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Wang AYM, Sanderson J, Sea MMM, Wang M, Lam CWK, Li PKT, Lui SF, Woo J. Important factors other than dialysis adequacy associated with inadequate dietary protein and energy intakes in patients receiving maintenance peritoneal dialysis. Am J Clin Nutr 2003; 77:834-41. [PMID: 12663280 DOI: 10.1093/ajcn/77.4.834] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anorexia that results in inadequate nutrient intake is considered one of the most important causes of malnutrition in dialysis patients. OBJECTIVE The objective was to determine factors other than dialysis adequacy that are associated with inadequate protein and energy intakes in patients receiving continuous ambulatory peritoneal dialysis. DESIGN Dietary protein and energy intakes were assessed with a food-frequency questionnaire in 266 patients, and factors other than dialysis adequacy that are potentially associated with reductions in energy and protein intakes were examined. RESULTS Only 39% of the patients had protein intakes > or = 1.2 g x kg(- 1) x d(- 1), and 26% had energy intakes > or = 126 kJ x kg(- 1) x d(- 1). Other than having a greater total urea clearance and glomerular filtration rate, patients with protein intakes > or = 1.2, as opposed to < 1.2, g x kg(- 1) x d(- 1) had lower high-sensitive C-reactive protein concentrations and fewer complications with volume overload (29% compared with 46%; P = 0.006). Patients with energy intakes > or = 126, as opposed to < 126, kJ x kg(- 1) x d(- 1) were younger, had lower high-sensitive C-reactive protein concentrations, and had a lower prevalence of diabetes (P = 0.006), atherosclerotic vascular disease (P = 0.020), and history of volume overload (P = 0.013). Multiple regression analysis showed that other than increasing age, diabetes, and total urea clearance, having a history of volume overload was independently associated with a 0.22-g x kg(- 1) x d(- 1)decrease in protein (P = 0.001) and a 13.07-kJ x kg(- 1) x d(- 1) decrease in energy intake (P = 0.006). CONCLUSION An important yet unrecognized association was observed between a history of volume overload and dietary intake in peritoneal dialysis patients.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, New Territories, China.
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102
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Yu CM, Fung WH, Lin H, Zhang Q, Sanderson JE, Lau CP. Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy. Am J Cardiol 2003; 91:684-8. [PMID: 12633798 DOI: 10.1016/s0002-9149(02)03404-5] [Citation(s) in RCA: 492] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Biventricular pacing results in left ventricular (LV) reverse remodeling in heart failure patients with wide QRS complexes. This study examines potential predictors of reverse remodeling. Echocardiography with tissue Doppler imaging was performed at baseline and 3 months after biventricular pacing in 30 patients (21 men and 9 women, mean age 62 +/- 14 years). There were 17 responders to reverse remodeling (defined as a reduction in LV end-systolic volume by >15%) and 13 nonresponders. Responders had significant improvement in 6-minute hall-walking distance (p = 0.006), metabolic equivalents (p = 0.02), peak oxygen uptake (p = 0.02), New York Heart Association functional class (p <0.001), and quality of life (p <0.001); an increase in the sphericity index (p = 0.007), ejection fraction (p <0.001), and diastolic filling time (p = 0.03); a decrease in myocardial performance index (p = 0.02), isovolumic relaxation time (p = 0.004), and mitral regurgitation (p = 0.007); and an improvement in systolic dyssynchrony (SD of the time to peak myocardial systolic contraction of the 12 LV segments as dyssynchrony index) (45.0 +/- 8.3 vs 32.5 +/- 14.5 ms, p = 0.003). In contrast, nonresponders only had a small degree of clinical improvement in New York Heart Association class (p = 0.03) and quality-of-life scores (p = 0.03), without any change in cardiac function, and worsening of systolic dyssynchrony (24.8 +/- 4.5 vs 34.1 +/- 13.5 ms, p = 0.02). When all the above factors were put into univariate and multivariate analyses models, systolic dyssynchrony was the only independent predictor of reverse remodeling (r = -0.76, p <0.001) (beta = -1.54, p = 0.007). A preimplant dyssynchrony index of 32.6 ms (+2 SDs from mean of 88 normal controls) was able to totally segregate responders from nonresponders of biventricular pacing. Thus, responders of LV reverse remodeling were associated with improvement in clinical status, cardiac function, and systolic synchronicity. Direct assessment of systolic synchronicity by tissue Doppler imaging is highly accurate in predicting responders to therapy.
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Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong.
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103
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Rodríguez AD, Isabel Amaro León M, Burillo Putze G. Péptido natriurético cerebral: diagnóstico y tratamiento. Med Clin (Barc) 2003. [DOI: 10.1016/s0025-7753(03)73711-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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104
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Gianni L, Grasselli G, Cresta S, Locatelli A, Viganò L, Minotti G. Anthracyclines. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS ANNUAL 2003. [DOI: 10.1016/s0921-4410(03)21002-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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105
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Hervas I, Osca J, Perez-Pastor JL, Quesada A, Arnau MA, Marti JF, Almenar L, Bello P, Mateo A. Radioimmunometric assay of natriuretic peptide type-B (BNP) in heart failure. Nucl Med Commun 2003; 24:61-9. [PMID: 12501021 DOI: 10.1097/00006231-200301000-00016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess the value of the radioimmunometric determination of natriuretic peptide type-B (brain natriuretic peptide, BNP) in the diagnosis and prognosis of heart failure, and to study the association between BNP and the clinical, analytical and echocardiographic variables associated with the evolution of heart failure. The study group included 169 patients (74 women and 95 men; mean, 66 years) with heart failure of different causes, admitted consecutively to our hospital. BNP levels were measured with a radioimmunometric assay (Shionora BNP Cis ) after day 3 of admission. Patients were also studied by echocardiography. A significant association between the cause of heart failure and the BNP concentration was found (patients with ischaemic disease had the highest BNP values). Systolic function was worse in patients with ischaemic disease or dilated cardiomyopathy. High BNP values were also associated with advanced functional class and male sex. Plasma creatinine correlated positively with plasma BNP. However, we found no significant association with the other clinical variables evaluated. Of the echocardiographic variables analysed, BNP correlated positively with the ventricular diameter and pulmonary artery systolic pressure, and inversely with the shortening fraction; patients with severely impaired systolic function had the highest BNP values. It can be concluded that BNP levels (by radioimmunometric assay) are increased in patients with heart failure, and increase in relation to left ventricular dysfunction and the severity of heart failure. The strong independent association of plasma BNP with the left ventricular ejection fraction, its stability and the low cost of measurement suggest that plasma BNP assay could become a routine test. BNP assay could be included as an important factor in clinical and therapeutic decision making, as it complements the information provided by other variables used in the diagnosis of heart failure.
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Affiliation(s)
- I Hervas
- Department of Nuclear Medicine, University Hospital La Fe, Valencia, Spain.
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106
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Gabrielli O, Puyó AM, De Rosa A, Armando I, Barontini M, Levin G. Atenolol improves ventricular function without changing plasma noradrenaline but decreasing plasma atrial natriuretic factor in chronic heart failure. AUTONOMIC & AUTACOID PHARMACOLOGY 2002; 22:261-8. [PMID: 12866806 DOI: 10.1046/j.1474-8673.2002.00266.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1 There is good evidence that beta-blockers improve ventricular function, disease progression and survival in patients with left ventricular systolic dysfunction. The aim of this study was to determine the effects of atenolol therapy on the sympathetic nervous system at rest and after ergometric exercise, on left ventricular function and on baseline plasma atrial natriuretic factor (ANF) in ambulatory patients with chronic heart failure (CHF). 2 Twenty-two patients [left ventricular ejection fraction (LVEF) <36%; New York Heart Association II-III] were studied before atenolol treatment. Because of cardiac events (new Hospital admission or death) only 13 patients completed 1 year of treatment. Baseline noradrenaline (NE) concentrations were similar in patients and controls while ANF was higher in patients than in controls (328 +/- 35 pg ml(-1) vs. 37 +/- 3 pg ml(-1); P<0.01). 3 Patients with events showed higher NE (540 +/- 87 pg ml(-1) vs. 303 +/- 44 pg ml(-1); P<0.01) and ANF (460 +/- 70 pg ml(-1) vs. 291 +/- 44 pg ml(-1); P<0.03) at rest; and greater NE response to exercise (2.003 +/- 525 pg ml(-1) vs. 694 +/- 121 pg ml(-1); P<0.005). Atenolol treatment improved LVEF (19.5 +/- 1.9% vs. 33 +/- 3.9%; P<0.001), increased exercise tolerance (9 +/- 3.2 min vs. 17 +/- 4.8 min; P<0.001) and decreased plasma ANF (292 +/- 42 pg ml(-1) vs. 133 +/- 35 pg ml(-1); P<0.01). 4 Reduced basal dihydroxyphenylglycol (DHPG)/NE ratio (3.4 +/- 0.46 vs. 4.3 +/- 0.35; P<0.01) was observed in patients compared with healthy volunteers. Atenolol increased DHPG plasma levels (1.398 +/- 129 pg ml(-1) vs. 913 +/- 86 pg ml(-1); P<0.005) but the DHPG/NE ratio during exercise was not modified after treatment, suggesting that re-uptake of released NE is not changed by beta-blocker treatment. 5 In conclusion, the fact that atenolol treatment improves ventricular dysfunction and clinical status without changing plasma NE levels in CHF patients, suggests that plasma NE is a poor surrogate measurement for cardiac sympathetic activity in this pathology. In addition, decrease in plasma ANF produced by atenolol treatment may reflect the improvement of ventricular function.
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Affiliation(s)
- O Gabrielli
- Sección Insuficiencia Cardíaca, División Cardiología, Hospital Juan A. Fernández, Buenos Aires, Argentina
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107
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Abstract
The natriuretic peptides and their role in neurohumoral regulation of the cardiovascular system have become the focus of considerable interest from the scientific and clinical community in recent years. BNP in particular has been shown to be an important diagnostic and prognostic marker of use in a wide range of applications. As measurement techniques develop and are refined, routine evaluation of serum levels of these markers is expected to become more widespread. We have reviewed the biochemistry of the natriuretic peptide family, their role in cardiovascular pathophysiology and the evidence supporting their use in the clinical setting.
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108
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McGeoch G, Lainchbury J, Town GI, Toop L, Espiner E, Richards AM. Plasma brain natriuretic peptide after long-term treatment for heart failure in general practice. Eur J Heart Fail 2002; 4:479-83. [PMID: 12167387 DOI: 10.1016/s1388-9842(02)00027-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
AIM Plasma brain natriuretic peptide (BNP) concentrations are known to have high sensitivity and specificity in the diagnosis of heart failure in newly symptomatic patients. The relationship of plasma BNP to cardiac function in stable patients on long-term established treatment for heart failure is unknown. Plasma BNP was assessed for its ability to predict echocardiographic abnormality in 100 patients receiving long-term treatment in general practice for a provisional diagnosis of heart failure. METHODS AND RESULTS BNP >35 pmol/l had a sensitivity and specificity of 69% and 67%, respectively, for a left ventricular ejection fraction of <45%. However, 19% of patients had an LVEF of below 45% whilst BNP was below 35 pmol/l. These patients, in whom a diagnosis of heart failure had been made years previously (mean 3.9 years), were all clinically stable on treatment. CONCLUSION These findings support the view that BNP can be restored to normal levels in well-compensated patients despite persisting significant systolic dysfunction and suggest that BNP assays may be helpful for monitoring adequacy of therapy. BNP assays will have limited utility in the diagnosis of cardiac impairment once anti-failure therapy is well established and symptoms have been abolished.
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Affiliation(s)
- Graham McGeoch
- Department of Public Health and General Practice, The Christchurch School of Medicine, University of Otago, New Zealand.
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109
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Nakamura T, Sakamoto K, Yamano T, Kikkawa M, Zen K, Hikosaka T, Kubota T, Azuma A, Nishimura T. Increased plasma brain natriuretic peptide level as a guide for silent myocardial ischemia in patients with non-obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2002; 39:1657-63. [PMID: 12020494 DOI: 10.1016/s0735-1097(02)01813-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We measured plasma atrial/brain natriuretic peptide (ANP/BNP) levels at rest and during exercise and correlated the results with various clinical findings, particularly with myocardial ischemia, in asymptomatic hypertrophic cardiomyopathy (HCM). BACKGROUND In patients with HCM, ANP and BNP levels are elevated and exercise-induced myocardial ischemia is common. However, it has not yet been elucidated how these levels at rest and their change with dynamic exercise are related to ischemia. METHODS Levels of ANP and BNP were measured at rest and at peak exercise during (99m)Tc-tetrofosmin scintigraphy in 31 asymptomatic patients with non-obstructive HCM and in 10 control subjects. RESULTS Levels of ANP and BNP at rest and the change of ANP and BNP levels (PG/ML) from rest to exercise were significantly greater in HCM than in control subjects (ANP: rest, 53.2 +/- 31.8 vs. 11.6 +/- 6.1; exercise, 114.5 +/- 74.8 vs. 28.3 +/- 23.4. BNP: rest, 156.7 +/- 104.1 vs. 9.8 +/- 9.6; exercise, 201.6 +/- 131.5 vs. 13.2 +/- 14.5). Septal perforator compression (SPC) and exercise-induced ischemia were observed, respectively, in 20 (64.5%) and in 19 (61.3%) patients with HCM. The increment of ANP during exercise was similar between HCM subgroups with or without inducible ischemia. However, BNP levels at rest and BNP increments during exercise were significantly greater in the HCM subgroup with inducible ischemia than in the subgroup without (rest, 190.5 +/- 116.2 vs. 103.1 +/- 48.3; exercise, 250.5 +/- 142.2 vs. 124.2 +/- 58.6). Multiple logistic regression analysis revealed that SPC and BNP levels at rest were independently associated with exercise-induced ischemia. CONCLUSIONS Measurement of plasma BNP levels at rest may be useful in predicting silent myocardial ischemia in HCM.
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Affiliation(s)
- Tomoki Nakamura
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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110
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Walther T, Schultheiss HP, Tschöpe C, Stepan H. Natriuretic peptide system in fetal heart and circulation. J Hypertens 2002; 20:785-91. [PMID: 12011627 DOI: 10.1097/00004872-200205000-00001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atrial natriuretic peptide, brain natriuretic peptide and C-type natriuretic peptide belong to a family of hormones that have diuretic, natriuretic and vasodepressor activity and play a part in pressure and volume homeostasis in adults. As little is known about the natriuretic peptides during cardiac maturation, this review summarizes current knowledge about the early expression of components of the natriuretic peptide system in the heart during embryonic and fetal development. The data indicate a functional importance of the fetal natriuretic peptide system, especially under pathophysiological conditions. Thus, in the fetus, the system fulfils important beneficial compensatory roles in cardiovascular disease, rather than in day-to-day pressure and volume homeostasis. In comparison with data on the relevance of natriuretic peptides in adults, those summarized here indicate a functional maturation of the natriuretic peptide system during ontogeny in mammals.
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Affiliation(s)
- Thomas Walther
- Department of Cardiology and Pneumology, Free University of Berlin, Germany.
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111
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Yu CM, Lin H, Yang H, Kong SL, Zhang Q, Lee SWL. Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction. Circulation 2002; 105:1195-201. [PMID: 11889013 DOI: 10.1161/hc1002.105185] [Citation(s) in RCA: 357] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The definition of diastolic heart failure (DHF) relies on the use of sensitive tools to exclude the presence of systolic dysfunction. The use of ejection fraction (EF) of 50% as the cutoff point may not be adequate to address such a task. We believe that systolic dysfunction is common in DHF. METHODS AND RESULTS Echocardiography with tissue Doppler imaging was performed in 339 subjects, of whom 92 had systolic heart failure (SHF) (EF<50%), 73 had DHF (EF > or = 50% with diastolic abnormalities on Doppler echocardiography), and 68 had isolated diastolic dysfunction (DD); 106 were normal control subjects. Regional myocardial velocity curves were constructed off-line with the use of a 6-basal, 6-midsegmental model. The peak regional myocardial sustained systolic (S(M)) and early diastolic (E(M)) velocities were significantly lower in patients with SHF, DHF, and DD than in control subjects in almost all the myocardial segments. Likewise, the mean S(M) (SHF<DHF<DD<control subjects; 3.3 plus/minus 1.0 < 4.6 plus/minus 1.3 < 5.4 plus/minus 1.0 < 6.3 plus/minus 1.0 cm/s; all P less-than-or-equal 0.001) and mean E(M) (SHF=DHF<DD<control subjects; 3.6 plus/minus 1.2 =3.9 plus/minus 1.3 < 5.3 plus/minus 1.6 < 7.2 plus/minus 1.7 cm/s; all P<0.001) from the six basal segments were decreased in all the disease groups. A mean S(M) of 4.4 cm/s (-2 SD of control subjects) predicted the presence of systolic dysfunction in 92% of patients with SHF, 52% with DHF, and 14% with DD. CONCLUSIONS Through the use of tissue Doppler imaging, systolic abnormalities were evident in patients previously labeled as DHF and to a much lesser extent, isolated DD. This indicates the common coexistence of systolic and diastolic dysfunction in a spectrum of different severity in the pathophysiological process of heart failure.
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Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
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112
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Nousiainen T, Vanninen E, Jantunen E, Puustinen J, Remes J, Rantala A, Vuolteenaho O, Hartikainen J. Natriuretic peptides during the development of doxorubicin-induced left ventricular diastolic dysfunction. J Intern Med 2002; 251:228-34. [PMID: 11886482 DOI: 10.1046/j.1365-2796.2002.00951.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate changes in plasma atrial natriuretic peptide (ANP), N-terminal pro-atrial natriuretic peptide (NT-pro-ANP) and brain natriuretic peptide (BNP) during the development of doxorubicin-induced left ventricular systolic and diastolic dysfunction as measured by echocardiography (ECHO). DESIGN Prospective study. SETTING University hospital. SUBJECTS Twenty-eight adult patients with non-Hodgkin's lymphoma, who received doxorubicin to the cumulative dose of 400-500 mg m(-2). MAIN OUTCOME MEASURES The relationship between plasma natriuretic peptides and systolic and diastolic ECHO indices after the cumulative doxorubicin doses of 200, 400 and 500 mg m(-2). RESULTS Left ventricular ejection fraction (LVEF, by 2D ECHO) decreased from 58 +/- 1.7 to 52.5 +/- 1.3% (P=0.036) and fractional shortening (FS) from 34.6 +/- 1.4 to 27.8 +/- 0.9% (P=0.002). Peak E wave velocity decreased from 63.3 +/- 3.2 to 51.3 +/- 2.6 cm s(-1) (P=0.008) resulting in a statistically nonsignificant decrease in E/A ratio from 1.08 +/- 0.01 to 0.85 +/- 0.07. A significant decrease was observed in the percentage of left ventricular filling during the 1/3 of diastole (1/3FF) from 42.2 +/- 1.7 to 36.5 +/- 2.0% (P < 0.001). LV end systolic diameter increased from 32 +/- 1 to 38 +/- 1 mm (P=0.011), whereas left atrial (LA) diameter remained unchanged. Peak filling rate decreased from 4.4 +/- 0.2 to 4.0 +/- 0.2 stroke volume s(-1) (SV s(-1)) (ns). Plasma levels of ANP increased from 16.4 +/- 1.3 to 22.7 +/- 2.4 pmol L(-1) (P=0.002), NT-pro-ANP from 288 +/- 22 to 380 +/- 42 pmol L(-1) (P=0.019) and BNP from 3.3 +/- 0.4 to 8.5 +/- 2.0 pmol L(-1) (P=0.020). There was a significant inverse correlation between the decrease in FS and the increases in plasma NT-pro-ANP (r= -0.524, P=0.018) and plasma BNP (r=0.462, P=0.04) and between the decrease in PFR and the increases in plasma ANP (r= -0.457, P=0.043) and plasma NT-pro-ANP (r= -0.478, P=0.033). Furthermore, after doxorubicin therapy, significant inverse correlations were observed between E/A ratio and plasma ANP (r= -0.535, P=0.008), between E/A ratio and plasma NT-pro-ANP (r= -0.432, P=0.04) and between E/A ratio and plasma BNP (r= -0.557, P=0.006) as well as between 1/3FF and plasma BNP (r= -0.493, P=0.017). There was also a trend for correlation between LA diameter and plasma BNP (r=0.395, P=0.062) and peak E wave velocity and plasma BNP (r= -0.414, P=0.05), respectively. However, no significant correlations were observed between any of the systolic parameters and natriuretic peptide levels. CONCLUSIONS The results of this prospective study show that during the evolution of doxorubicin-induced LV dysfunction the secretion of natriuretic peptides is more closely associated with the impairment of left ventricular diastolic filling than with the deterioration of LV systolic function.
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Affiliation(s)
- T Nousiainen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.
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113
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Lubien E, DeMaria A, Krishnaswamy P, Clopton P, Koon J, Kazanegra R, Gardetto N, Wanner E, Maisel AS. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002; 105:595-601. [PMID: 11827925 DOI: 10.1161/hc0502.103010] [Citation(s) in RCA: 540] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although Doppler echocardiography has been used to identify abnormal left ventricular (LV) diastolic filling dynamics, inherent limitations suggest the need for additional measures of diastolic dysfunction. Because data suggest that B-natriuretic peptide (BNP) partially reflects ventricular pressure, we hypothesized that BNP levels could predict diastolic abnormalities in patients with normal systolic function. METHODS AND RESULTS We studied 294 patients referred for echocardiography to evaluate ventricular function. Patients with abnormal systolic function were excluded. Cardiologists making the assessment of LV function were blinded to BNP levels. Patients were classified as normal, impaired relaxation, pseudonormal, and restrictivelike filling patterns. Patients diagnosed with evidence of abnormal LV diastolic function (n=119) had a mean BNP concentration of 286 +/- 31 pg/mL; those in the normal LV group (n=175) had a mean BNP concentration of 33 +/- 3 pg/mL. Patients with restrictive like filling patterns on echocardiography had the highest BNP levels (408 +/- 66 pg/mL), and patients with symptoms had higher BNP levels in all diastolic filling patterns. The area under the receiver-operating characteristic curve for BNP to detect any diastolic dysfunction was 0.92 (95% CI, 0.87 to 0.95; P<0.001). A BNP value of 62 pg/mL had a sensitivity of 85%, a specificity of 83%, and an accuracy of 84% for detecting diastolic dysfunction. CONCLUSIONS A rapid assay for BNP can reliably detect the presence of diastolic abnormalities on echocardiography. In patients with normal systolic function, elevated BNP levels and diastolic filling abnormalities might help to reinforce the diagnosis diastolic dysfunction.
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Affiliation(s)
- Emily Lubien
- Division of Cardiology, Department of Medicine, Veteran's Affairs Medical Center, and University of California, San Diego, USA
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114
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Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, Lin H, Kong SL, Lam YM, Hill MRS, Lau CP. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation 2002; 105:438-45. [PMID: 11815425 DOI: 10.1161/hc0402.102623] [Citation(s) in RCA: 734] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biventricular pacing has been proposed to improve symptoms and exercise capacity in patients with advanced heart failure and wide electrocardiographic wave complexes. This study investigated the effect of biventricular pacing on reverse remodeling and the underlying mechanisms. METHODS AND RESULTS Twenty-five patients with NYHA class III to IV heart failure and electrocardiographic wave complex duration >140 ms receiving biventricular pacing therapy were assessed serially up to 3 months after pacing and when pacing was withheld for 4 weeks. Tissue Doppler echocardiography was performed using a 6-basal, 6-mid segmental model to assess the time to peak sustained systolic contraction (T(S)). There was significant improvement of ejection fraction, dP/dt, and myocardial performance index; decrease in mitral regurgitation, left ventricular (LV) end-diastolic (205+/-68 versus 168+/-67 mL, P<0.01) and end-systolic volume (162+/-54 versus 122+/-42 mL, P<0.01); and improved 6-minute hall-walk distance and quality of life score after pacing for 3 months. The mechanisms of benefits were as follows: (1) improved LV synchrony, as evident by homogeneous delay of T(S) to a timing close to the latest (usually the lateral) segment abolishing the intersegmental difference in T(S) and decreasing the standard deviation of T(S) within the left ventricle (37.7+/-10.9 versus 29.3+/-8.3 ms, P<0.05); (2) improved interventricular synchrony; and (3) shortened isovolumic contraction time (122+/-57 versus 82+/-36 ms, P<0.05) but increased diastolic filling time. These benefits are pacing dependent, because withholding the pacing resulted in varying speeds in the loss of cardiac improvements. CONCLUSIONS Biventricular pacing reverses LV remodeling and improves cardiac function. Improvement of LV mechanical synchrony seems to be the predominant mechanism.
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Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong.
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115
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Abstract
Brain natriuretic peptide (BNP), a peptide hormone secreted chiefly by ventricular myocytes, plays a key role in volume homeostasis. The plasma concentration of BNP is raised in various pathological states, especially heart failure. Many studies suggest that measurement of plasma BNP has clinical utility for excluding a diagnosis of heart failure in patients with dyspnea or fluid retention and for providing prognostic information in those with heart failure or other cardiac disease. It may also be of value in identifying patients after myocardial infarction in whom further assessment of cardiac function is likely to be worthwhile. Preliminary evidence suggests that measuring the plasma concentration of BNP may be useful in fine tuning therapy for heart failure. Artificially raising the circulating levels of BNP shows considerable promise as a treatment for heart failure. With simpler assay methods now available, it is likely that many physicians will measure plasma BNP to aid them in the diagnosis, risk stratification, and monitoring of their patients with heart failure or other cardiac dysfunction.
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Affiliation(s)
- Martin R Cowie
- Imperial College School of Medicine, Science & Technology, Royal Brompton Hospital, London, UK
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Persson H, Andréasson K, Kahan T, Eriksson SV, Tidgren B, Hjemdahl P, Hall C, Erhardt L. Neurohormonal activation in heart failure after acute myocardial infarction treated with beta-receptor antagonists. Eur J Heart Fail 2002; 4:73-82. [PMID: 11812667 DOI: 10.1016/s1388-9842(01)00196-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Few studies have described how neurohormonal activation is influenced by treatment with beta-receptor antagonists in patients with heart failure after acute myocardial infarction. The aims were to describe neurohormonal activity in relation to other variables and to investigate treatment effects of a beta(1) receptor-antagonist compared to a partial beta(1) receptor-agonist. METHODS Double-blind, randomized comparison of metoprolol 50-100 mg b.i.d. (n=74), and xamoterol 100-200 mg b.i.d (n=67). Catecholamines, neuropeptide Y-like immunoreactivity (NPY-LI), renin activity, and N-terminal pro-atrial natriuretic factor (N-ANF) were measured in venous plasma before discharge and after 3 months. Clinical and echocardiographic variables were assessed. RESULTS N-ANF showed the closest correlations to clinical and echocardiographic measures of heart failure severity, e.g. NYHA functional class, furosemide dose, exercise tolerance, systolic and diastolic function. Plasma norepinephrine, dopamine and renin activity decreased after 3 months on both treatments, in contrast to a small increase in NPY-LI which was greater (by 3.9 pmol/l, 95% CI 1.2-6.6) in the metoprolol group. N-ANF increased on metoprolol, and decreased on xamoterol (difference: 408 pmol/l, 95% CI 209-607). Increase above median of NPY-LI (>25.2 pmol/l, odds ratio 2.8, P=0.0050) and N-ANF (>1043 pmol/l, odds ratio 2.8, P=0.0055) were related to long term (mean follow-up 6.8 years) cardiovascular mortality. CONCLUSIONS Decreased neurohormonal activity, reflecting both the sympathetic nervous system and the renin-angiotensin system, was found 3 months after an acute myocardial infarction with heart failure treated with beta-receptor antagonists. The small increase in NPY-LI may suggest increased sympathetic activity or reduced clearance from plasma. The observed changes of N-ANF may be explained by changes in cardiac preload, renal function, and differences in beta-receptor mediated inhibition of atrial release of N-ANF. NPY-LI, and N-ANF at discharge were related to long term cardiovascular mortality.
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Affiliation(s)
- Hans Persson
- Section of Cardiology, Division of Internal Medicine, Karolinska Institutet Danderyd Hospital, S-182 88, Stockholm, Sweden.
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117
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Osca J, Quesada A, Arnau MA, Osa A, Hervás I, Almenar L, Palencia M, Mateo A, Algarra F. [Brain natriuretic peptide. Diagnostic value in heart failure]. Rev Esp Cardiol 2002; 55:7-15. [PMID: 11784518 DOI: 10.1016/s0300-8932(02)76547-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nowadays a number of diverse biochemical markers have been identified in patients with heart failure (HF) that could indicate the severity of the patients' illness. Among them, probably the most useful is brain natriuretic peptide (BNP) because it is easily obtained and because of its diagnostic and prognostic information. Our objective was to assess the association between BNP and other different associated variables previously known to be related to the evolution of HF, as well as its utility to distinguish systolic from diastolic HF. PATIENTS AND METHOD We studied 114 patients admitted consecutively for symptomatic HF for all causes (age: 66 years, male: 60%). In all patients plasma BNP was measured, from the third day of admission, with a specific radioinmunoassay. Echocardiography was performed in 101 patients. RESULTS BNP plasma levels increased in proportion to functional class (p = 0.01) and the degree of left ventricular dysfunction (p = 0.0001, r = 0.44). There was also an association between BNP and male sex (p = 0.008), higher plasmatic creatinine (p = 0.01, r = 0.25), Iarger ventricular diameters (p = 0.0001) and higher pulmonary systolic pressure (p = 0.001, r = 0.44). In the multivariate analysis, BNP was independently related to the rest of variables with left systolic ventricular function (p = 0.0001). Despite this association, we did not find a satisfactory cut-off value in BNP, with a good sensitivity and specificity value from the total number of patients, of which specifically systolic dysfunction as a cause of HF was detected. CONCLUSIONS a) BNP increases proportionately to the left ventricular dysfunction and HF severity, and b) BNP is not a useful tool to distinguish systolic from diastolic HF.
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Affiliation(s)
- Joaquín Osca
- Servicios de Cardiología, Hospital Universitario La Fe, Valencia, Spain.
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118
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Los péptidos natriuréticos en la insuficiencia cardíaca: mejorando el diagnóstico y el manejo del síndrome. Rev Esp Cardiol 2002. [DOI: 10.1016/s0300-8932(02)76546-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Cabanes L, Richaud-Thiriez B, Fulla Y, Heloire F, Vuillemard C, Weber S, Dusser D. Brain natriuretic peptide blood levels in the differential diagnosis of dyspnea. Chest 2001; 120:2047-50. [PMID: 11742939 DOI: 10.1378/chest.120.6.2047] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES In dyspneic patients without left ventricular enlargement, it may be difficult to differentiate between obstructive lung disease and diastolic heart failure. Determination of plasma brain natriuretic peptide (BNP) levels, known to increase with ventricular stretch, may be of clinical relevance in this situation. We compared the discriminant power of BNP blood levels and of echocardiography in patients with either chronic obstructive lung disease or diastolic heart failure. PATIENTS Twenty-six New York Heart Association class III dyspneic patients with normal left ventricular systolic function were enrolled: 17 patients with chronic obstructive lung disease and 9 patients with unequivocal diastolic heart failure. RESULTS Echocardiographic data were unable to accurately differentiate between the two groups, whereas BNP levels were significantly and markedly higher in patients with diastolic heart failure when compared to those with obstructive lung disease (224 +/- 240 pg/mL vs 14 +/- 12 pg/mL, p < 0.0001). CONCLUSIONS These preliminary results warrant a prospective, large-scale evaluation of the value of BNP assay for determining diastolic dysfunction, a common cause of dyspnea in elderly patients, and differentiating it from other diagnoses such as obstructive lung disease.
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Affiliation(s)
- L Cabanes
- Department of Cardiology, Cochin Hospital, René Descartes University, Paris, France.
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120
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Kelly R, Struthers AD. Are natriuretic peptides clinically useful as markers of heart failure? Ann Clin Biochem 2001; 38:575-83. [PMID: 11587142 DOI: 10.1177/000456320103800522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- R Kelly
- Department of Cardiology, St James Hospital, Dublin, Republic of Ireland
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121
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Krishnaswamy P, Lubien E, Clopton P, Koon J, Kazanegra R, Wanner E, Gardetto N, Garcia A, DeMaria A, Maisel AS. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med 2001; 111:274-9. [PMID: 11566457 DOI: 10.1016/s0002-9343(01)00841-5] [Citation(s) in RCA: 186] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Although echocardiography is important for making the diagnosis of left ventricular dysfunction, its cost and lack of availability limit its use as a routine screening test. B-Natriuretic peptide levels accurately reflect ventricular pressure, and preliminary studies with a rapid assay have found that levels are sensitive and specific for diagnosing heart failure in patients with dyspnea. We hypothesized that B-natriuretic peptide levels obtained through the use of a rapid assay should correlate with echocardiographic abnormalities of ventricular function. SUBJECTS AND METHODS We studied 400 patients who were referred for echocardiography at the San Diego Veteran's Healthcare System between June and August 2000 to evaluate ventricular function. B-natriuretic peptide levels were measured by a point-of-care immunoassay; cardiologists assessing left ventricular function were blinded to the assay results. Patients were grouped into those with normal ventricular function, systolic dysfunction only, diastolic dysfunction only, and both systolic and diastolic dysfunction. RESULTS Mean (+/- SD) B-natriuretic peptide concentration was 416 +/- 413 pg/mL in the 253 patients diagnosed with abnormal left ventricular function, compared with 30 +/- 36 pg/mL in the 147 patients with normal left ventricular function. Patients with both systolic and diastolic dysfunction had the highest levels (675 +/- 423 pg/mL). The area under the receiver operating characteristic (ROC) curve for B-natriuretic peptide levels to detect any abnormal echocardiographic finding was 0.95 (91% confidence interval: 0.93 to 0.97). B-Natriuretic peptide levels were unable to differentiate systolic vs. diastolic dysfunction. In patients with symptoms of heart failure and normal systolic function, B-natriuretic peptide levels >57 pg/mL had a positive predictive value of 100% for diastolic abnormalities. CONCLUSIONS A simple, rapid test for B-natriuretic peptide levels can reliably predict the presence or absence of left ventricular dysfunction on echocardiogram. For some patients, a normal level may preclude the need for echocardiography.
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Affiliation(s)
- P Krishnaswamy
- Division of Cardiology, Department of Medicine, Veteran's Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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122
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Yu CM, Cheung BM, Leung R, Wang Q, Lai WH, Lau CP. Increase in plasma adrenomedullin in patients with heart failure characterised by diastolic dysfunction. Heart 2001; 86:155-60. [PMID: 11454830 PMCID: PMC1729865 DOI: 10.1136/heart.86.2.155] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the relation between plasma adrenomedullin and the severity of diastolic dysfunction in patients with heart failure. DESIGN Prospective study. SETTING University teaching hospital. PATIENTS 77 patients (mean (SEM) age 66.3 (1.2) years; 75% male) who were being followed in the outpatient clinic after admission to hospital for acute heart failure. INTERVENTIONS Same day echocardiography with Doppler studies; determination of venous adrenomedullin concentration by radioimmunoassay. MAIN OUTCOME MEASURES Plasma adrenomedullin concentration and its correlation with systolic and diastolic function. RESULTS 31 patients (40%) had isolated diastolic dysfunction (ejection fraction > 50%), and the remaining 46 had a depressed ejection fraction (< 50%). Of the patients with diastolic dysfunction, 17 had a restrictive filling pattern. In all but one of these there was coexisting systolic failure (chi(2) = 10.7, p = 0.001). Patients with systolic heart failure and a restrictive filling pattern (group 1, n = 16) had a higher plasma adrenomedullin than those with systolic failure and a non-restrictive filling pattern (group 2, n = 30) or with isolated diastolic heart failure and a non-restrictive filling pattern (group 3, n = 30) (mean (SEM): 91.7 (21.1) v 38.4 (8.8) v 34.0 (6.5) pmol/l, both p < 0.05). All heart failure values were higher (p < 0.01) than the control value (6.9 (1.2) pmol/l). Ejection fraction and left ventricular dimensions were similar in groups 1 and 2. Plasma adrenomedullin did not correlate with ejection fraction or New York Heart Association functional class. Stepwise multiple regression analysis showed that the presence of a restrictive filling pattern was the only independent variable associated with a high plasma adrenomedullin. CONCLUSIONS Plasma adrenomedullin concentrations in patients with heart failure are determined by the presence of diastolic dysfunction, and are especially raised in the presence of a restrictive filling pattern. There appears to be no correlation with systolic dysfunction.
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Affiliation(s)
- C M Yu
- Department of Medicine, Queen Mary Hospital and the Institute of Cardiovascular Science and Medicine, University of Hong Kong, Pokfulam Road, Hong Kong.
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123
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Uusimaa P, Tokola H, Ruskoaho H, Vuolteenaho O, Risteli J, Ylitalo A, Peuhkurinen K. Vasoactive peptides and procollagen propeptides in patients with hypertension in relation to cardiac hypertrophy and diastolic heart failure: design of the study and patient characteristics. J Hum Hypertens 2001; 15 Suppl 1:S19-22. [PMID: 11685903 DOI: 10.1038/sj.jhh.1001094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- P Uusimaa
- Department of Internal Medicine, University of Oulu, Kajaanintie 50, 90220 Oulu, Finland.
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124
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Yu CM, Cheung BMY, Leung R, Wang Q, Lai WH, Lau CP. Increase in plasma adrenomedullin in patients with heart failure characterised by diastolic dysfunction. Heart 2001. [DOI: 10.1136/hrt.86.2.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVETo investigate the relation between plasma adrenomedullin and the severity of diastolic dysfunction in patients with heart failure.DESIGNProspective study.SETTINGUniversity teaching hospital.PATIENTS77 patients (mean (SEM) age 66.3 (1.2) years; 75% male) who were being followed in the outpatient clinic after admission to hospital for acute heart failure.INTERVENTIONSSame day echocardiography with Doppler studies; determination of venous adrenomedullin concentration by radioimmunoassay.MAIN OUTCOME MEASURESPlasma adrenomedullin concentration and its correlation with systolic and diastolic function.RESULTS31 patients (40%) had isolated diastolic dysfunction (ejection fraction > 50%), and the remaining 46 had a depressed ejection fraction (< 50%). Of the patients with diastolic dysfunction, 17 had a restrictive filling pattern. In all but one of these there was coexisting systolic failure (χ2 = 10.7, p = 0.001). Patients with systolic heart failure and a restrictive filling pattern (group 1, n = 16) had a higher plasma adrenomedullin than those with systolic failure and a non-restrictive filling pattern (group 2, n = 30) or with isolated diastolic heart failure and a non-restrictive filling pattern (group 3, n = 30) (mean (SEM): 91.7 (21.1) v 38.4 (8.8) v 34.0 (6.5) pmol/l, both p < 0.05). All heart failure values were higher (p < 0.01) than the control value (6.9 (1.2) pmol/l). Ejection fraction and left ventricular dimensions were similar in groups 1 and 2. Plasma adrenomedullin did not correlate with ejection fraction or New York Heart Association functional class. Stepwise multiple regression analysis showed that the presence of a restrictive filling pattern was the only independent variable associated with a high plasma adrenomedullin.CONCLUSIONSPlasma adrenomedullin concentrations in patients with heart failure are determined by the presence of diastolic dysfunction, and are especially raised in the presence of a restrictive filling pattern. There appears to be no correlation with systolic dysfunction.
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125
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Dudek D, Rzeszutko L, Petkow Dimitrow P, Bartus S, Sorysz D, Chyrchel M, Rakowski T, Zdzienicka A, Guevara I, Dembinska-Kiec A, Dubiel JS. Circulating N-terminal brain natriuretic peptide precursor and endothelin levels in patients with syndrome X and left bundle branch block with preserved systolic function. Int J Cardiol 2001; 79:25-30. [PMID: 11399338 DOI: 10.1016/s0167-5273(01)00400-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deterioration of left ventricular function during follow-up was reported in some patients with syndrome X and concomitant left bundle branch block. The patients with syndrome X and left bundle branch block has been frequently presented with elevated Endothelin-1 (ET-1) level while brain natriuretic peptide (BNP) (a sensitive marker of left ventricular dysfunction) has not been measured in patients with syndrome X. METHODS The purpose of the present study was to assess left ventricular diastolic function, levels of N-terminal Brain Natriuretic Peptide (NT-proBNP) precursor and biochemical parameters of endothelial function in patients with syndrome X complicated by left bundle branch block but preserved left ventricular systolic function (group A, n=8). The echocardiographic and neurohormonal measures in these patients were compared to those in patients with syndrome X without left bundle branch block (group B, n=13), and controls (group C, n=15). RESULTS At rest and after exercise the serum concentration of NT-proBNP was significantly higher in group A than in the controls (at rest: 232+/-96 vs. 133+/-23 fmol/ml, P=0.03; after exercise: 313+/-96 vs. 180+/-33 fmol/ml, P=0.02). The highest concentration of endothelin-1 was also found in group A, being significantly higher than in the controls (6.81 vs. 4.52 pg/ml, P<0.05). Mitral flow abnormalities were detected in left bundle branch block patients. Accordingly, the lowest E/A ratio was in group A and it differed significantly from that in group C (0.85 vs. 1.1, P<0.05). E/A ratio inversely correlated with plasma NT-proBNP concentration in patients with left bundle branch block (r=-0.48, P=0.02). CONCLUSIONS Elevated NT-proBNP and endothelin-1 plasma concentrations were demonstrated in patients with syndrome X complicated by left bundle branch block even when left ventricular systolic function was still preserved. In this subgroup the magnitude of left ventricular diastolic dysfunction correlated with the increase of BNP level which reflects neurohormonal activation.
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Affiliation(s)
- D Dudek
- IInd Department of Cardiology, Jagiellonian University, Kopernika 17, 31-501, Krakow, Poland.
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126
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Maisel AS, Koon J, Krishnaswamy P, Kazenegra R, Clopton P, Gardetto N, Morrisey R, Garcia A, Chiu A, De Maria A. Utility of B-natriuretic peptide as a rapid, point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction. Am Heart J 2001; 141:367-74. [PMID: 11231433 DOI: 10.1067/mhj.2001.113215] [Citation(s) in RCA: 277] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although echocardiography is an important tool for making the diagnosis of left ventricular (LV) dysfunction, the cost of this procedure limits its use as a routine screening tool for this purpose. Brain natriuretic peptide (BNP) accurately reflects ventricular pressure, and preliminary studies have found it to be highly sensitive and highly specific in diagnosing congestive heart failure in the emergency department. We hypothesized that BNP might therefore be useful as a screening tool before echocardiography in patients with suspected LV dysfunction. METHODS Subjects included patients referred for echocardiography to evaluate the presence or absence of LV dysfunction. Patients with known LV dysfunction were excluded from analysis. BNP was measured by a point-of-care immunoassay (Biosite Diagnostics, San Diego, Calif). The results of BNP levels were blinded from cardiologists making the assessment of LV function. Patients were divided into those with normal ventricular function, abnormal systolic ventricular function, abnormal diastolic function, and evidence of both systolic and diastolic dysfunction. RESULTS Two hundred patients in whom LV function was unknown were studied. In the 105 patients (53%) whose ventricular function was subsequently determined to be normal by echocardiography, BNP levels averaged 37 +/- 6 pg/mL. This was significantly less than in those patients with either ultimate diastolic dysfunction (BNP 391 +/- 89 pg/mL (P <.001) or systolic dysfunction (BNP 572 +/- 115 pg/mL (P <.001). A receiver-operator characteristic curve showing the sensitivity and specificity of BNP against the echocardiography diagnosis revealed the area under the curve (accuracy) was 0.95. At a BNP level of 75 pg/mL was 98% specific for detecting the presence or absence of LV dysfunction by echocardiography. CONCLUSIONS A simple, rapid test for BNP, which can be performed at the bedside or in the clinic, can reliably predict the presence or absence of LV dysfunction on echocardiogram. The data indicate that BNP may be an excellent screening tool for LV dysfunction and may, in fact, preclude the need for echocardiography in many patients.
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Affiliation(s)
- A S Maisel
- Division of Cardiology, Veterans Affairs Medical Center and University of California, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
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127
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Parthenakis FI, Kanoupakis EM, Kochiadakis GE, Skalidis EI, Mezilis NE, Simantirakis EN, Kanakaraki MK, Vardas PE. Left ventricular diastolic filling pattern predicts cardiopulmonary determinants of functional capacity in patients with congestive heart failure. Am Heart J 2000; 140:338-44. [PMID: 10925352 DOI: 10.1067/mhj.2000.108243] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Abnormalities of diastolic function are an important determinant of exercise intolerance in patients with heart failure. However, the relation between left ventricular filling pattern and cardiopulmonary exercise performance has not been adequately studied. METHODS Thirty-one patients with idiopathic (n = 14) or ischemic (n = 17) dilated cardiomyopathy, demonstrated by coronary angiography, and radionuclide ejection fraction 30.5% +/- 9% underwent cardiopulmonary exercise testing with a modified Naughton protocol and a complete echocardiographic study. Patients were subdivided into restrictive and nonrestrictive groups according to their Doppler transmitral flow pattern. Gas exchange data were measured during exercise testing. The relation of left ventricular filling pattern to cardiopulmonary parameters was assessed in both groups. RESULTS Exercise duration was similar in the restrictive and nonrestrictive groups but significant differences were found in oxygen consumption (VO(2)) at peak exercise (14.3 +/- 2.4 vs 20.4 +/- 4.7 mL/kg per minute; P <.001) and at the anaerobic threshold (VO(2AT)) (13 +/- 2.2 vs 17.3 +/- 3 mL/kg per minute; P <.001). Simple linear regression analysis revealed that both peak VO(2) and VO(2AT) were significantly correlated with the ratio of peak early (E wave) to late (A wave) transmitral filling velocity, early filling deceleration time, atrial filling fraction, and A-wave velocity but not with left ventricular ejection fraction. Multivariate regression analysis gave only the peak A-wave velocity as an independent predictor for both peak VO(2) and VO(2AT). CONCLUSIONS In patients with heart failure, abnormalities of diastolic function are the most important determinant of exercise intolerance. A restrictive transmitral flow pattern by Doppler echocardiography is a marker of diminished cardiopulmonary exercise performance in these patients.
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Affiliation(s)
- F I Parthenakis
- Cardiology Department, Heraklion University Hospital, Crete, Greece
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128
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Turk JR. Physiologic and pathophysiologic effects of natriuretic peptides and their implications in cardiopulmonary disease. J Am Vet Med Assoc 2000; 216:1970-6. [PMID: 10863599 DOI: 10.2460/javma.2000.216.1970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J R Turk
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Missouri-Columbia 65205, USA
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129
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Affiliation(s)
- D L Dries
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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130
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Suzuki T, Yamaoki K, Nakajima O, Yamazaki T, Yamada Y, Akioka H, Yazaki Y, Nagai R. Screening for cardiac dysfunction in asymptomatic patients by measuring B-type natriuretic peptide levels. JAPANESE HEART JOURNAL 2000; 41:205-14. [PMID: 10850536 DOI: 10.1536/jhj.41.205] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Early diagnosis and treatment of heart failure lead to improved survival; pre-clinical detection would thus be beneficial. A non-invasive biochemical testing method would indeed be ideal to screen for the condition. In the present study, we sought to determine whether circulating levels of B-type natriuretic peptide (BNP) correlate with cardiac function in asymptomatic subjects. 294 consenting asymptomatic subjects were examined. BNP levels in elevated patients (> 18.4 pg / ml) showed significant correlation with echocardiographic parameters of the systolic and diastolic functions (EF r = -0.51, FS r = -0.50, E/A r = 0.42, p < 0.01). Moderate correlation with the CTR on chest X-ray was also seen (r = 0.23, p < 0.01). Multiple regression analysis showed numerous echocardiographic and hemodynamic parameters including those of systolic and diastolic function in addition to left ventricular wall thickness, blood pressure and serum creatinine levels to be significantly associated with raised BNP levels. Elevated BNP levels reflect cardiac function (both systolic and diastolic) in the asymptomatic population. Detection of cardiac dysfunction by the non-invasive biochemical test may prove useful in early pre-clinical diagnosis of heart failure.
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Affiliation(s)
- T Suzuki
- Department of Cardiovascular Medicine, University of Tokyo, Japan
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131
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Fruhwald FM, Fahrleitner A, Watzinger N, Dobnig H, Schumacher M, Maier R, Zweiker R, Leb G, Klein W. N-terminal proatrial natriuretic peptide correlates with systolic dysfunction and left ventricular filling pattern in patients with idiopathic dilated cardiomyopathy. Heart 1999; 82:630-3. [PMID: 10525523 PMCID: PMC1760791 DOI: 10.1136/hrt.82.5.630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the diastolic Doppler filling pattern in patients with idiopathic dilated cardiomyopathy and its relation to N-terminal pro-atrial natriuretic peptide (NT-pro-ANP). METHODS 32 patients (26 male, six female) with idiopathic dilated cardiomyopathy were investigated. All were in sinus rhythm. Conventional M mode echocardiography and Doppler echocardiography was done in each patient. Pulsed wave Doppler inflow signals were obtained and the following variables were measured: maximum E wave, maximum A wave, E/A ratio, E wave deceleration time, A wave deceleration time. NT-pro-ANP was measured using radioimmunoassay. RESULTS Mean (SD) left ventricular ejection fraction was 34 (7)% and mean left ventricular end diastolic diameter on M mode echocardiography was 69 (7) mm. Left ventricular filling indices were as follows: maximum E wave velocity, 0.86 (0.22) m/s; maximum A wave velocity, 0.71 (0.24) m/s; E/A ratio, 1.41 (0.65). Mean E wave deceleration time was 140 (50) ms; mean A wave deceleration time was 100 (20) ms. In a stepwise forward regression model, NT-pro-ANP correlated significantly with left atrial diameter (r = 0.603; p < 0. 001), left ventricular ejection fraction (r = -0.758; p < 0.001), and Doppler derived E/A ratio (r = 0.740; p < 0.001). CONCLUSIONS In patients with idiopathic dilated cardiomyopathy there is a relation between NT-pro-ANP and both systolic and diastolic variables. In a multivariate model NT-pro-ANP correlated with left atrial diameter, left ventricular ejection fraction, and Doppler derived E/A ratio on transmitral inflow.
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Affiliation(s)
- F M Fruhwald
- Department of Internal Medicine, Division of Cardiology, Karl-Franzens University, Auenbruggerplatz 15, A-8036 Graz, Austria.
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132
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Bettencourt P, Ferreira A, Sousa T, Ribeiro L, Brandão F, Polónia J, Cerqueira-Gomes M, Martins L. Brain natriuretic peptide as a marker of cardiac involvement in hypertension. Int J Cardiol 1999; 69:169-77. [PMID: 10549840 DOI: 10.1016/s0167-5273(99)00023-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hypertensive patients with heart abnormalities have increased risk of cardiovascular events. Brain natriuretic peptide is a natriuretic peptide mainly of ventricular origin produced in response to pressure and stretch. We hypothesise that brain natriuretic peptide could be a useful marker of cardiac remodelling in hypertensive patients. We studied 36 consecutive community mild-to-moderate hypertensive patients and 11 well-matched normotensive controls with respect to clinical characteristics, brain natriuretic peptide, creatinine and echocardiography parameters (M-mode, 2-D arid transmitral pulsed Doppler). Brain natriuretic peptide levels were significantly higher in hypertensive patients than in controls [36.54 (IQR: 38.61) vs. 10.30 (IQR: 13.20) pg ml(-1), p<0.0001] and it was correlated with left ventricular mass index. Hypertensive patients with impairment of diastolic filling had significantly higher brain natriuretic peptide concentrations than patients with no abnormalities on echocardiography [61.16 (45.38) vs. 31.27 (18.10) pg ml(-1), p=0.001]. Multivariate analysis showed that only diastolic dysfunction and left ventricular mass index were significantly and independently related with brain natriuretic peptide concentrations in this population. In conclusion, impairment of diastolic function and left ventricular mass index are related to brain natriuretic peptide levels, thus giving the insight that this peptide can be a marker of ventricular remodelling in hypertensive patients.
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Affiliation(s)
- P Bettencourt
- Serviço de Medicina 3, Piso 8, Hospital S. Jodo, Alameda Hernani Monteiro, Porto, Portugal
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Yu CM, Sanderson JE. Plasma brain natriuretic peptide--an independent predictor of cardiovascular mortality in acute heart failure. Eur J Heart Fail 1999; 1:59-65. [PMID: 10937981 DOI: 10.1016/s1388-9842(98)00010-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To examine the prognostic importance of both plasma atrial natriuretic and B-(brain natriuretic peptide) following an episode of acute heart failure. SUBJECTS AND METHODS A prospective cohort of 91 patients admitted into hospital with acute heart failure were recruited. After initial in-hospital management plasma ANP and BNP levels were measured by radioimmunoassay, and echocardiography was performed on the same day. Patients were followed up for 12 months and the main outcome measure was cardiovascular death. RESULTS Plasma ANP and BNP levels were significantly higher in patients who died of a cardiovascular cause within 12 months (P<0.001 and P<0.0001, respectively) or at 1-month (P<0.05 and P<0.001) after recruitment. By Kaplan-Meier estimated life-table curves, patients with above median plasma ANP or BNP levels had significantly higher 1-year mortality (42.5% vs. 11.6%, both P<0.005). By multivariate Cox proportional hazard regression analysis, the plasma BNP level was the most important prognostic factor predicting mortality (chi2 = 18.3, P<0.0001), followed by age (chi2 = 11.5, P<0.001). Other factors including ANP, left ventricular ejection fraction by M-mode echocardiography, pulmonary arterial pressure, sex, cause of heart failure as well as New York Heart Association class were not significant. CONCLUSION A plasma BNP level has independent and at least short-term prognostic significance in patients admitted with acute heart failure. This non-invasive and readily available blood test should be considered for risk stratification in patients with acute heart failure.
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Affiliation(s)
- C M Yu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, People's Republic of China
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Wijbenga AA, Balk AH, Jonkman FA, Boomsma F, Simoons ML, Man in t Veld AJ. Relation of atrial natriuretic peptides to left ventricular systolic and diastolic function in heart failure. Eur J Heart Fail 1999; 1:51-8. [PMID: 10937980 DOI: 10.1016/s1388-9842(98)00005-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Plasma concentrations of atrial natriuretic peptides are correlated with atrial pressures, as are left ventricular ejection fraction and left ventricular filling abnormalities. AIMS This study investigated the relation of atrial natriuretic peptides to both left ventricular systolic and diastolic function in heart failure. METHODS Plasma concentrations of atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide were measured in 63 patients with chronic heart failure and left ventricular systolic dysfunction. According to Doppler transmitral flow measurements, 19 patients had a restrictive and 44 patients had a non-restrictive left ventricular filling pattern. RESULTS Plasma concentrations of atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide were higher in patients with a restrictive filling pattern than in patients with a non-restrictive filling pattern (197 vs. 75 pmol/l, P<0.0001 and 1.14 vs. 0.45 nmol/l, P<0.0001). In univariate analysis, atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide correlated with deceleration time, E/A ratio and left ventricular ejection fraction. In multivariate analysis, both peptides appeared independently related to left ventricular ejection fraction and left ventricular filling pattern. CONCLUSION In patients with chronic heart failure, atrial natriuretic peptides provide information on left ventricular systolic as well as diastolic function.
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Affiliation(s)
- A A Wijbenga
- Heart Center, University Hospital Rotterdam, The Netherlands.
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135
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Sanderson JE, Chan SK, Yu CM, Yeung LY, Chan WM, Raymond K, Chan KW, Woo KS. Beta blockers in heart failure: a comparison of a vasodilating beta blocker with metoprolol. Heart 1998; 79:86-92. [PMID: 9505927 PMCID: PMC1728575 DOI: 10.1136/hrt.79.1.86] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine whether a third generation vasodilating beta blocker (celiprolol) has long term clinical advantages over metoprolol in patients with chronic heart failure. DESIGN A double blind placebo controlled randomised trial. SETTING University teaching Hospital. PATIENTS 50 patients with stable chronic heart failure (NYHA class II-IV) due to idiopathic dilated, ischaemic, or hypertensive cardiomyopathy, with left ventricular ejection fraction < 0.45. INTERVENTIONS Celiprolol 200 mg daily (n = 21), metoprolol 50 mg twice daily (n = 19), or placebo (n = 10) for three months with a four week dose titration period. After the double blind period, patients entered an open label study (with placebo group receiving beta blockers) and were assessed after one year. MAIN OUTCOME MEASURES Clinical response, efficacy, and tolerance were assessed by the Minnesota heart failure symptom questionnaire six minute walk test, Doppler echocardiography (systolic and diastolic function), radionuclide ventriculography, and atrial and brain natriuretic peptides measured at baseline and after three months. RESULTS In the metoprolol group at 12 weeks v baseline there was a 47% reduction in symptom score (p < 0.001), improvement of NYHA class (mean (SEM), 2.6 (0.12) to 1.9 (0.13), p = 0.001), exercise distance (1246 (54) to 1402 (52) feet, p < 0.001), and left ventricular ejection fraction (26.9(3.1)% to 31(3.0)%, p = 0.016), and a fall in heart rate (resting, 79 (3) to 62 (3) beats/min, p < 0.001). In the celiprolol group there was a 38% reduction in symptom score (p = 0.02), less improvement in exercise distance (1191 (55) to 1256 (61) feet, p = 0.05), and no significant changes in NYHA class, left ventricular ejection fraction, or heart rate. Mortality at one year was 11% in metoprolol and 19% in the celiprolol group, and symptomatic improvement was maintained in the survivors. CONCLUSIONS Both drugs were well tolerated but the vasodilator properties of celiprolol do not seem to provide any obvious additional benefit in the long term treatment of heart failure.
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Affiliation(s)
- J E Sanderson
- Department of Medicine, Chinese University of Hong Kong, Prince of Wales Hospital.
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Affiliation(s)
- J E Sanderson
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T.
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Yu CM, Sanderson JE. Right and left ventricular diastolic function in patients with and without heart failure: effect of age, sex, heart rate, and respiration on Doppler-derived measurements. Am Heart J 1997; 134:426-34. [PMID: 9327698 DOI: 10.1016/s0002-8703(97)70077-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Doppler echocardiography is widely used to assess right and left ventricular diastolic function. Although the factors affecting Doppler-derived measurements have been described in unaffected patients, there is little information available for patients with heart failure. Therefore we performed two-dimensional Doppler echocardiography studies of right and left ventricular function in 140 subjects, 88 with congestive heart failure and 52 age-matched normal subjects. The separate effects of age, sex, heart rate, and respiration were assessed by correlation analysis and multiple linear regression. In normal subjects both left and right ventricular parameters significantly correlated with age and heart rate. No significant effect of respiration was apparent in left ventricular function, but in the right ventricle inspiration caused a significant increase in transtricuspid peak E-wave velocity, E/A ratio, and shortening of the E-wave deceleration time. There was a significant correlation between left and right ventricular diastolic parameters. In heart failure, age correlated weakly with mitral valve peak A wave (r = 0.23, p = 0.03) and with tricuspid valve peak E-wave velocity (r = 0.37, p < 0.001), although in those with a restrictive filling pattern age was associated with a significant increased shortening of the mitral E-wave deceleration time (r = -0.8; p = 0.0015). Heart rate and deceleration time of mitral and tricuspid E wave significantly correlated, but heart rate did not correlate with either mitral or tricuspid peak E-wave or A-wave velocities or E/A ratio. In heart failure the effect of respiration was similar to normal subjects. Sex was not associated with Doppler variables in either normals or heart failure subjects. Thus this study demonstrates that age, heart rate, and respiration have important and separate associations with Doppler echo diastolic parameters of the right and left ventricle in normal subjects and similar, although weaker relations in patients with heart failure.
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Affiliation(s)
- C M Yu
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, China
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