in the ventricular function in early period. NT-proBNP which is a more stable compound with a longer half-life is used in measurement of BNP.

METHODS

Left ventricular diastolic dysfunction (LVDD) was detected and NT-proBNP levels were measured in forty-four asymptomatic patients with ages of 30-70 and type 2 DM and control group consisted of 40 healthy individuals from the same age group.

RESULTS

NT-proBNP levels were found as 566.7 ± 738.5 pg/ml in the diabetics with LVDD detected, 166.3 ± 137.1 pg/ml in the diabetics without LVDD and 134.5 ± 77.2 pg/ml in the control group. Levels of NT-proBNP were significantly higher in the group with left ventricular diastolic dysfunction (p<0.05). However, when the levels of NT-proBNP in the diabetic patients without LVDD were compared with the controls, the difference was not significant (p>0.05). NT-proBNP levels were found significantly higher in LVDD group compared to the controls without a difference between the ejection fractions (p<0.05).

CONCLUSION

High levels of NT-proBNP was correlated tissue Doppler echocardiography findings in type 2 DM patients with preserved ejection fraction.

Blood signature of pre-heart failure: a microarrays study

BACKGROUND

The preclinical stage of systolic heart failure (HF), known as asymptomatic left ventricular dysfunction (ALVD), is diagnosed only by echocardiography, frequent in the general population and leads to a high risk of developing severe HF. Large scale screening for ALVD is a difficult task and represents a major unmet clinical challenge that requires the determination of ALVD biomarkers.

METHODOLOGY/PRINCIPAL FINDINGS

294 individuals were screened by echocardiography. We identified 9 ALVD cases out of 128 subjects with cardiovascular risk factors. White blood cell gene expression profiling was performed using pangenomic microarrays. Data were analyzed using principal component analysis (PCA) and Significant Analysis of Microarrays (SAM). To build an ALVD classifier model, we used the nearest centroid classification method (NCCM) with the ClaNC software package. Classification performance was determined using the leave-one-out cross-validation method. Blood transcriptome analysis provided a specific molecular signature for ALVD which defined a model based on 7 genes capable of discriminating ALVD cases. Analysis of an ALVD patients validation group demonstrated that these genes are accurate diagnostic predictors for ALVD with 87% accuracy and 100% precision. Furthermore, Receiver Operating Characteristic curves of expression levels confirmed that 6 out of 7 genes discriminate for left ventricular dysfunction classification.

CONCLUSIONS/SIGNIFICANCE

These targets could serve to enhance the ability to efficiently detect ALVD by general care practitioners to facilitate preemptive initiation of medical treatment preventing the development of HF.

N-terminal pro-b-type natriuretic peptide and left atrial function in patients with congestive heart failure and severely reduced ejection fraction

AIMS

Amino-terminal portion of pro-B-type natriuretic peptide (NT-pro-BNP) is a valuable diagnostic and prognostic marker in congestive heart failure (CHF). In CHF patients, elevation of natriuretic peptide levels correlate with decreased left ventricular (LV) ejection fraction (EF) and increased left atrial (LA) volumes, but a correlation with LA function that is a determinant of haemodynamic and clinical status in CHF with independent prognostic value has never been investigated. Aim of this study was to evaluate the relationship between cardiac neurohormonal activation and LA function in patients with CHF due to dilated cardiomyopathy.

METHODS AND RESULTS

One hundred and one patients (86% males; mean age, 64 ± 11 years) with dilated ischaemic or non-ischaemic cardiomyopathy, LV EF ≤45% (mean LV EF, 33 ± 8%), and New York Heart Association class II-IV underwent transthoracic echocardiography to evaluate LA fractional active and total emptying from M- and B-Mode images, and, on the same day, venous blood sample collection to dose NT-pro-BNP. By univariate analyses, NT-pro-BNP significantly correlated to age, LA dimensions, LA function indexes, EF, and functional class. At multivariate analysis, LV EF and M- or B-Mode indexes of LA function were the only independent predictors of NT-pro-BNP values. A NT-pro-BNP cut-off of 1480 pg/mL identified LA dysfunction with 89% specificity and 54% sensitivity.

CONCLUSION

In CHF patients with severely impaired systolic function, NT-pro-BNP levels reflect LA and LV dysfunction. These data should prompt studies to investigate the relationship between changes of LA function and NT-pro-BNP levels and their clinical value as prognostic and therapeutic targets in CHF.

[Validity and usefulness of B-type natriuretic peptide (BNP) for early detection of left ventricular dysfunction in high-risk patients in primary care]

OBJECTIVE

The aim of this study was to determine the accuracy of BNP test for early diagnosis of left ventricular dysfunction in patients at high-risk for heart failure.

DESIGN

Cross-sectional descriptive study.

SETTING

7 Primary Care Centres in Madrid (Spain).

PARTICIPANTS

A consecutive sample of 204 consecutive asymptomatic patients with high risk for heart failure (Stages A-B, AHA/ACC Classification).

MAIN MEASUREMENTS

BNP plasma levels were measured in the clinical setting using Triage BNP Test(®) (Biosite(®)) and an echocardiography was performed in the following 3 days in a single hospital unit as a reference standard. Plasma BNP levels were compared depending on the presence/absence of left ventricular dysfunction (LVD), type and severity degree. Sensitivity, specificity, positive and negative predictive values, and Área under the receiver operating characteristic curve (ROC) for BNP assay were calculated.

RESULTS

BNP values were significantly higher (P<.001) in patients with left ventricular systolic dysfunction (LVSD). No significant differences were found for diastolic dysfunction. The best cut-off value to discriminate the patients with LVSD was 71.00 pg/ml, with an Área under the ROC curve of 0.757 (95% CI 0.64-0.87). Sensitivity for LVD diagnosis was 75% (95% CI 50.66-99.34), specificity 70.19% (95% CI 62.81-77.57), positive predictive value (PPV) 20% (95% CI 9.05-30.95), and negative predictive value (NPV) 96.58% (95% CI 92.86-100), with LVSD prevalence of 9.04% in this population.

CONCLUSIONS

BNP determinations are of value in diagnosing LVSD in a primary care setting, with similar sensitivities and specificities. Due to the high NPV is useful to rule-out patients for echocardiography.

Age and gender differences in the association between Nt-proBNP and glucometabolic disturbances

OBJECTIVES

Glucometabolic disturbances are associated with myocardial dysfunction. Brain natriuretic peptides (BNP) are used for detecting myocardial dysfunction in clinical practice. However, studies on elderly subjects and gender-specific analyses are sparse.

DESIGN

We examined cross-sectional associations between Nt-proBNP and 1) fasting plasma glucose (FPG), and 2) categories of glucometabolic disturbances, in middle-aged and older subjects (1266 men, 526 women), applying multivariate linear regression analysis.

RESULTS

FPG was positively correlated with Nt-proBNP among middle-aged men (p = 0.04) and negatively albeit non-significantly (p = 0.1) among middle-aged women. Weaker non-significant correlations were seen among older subjects. Middle-aged men with new-onset and prevalent diabetes had higher Nt-proBNP than the reference group (FPG ≤5.0 mmol/L): 9.53 (p = 0.002) and 8.23 (p = 0.02) vs. 5.71 pmol/L. No differences in Nt-proBNP between categories of glucometabolic disturbance were observed among older men or women.

CONCLUSIONS

The results indicate an age- and gender difference in the ability of Nt-proBNP to identify myocardial dysfunction in relation to glucometabolic disturbances. Therefore, Nt-proBNP should be used with caution as a general surrogate marker for myocardial dysfunction in this setting.

B-type natriuretic peptides: looking to the future

Whereas the role of the cardiac natriuretic peptides, ANP and BNP, in some aspects of physiology and pathophysiology is clear, their potential in diagnosis, prognosis, and therapeutics in many clinical disorders remains uncertain. We predict that circulating levels of these peptides will find increasing diagnostic utility in patients presenting with dyspnoea, in guiding the complex pharmacotherapy in heart failure, and may likewise be useful in guiding the management of patients on chronic maintenance renal dialysis. We predict also that levels of these peptides will be of practical use as prognostic indicators in 'at-risk' populations (such as those with diabetes, coronary heart disease, hypertension, thalassaemia, etc.) but probably not in the general population. It appears likely that administration of these peptides will find a place in the therapeutics of acute myocardial infarction, but this is less clear for heart failure. We describe the presence of a segment of the signal peptide for BNP within the circulation and discuss its potential clinical utility.

The diagnostic significance of the plasma N-terminal pro-B-type natriuretic Peptide concentration in asymptomatic cats with cardiac enlargement

We evaluated the diagnostic significance of the N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration in asymptomatic cats with cardiac enlargement. The plasma NT-proBNP concentration was measured in 21 clinically healthy control cats, and 67 asymptomatic cats with cardiac enlargement defined as end-diastolic interventricular septum thickness (IVSd) and/or diastolic left ventricular posterior wall thickness (LVPWd) >0.6 cm, vertebla heart scale (VHS) >7.8, and/or left atria/aorta ratio (LA/Ao) >1.5. The plasma NT-proBNP concentration in the asymptomatic cats with cardiac enlargement (median: 662.0, range: 24.0-2,449.0 pmol/l) was significantly higher than that in the controls (24.0, 24.0-95.0 pmol/l, P<0.001). The plasma NT-proBNP concentration was significantly correlated with the VHS, LA/Ao, IVSd and LVPWd (r=0.578, P<0.001; r=0.462, P<0.001; r=0.563, P<0.001; and r=0.764, P<0.001, respectively). Receiver operating characteristic analysis showed a cut-off value of 95.0 pmol/l for the detection of asymptomatic cats with cardiac enlargement, sensitivity and specificity of 88.1 and 100%, respectively, and an area under the curve of 0.971. These results suggest that the determination of the plasma NT-proBNP concentration can be a useful screening test for asymptomatic cats with cardiac enlargement.

Prognostic utility of NT-proBNP in acute exacerbations of chronic pulmonary diseases

BACKGROUND

The prognostic value of NT-proBNP levels in patients admitted to hospital due to acute exacerbations of chronic pulmonary diseases (CPDs) is unknown.

SETTING

Internal Medicine units at two general hospitals.

METHODS

NT-proBNP levels were obtained within 72 h after admission in 192 consecutive patients with acute exacerbations of CPDs and no history of heart failure or diuretic treatment. Clinical characteristics and main outcomes were assessed over a 12-month follow-up. NT-proBNP cut-points for outcomes were obtained by ROC (receiver operating characteristics) curve analysis.

RESULTS

Chronic obstructive lung disease (69.3%) and chronic asthma (22.4%) were the most prevalent CPDs, and non-pneumonic acute respiratory infection (72.4%) and pneumonia (22.9%) were the most frequent causes of exacerbation. Atrial flutter or fibrillation rate was 11%. During the one-year follow-up period, 22 patients died, 42 were re-admitted, 46 received new long-term oxygen therapy, and 39 received new diuretic treatment. NT-proBNP values correlated with hospitalisation days. NT-proBNP values over 587.9 pg/ml were associated with significantly raised one-year mortality (OR=3.90; 95% IC 1.46-10.47; p=0.006) and over 782.2 pg/ml with cardio-pulmonary deaths (OR=6.38; 95% IC 1.91-21.3; p=0.002). That association persisted after adjustment for age, gender, creatinine levels and cardiac rhythm. NT-proBNP values over 628.7 pg/ml were associated with significantly higher probability of new diuretic treatment (OR=4.38; IC 95% 2.07-9.25; p<0.001). The negative predictive values for these cut-points ranged from 89% to 97%.

CONCLUSION

NT-proBNP levels below 587.9 pg/ml in patients with acute exacerbations of CPD were associated with favourable one-year outcomes.

Early diagnosis of left ventricular diastolic dysfunction in diabetic patients: a possible role for natriuretic peptides

Background

The aim of the present study was to verify whether BNP might detect pre-clinical diastolic dysfunction (LVDD) in type-2 diabetic patients.

Methods

One-hundred and twenty-seven consecutive outpatients with type-2 diabetes mellitus were enrolled into the study. Subjects with overt heart failure or NYHA class > 1, history of coronary artery disease, severe valvulopathy or chronic atrial fibrillation were excluded from the study. All patients underwent clinical evaluation, laboratory assessment of brain natriuretic peptide (BNP) and echocardiographic examination.

Results

No patients showed systolic impairment of left ventricular function, whereas diastolic dysfunction was detected in 53 (42%) cases (all impaired relaxation). Median BNP was 27 pg/ml without any significant difference between 76 patients with normal left ventricular function and 53 with diastolic dysfunction; in 54 (43%) patients showing HBA1C≥8 (uncontrolled diabetes) normal function was found in 32 and diastolic dysfunction in 22, with a significant difference of BNP at multivariate analysis (OR = 1.02, 95%CI = 1.05-1.09, p = 0.003). In uncontrolled diabetic cohort, BNP was a strong predictor for LVDD (OR = 2.7, 95%CI = 1.3-5.6, p = 0.006) along with the duration of diabetes (OR = 1.6, 95%CI = 1.1-2.9, p = 0.046). BNP > 25 pg/ml was a cut-off value with high accuracy to detect a LVDD.

Discussion

Early screening of high-risk patients for diabetic cardiomyopathy development might be useful to better control glycemic profile in order to reduce heart disease progression or even to reverse it

Conclusions

BNP could be a cheap, easy and useful tool to screen those ones with preclinical ventricular diastolic dysfunction in a subset of patients particularly prone to develop cardiovascular complications, like uncontrolled diabetic patients.

Postoperative increase in B-type natriuretic peptide levels predicts adverse outcome after cardiac surgery

OBJECTIVE

To evaluate the prognostic implication of changes in postoperative B-type natriuretic peptide (BNP) concentrations in patients undergoing cardiopulmonary bypass for cardiac surgery.

DESIGN

A retrospective analysis of prospectively collected clinical data.

SETTING

Cardiothoracic surgery and an intensive care unit (ICU) in a university hospital.

PARTICIPANTS

The present study included a total of 407 consecutive patients undergoing cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

BNP concentrations were measured on admittance to the ICU (D0) and at day 1 after surgery. Patients were divided into quintiles according to their BNP level on admittance to the ICU. The predictive value of absolute changes in BNP levels during the first 24 hours postoperatively was analyzed with Kaplan-Meier estimates of survival and Cox multivariate proportional analysis. Prognostic factors for impaired midterm survival included elevation of the BNP level (HR, 7.3/ log10(x); 95% confidence interval, 1.8-29, p = 0.005). The BNP levels of patients undergoing isolated valve surgery or valve and concomitant CABG surgery were significantly higher (p = 0.012 and p = 0.032, respectively) than those undergoing isolated coronary artery bypass graft surgery. Patients in higher quintiles required ventilation for a longer time (p < 0.001), and prolonged inotropic support (p < 0.001). The mean plasma BNP concentration of 172 pg/mL (median, 64; interquartile range, 172) on arrival at the ICU had a sensitivity of 75% and a specificity of 74% for predicting 1-year mortality.

CONCLUSIONS

Elevated BNP levels on admittance to the ICU and postoperatively increasing BNP levels are associated with adverse postoperative outcome and are predictive of impaired late survival. Sequential postoperative BNP monitoring facilitates the early identification of patients at an increased risk of heart failure and may be used as an adjunct for clinical decision making and optimized patient management.

Natriuretic Peptides and Assessment of Cardiovascular Disease Risk in Asymptomatic Persons

Current tools for cardiovascular disease (CVD) risk assessment in asymptomatic individuals are imperfect. Preventive measures aimed only at individuals deemed high risk by current algorithms neglect large numbers of low-risk and intermediate-risk individuals who are destined to develop CVD and who would benefit from early and aggressive treatment. Natriuretic peptides have the potential both to identify individuals at risk for future cardiovascular events and to help detect subclinical CVD. Choosing the appropriate subpopulation to target for natriuretic peptide testing will help maximize the performance and the cost effectiveness. The combined use of multiple risk markers, including biomarkers, genetic testing, and imaging or other noninvasive measures of risk, offers promise for further refining risk assessment algorithms. Recent studies have highlighted the utility of natriuretic peptides for preoperative risk stratification; however, cost effectiveness and outcomes studies are needed to affirm this and other uses of natriuretic peptides for cardiovascular risk assessment in asymptomatic individuals.

Chronic heart failure: contemporary diagnosis and management

Chronic heart failure (CHF) remains the only cardiovascular disease with an increasing hospitalization burden and an ongoing drain on health care expenditures. The prevalence of CHF increases with advancing life span, with diastolic heart failure predominating in the elderly population. Primary prevention of coronary artery disease and risk factor management via aggressive blood pressure control are central in preventing new occurrences of left ventricular dysfunction. Optimal therapy for CHF involves identification and correction of potentially reversible precipitants, target-dose titration of medical therapy, and management of hospitalizations for decompensation. The etiological phenotype, absolute decrease in left ventricular ejection fraction and a widening of QRS duration on electrocardiography, is commonly used to identify patients at increased risk of progression of heart failure and sudden death who may benefit from prophylactic implantable cardioverter-defibrillator placement with or without cardiac resynchronization therapy. Patients who transition to advanced stages of disease despite optimal traditional medical and device therapy may be candidates for hemodynamically directed approaches such as a left ventricular assist device; in selected cases, listing for cardiac transplant may be warranted.