High levels of plasma brain natriuretic peptide and interleukin-6 after optimized treatment for heart failure are independent risk factors for morbidity and mortality in patients with congestive heart failure

Safety and tolerability of once-daily controlled-release carvedilol 10-80 mg in Japanese patients with chronic heart failure

BACKGROUND

The aim of the present study was to assess the safety and tolerability of the controlled-release (CR) formulation of the β-blocker carvedilol in Japanese patients with chronic heart failure (HF).

METHODS AND RESULTS

In this multicenter, randomized, open-label, phase I/II dose-escalation study, 41 patients receiving standard therapy for chronic HF were randomized in a ratio of 1:1 to carvedilol CR or immediate-release (IR) carvedilol. The primary objective was to evaluate the tolerability and safety of escalating doses of carvedilol CR (10-40 mg/day), with a reference arm of 5-20 mg/day of carvedilol IR. In addition, the tolerability and safety of titration to a carvedilol CR dose up to 80 mg/day were examined, as were plasma concentrations of carvedilol and changes in vital signs. The proportions of patients who completed 40-mg/day carvedilol CR and 20-mg/day carvedilol IR were 42% (8/19) and 50% (11/22), respectively. In the CR group, 7/19 (37%) attained a dose of 80 mg. During the primary evaluation period, 7/19 (37%) and 4/22 (18%) patients experienced drug-related adverse events in the CR and IR groups, respectively, the characteristics of which were similar between groups.

CONCLUSIONS

No new safety issues emerged in Japanese chronic HF patients treated with carvedilol CR in contrast to those known in carvedilol IR.

Marked decrease in BNP levels in 2 related patients with reversible dilated cardiomyopathy

Two male patients, one in his thirties and the other in his fifties, were admitted to different hospitals for congestive heart failure (CHF). In both patients, laboratory findings indicated high plasma B-type natriuretic peptide (BNP) levels (266.0 and 902.7 pg/mL, respectively) and echocardiography showed large left ventricular diastolic dimensions (LVDd) (67 and 73 mm, respectively) and low ejection fractions (EF) (26% and 18%, respectively). Coronary arteriography revealed no organic stenosis in either patient. Following treatment, plasma BNP levels decreased to below the limit of measurement (4 pg/mL) in both patients and echocardiography revealed improved LVDd (61 and 52 mm, respectively) and EF (41% and 45%, respectively). Because these patients are related, genetic factors might have affected low plasma BNP levels. Moreover, these results suggest that marked decrease in plasma BNP during follow up may be an indicator of preserved neurohormonal and organ systems.

Absence of SOCS3 in the cardiomyocyte increases mortality in a gp130-dependent manner accompanied by contractile dysfunction and ventricular arrhythmias

BACKGROUND

Suppressor of cytokine signaling-3 (SOCS3) is a key negative-feedback regulator of the gp130 receptor that provides crucial signaling for cardiac hypertrophy and survival; however, an in vivo role of SOCS3 regulation on cardiac gp130 signaling remains obscure.

METHODS AND RESULTS

We generated cardiac-specific SOCS3 knockout (SOCS3 cKO) mice. These mice showed increased activation of gp130 downstream signaling targets (STAT3, ERK1/2, AKT, and p38) from 15 weeks of age and developed cardiac dysfunction from approximately 25 weeks of age with signs of heart failure. Surprisingly, SOCS3 cKO failing hearts had minimal histological abnormalities with intact myofibril ultrastructure. In addition, Ca(2+) transients were significantly increased in SOCS3 cKO failing hearts compared with wild-type hearts. We also found that Ser23/24 residues of troponin I were hypophosphorylated in SOCS3 cKO hearts before the manifestation of cardiac dysfunction. These data suggested the presence of abnormalities in myofilament Ca(2+) sensitivity in SOCS3 cKO mice. In addition to the contractile dysfunction, we found various ventricular arrhythmias in SOCS3 cKO nonfailing hearts accompanied by a sarcoplasmic reticulum Ca(2+) overload. To determine the contribution of gp130 signaling to the cardiac phenotype that occurs with SOCS3 deficiency, we generated cardiac-specific gp130 and SOCS3 double KO mice. Double KO mice lived significantly longer and had different histological abnormalities when compared with SOCS3 cKO mice, thus demonstrating the importance of gp130 signaling in the SOCS3 cKO cardiac phenotype.

CONCLUSIONS

Our results demonstrate an important role of SOCS3 regulation on cardiac gp130 signaling in the pathogenesis of contractile dysfunction and ventricular arrhythmias.

Prognostic value of serial measurements of highly sensitive cardiac troponin I in stable outpatients with nonischemic chronic heart failure

BACKGROUND

Cardiac troponin I (cTnI) is a useful biomarker in patients with chronic heart failure (CHF), and a highly sensitive cTnI (hs-cTnI) commercial assay has become available. However, the prognostic role of serial measurements of hs-cTnI in stable outpatients with CHF remains unknown.

METHODS

At entry to the study, we evaluated 95 stable outpatients with nonischemic CHF showing a serum hs-cTnI (Centaur TnI-Ultra [Siemens Medical Solution Diagnostics, New York, NY], lower limit of detection 0.006 ng/mL) value ≥0.006 ng/mL. To evaluate the role of repetitive measurements of hs-cTnI, we performed echocardiography and measured serum levels of cTnI and N-terminal proBNP at baseline and 6 months later and then prospectively followed up these patients for 4.25 years.

RESULTS

During long-term follow-up, there were 27 cardiac deaths. On multivariate analyses, high plasma N-terminal pro-brain natriuretic peptide (≥711 pg/mL, P = .0008), high serum hs-cTnI at baseline (≥0.03 ng/mL, P = .0011), and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL, P = .022) after 6 months were independent significant prognostic predictors. The hazard ratio for mortality of patients with high hs-cTnI (≥0.03 ng/mL) and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL) was 3.59 (95% CI 1.3-9.9, P = .014) compared with that of those with high hs-cTnI (≥0.03 ng/mL) and a decrease in hs-cTnI (Δhs-cTnI <0 ng/mL).

CONCLUSIONS

These findings indicated that not only the serum concentration of hs-cTnI at baseline but also an increase in hs-cTnI were independent and useful prognostic predictors in patients with nonischemic CHF.

Is there an additional benefit of serial NT-proBNP measurements in patients with stable chronic heart failure receiving individually optimized therapy?

BACKGROUND

The role of serial NT-proBNP measurements in patients suffering from chronic systolic heart failure (CHF) who already receive individually optimized pharmacotherapy is still unresolved.

METHODS

NT-proBNP was assessed at baseline and at 6 months follow-up in 504 stable CHF patients treated with individually optimized pharmacotherapy. After assessment of clinical stability at 6 months, patients were followed up for at least 1 year. The combined primary endpoint was defined as death, hospitalization due to cardiac reasons or heart transplantation in 1-year follow-up. We stratified our patients according to two principles: first, a percent change of value (CV) between the first and second measurement of NT-proBNP and secondly, the transformed logarithm of NT-proBNP measured at 6 months.

RESULTS

During the follow-up period of 1 year, 50 patients (9.9%) reached the combined primary endpoint. Stratification according to percentage CV was less accurate in predicting endpoint-free survival compared to a classification in categories of lnNT-proBNP measured at 6 months (ROC AUC = 0.615; 95% CI 0.525-0.70 vs. ROC AUC = 0.790; 95% CI 0.721-0.856, respectively). When entered into proportional hazard regression analysis, lnNT-proBNP measured at 6 months remained an independent predictor of the combined primary endpoint with an associated HR of 2.53 (95% CI 1.385-4.280).

CONCLUSION

To date, this is the largest analysis of serial NT-proBNP measurements in patients with CHF receiving individually optimized medical therapy. These data suggest that a single NT-proBNP measurement after 6 months in stable clinical conditions may have higher predictive value than stratification of change in serial measurements.

Natriuretic Peptide testing in primary care

The incidence, as well as the morbidity and mortality associated with heart failure (HF) continue to rise despite advances in diagnostics and therapeutics. A recent advance in the diagnostic and therapeutic approach to HF is the use of natriuretic peptide (NP) testing, including both B-type natriuretic peptide (BNP) and its amino terminal cleavage equivalent (NT-proBNP). NPs may be elevated at an early stage among those with symptoms as well among those without. The optimal approach for applying NP testing in general populations is to select the target population and optimal cut off values carefully. Superior diagnostic performance is observed among those with higher baseline risk (such as hypertensives or diabetics). As well, unlike for acute HF, the cut off value for outpatient testing for BNP is 20-40 pg/mL and for NTproBNP it is 100-150 ng/L. In symptomatic primary care patients, both BNP and NT-proBNP serve as excellent tools for excluding HF based on their excellent negative predictive values and their use may be cost effective. Among those with established HF, it is logical to assume that titration of treatment to achieve lower NPs levels may be advantageous. There are several ongoing trials looking at that prospect.

NT-proBNP provides incremental prognostic information in cardiac outpatients with and without echocardiographic findings

BACKGROUND

Outpatients frequently present with elevated natriuretic peptides in the absence of an obvious cardiac abnormality or with normal natriuretic peptides despite echocardiographic findings.

HYPOTHESIS

We aimed to determine the prognostic value of N-terminal pro B-type natriuretic peptide (NTpBNP) in outpatients with normal and abnormal echocardiography.

METHODS

A total of 433 cardiovascular outpatients were included. The prognostic value of NTpBNP in patients with normal and abnormal echocardiography during a 2-year follow-up was evaluated.

RESULTS

Patients with abnormal echocardiography and elevated NTpBNP had a mortality rate of 8.7% and an overall event rate of 20.2% (composite end point of overall mortality, myocardial infarction, and hospitalization for heart failure), which was significantly higher than in patients with abnormal echocardiography and normal NTpBNP, in which no mortality (P=0.011) and no events were observed (P<0.001). In patients with a normal echocardiography, mortality was 1.5% and 1.8% for patients with normal and elevated NTpBNP, respectively (P=1.000). Composite event rate was 1.5% and 8.9% (P=0.093), respectively.

CONCLUSIONS

Patients with low NTpBNP have an excellent prognosis irrespective of echocardiographic findings. Therefore, determination of NTpBNP appears useful in assessing the clinical relevance of echocardiographic findings.

Cardiac complications of systemic sclerosis: recent progress in diagnosis

PURPOSE OF REVIEW

Systemic sclerosis (SSc), a collagen vascular disease characterized by diverse organ system involvement, is associated with serious cardiac complications. Cardiac symptoms are much less frequent than autopsy-demonstrated cardiac involvement. Although frequent calls for early diagnosis have been made, validated strategies for assessment of scleroderma cardiac disease are not yet well established, mainly because the right ventricle, a common target of the disease, presents considerable obstacles to simple and reliable appraisal of its structure and function. This article reviews the current information about cardiac dysfunction in scleroderma, with special emphasis on its detection and prognostic implications.

RECENT FINDINGS

Cardiac involvement is a harbinger of poor prognosis in patients with SSc. Recent progress in its diagnosis has been made with the availability of more sophisticated diagnostic tools.

SUMMARY

Early detection of scleroderma heart disease will allow exploration of novel therapies with potential positive impact on the quality of life and life expectancy of this patient population.

Depressive symptoms and inflammation in patients hospitalized for heart failure

BACKGROUND

Depressive symptoms in patients with heart failure (HF) are common and might be associated with inflammation. No studies have examined both the cross-sectional and prospective association between inflammation and depressive symptoms in patients with HF with adequate correction for disease severity. The aim of this study was to describe if the cytokines interleukin-6 (IL-6) and C-reactive protein (CRP) are associated with depressive symptoms in hospitalized HF patients.

METHODS

Data from 517 patients hospitalized for HF from the COACH study were analyzed on inflammation markers (IL-6 and CRP) and depressive symptoms (Center for Epidemiological Studies Depression-Scale).

RESULTS

Heart failure patients with depressive symptoms (n = 208, 40%) had significantly higher plasma values of IL-6 (median 12.8 pg/mL vs median 11.0 pg/mL, P = .018) and CRP (median 2.4 mg/mL vs median 2.1 mg/mL, P = .03) compared with the nondepressed patients. Structural equation modelling showed that the factor inflammation (including IL-6 and CRP) was associated with depressive symptoms (β = 0.18, P < .05) when left ventricular ejection fraction and plasma values brain natriuretic peptides were included in the model. A small negative (β = -0.18, P < .05) effect was found between inflammation at baseline and the change in depressive symptoms during the 18 months of follow-up.

CONCLUSIONS

Higher levels of inflammatory markers are independently associated with depressive symptoms in HF patients, even after correcting for disease severity. There is no clear relationship between inflammation at baseline and depressive symptoms during the 18 months of follow-up.

Increased peak postoperative B-type natriuretic peptide predicts decreased longer-term physical function after primary coronary artery bypass graft surgery

BACKGROUND

Increased peak postoperative B-type natriuretic peptide (BNP) is associated with increased major adverse cardiovascular events and all-cause mortality after coronary artery bypass graft (CABG) surgery. Whether increased postoperative BNP predicts worse postdischarge physical function (PF) is unknown. We hypothesized that peak postoperative BNP associates with PF assessed up to 2 yr after CABG surgery, even after adjusting for clinical risk factors. including preoperative PF.

METHODS

This two-institution prospective cohort study included patients undergoing primary CABG surgery with cardiopulmonary bypass. Short Form-36 questionnaires were administered to subjects preoperatively and 6 months, 1 yr, and 2 yr postoperatively. Short Form-36 PF domain scores were calculated using the Short Form-36 norm-based scoring algorithm. Plasma BNP concentrations measured preoperatively and on postoperative days 1-5 were log(10) transformed before analysis. To determine whether peak postoperative BNP independently predicts PF scores 6 months through 2 yr after CABG surgery, multivariable longitudinal regression analysis of the postoperative PF scores was performed, adjusting for important clinical risk factors.

RESULTS

A total of 845 subjects (mean ± SD age, 65 ± 10 yr) were analyzed. Peak postoperative BNP was significantly associated with postoperative PF (effect estimate for log(10) peak BNP, -7.66 PF score points [95% CI, -9.68 to -5.64]; P = <0.0001). After multivariable adjustments, peak postoperative BNP remained independently associated with postoperative PF (effect estimate for log(10) peak BNP, -3.06 PF score points [95% CI, -5.15 to -0.97]; P = 0.004).

CONCLUSIONS

Increased peak postoperative BNP independently associates with worse longer-term PF after primary CABG surgery. Future studies are needed to determine whether medical management targeted toward reducing increased postoperative BNP can improve PF after CABG surgery.

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Profiling B-type natriuretic peptide in a stable heart failure population: a valuable adjunct to care

AIM

To examine the prognostic importance of absolute values and change in values of BNP in patients with stable heart failure (HF).

METHODS

Five-hundred and fifty-nine patients attending a disease management programme were categorized into tertiles of BNP (group 1; ≤ 95 pg/ml, group 2; 96-249 pg/ml and group 3; ≥ 250 pg/ml). A change in BNP between two stable visits was recorded. Patients were followed up for 1 year for death and a composite morbidity measure of HF hospitalization, all-cause hospitalization, unscheduled visits for clinical deterioration(UC) of HF using survival analysis.

RESULTS

The risk of the combined morbidity outcome increased with increasing tertiles of BNP (Log rank = 17.8 (2), p < 0.001). Furthermore, a 50 and 25% increase in BNP predicted morbidity in stable HF patients with an initial BNP > 200 pg/ml (p = 0.02) and > 450 pg/ml (p = 0.03), respectively.

CONCLUSION

In a stable community HF population, an elevated BNP or an increase in BNP predicts an adverse prognosis thereby potentially identifying a population in need of closer clinical follow-up.

Effect of valsartan on N-terminal pro-brain natriuretic Peptide in patient with stable chronic heart failure: comparison with enalapril

BACKGROUND AND OBJECTIVES

The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker.

SUBJECTS AND METHODS

This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril.

RESULTS

The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups.

CONCLUSION

Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

Prognostic role of high-sensitivity cardiac troponin T in patients with nonischemic dilated cardiomyopathy

BACKGROUND

Cardiac troponin T (cTnT) is useful biomarker in patients with chronic heart failure (CHF). However, its clinical use is limited by the low sensitivity of the conventional commercial assay system. Recently, a highly sensitive cTnT (hs-cTnT) assay has become commercially available.

METHODS AND RESULTS

To compare the prognostic value of conventional cTnT and hs-cTnT in patients with nonischemic dilated cardiomyopathy (DCM), hemodynamic parameters and the serum levels of conventional cTnT, hs-cTnT and brain natriuretic peptide (BNP) were measured in 85 consecutive CHF patients with nonischemic DCM and then these patients were followed for a mean of 4.1 years. During long-term follow up, there were 20 cardiac deaths. In 85 DCM patients, conventional cTnT was elevated (≥0.03ng/ml) in 4 patients (5%) and hs-cTnT was elevated (≥0.01ng/ml) in 46 patients (54%). In non-survivors (n=20), conventional cTnT was elevated (≥0.03ng/ml) in 2 patients (2%) and hs-cTnT was elevated (≥0.01ng/ml) in 17 patients (85%). In the stepwise multivariate analyses, a high plasma level of BNP (P=0.002), low left ventricular ejection fraction (<30%, P=0.012) and high hs-cTnT (≥0.01ng/ml, P=0.006) were independent significant prognostic predictors, but conventional cTnT (≥0.03ng/ml) was not.

CONCLUSIONS

The findings of the present study indicated that a high serum concentration of hs-cTnT is a useful prognostic predictor that is independent of LVEF or BNP in CHF patients with non-ischemic DCM, suggesting that an increased hs-cTnT concentration sensitively reflects ongoing myocardial damage.

Biological variation of brain natriuretic peptide and cardiac events in stable outpatients with nonischemic chronic heart failure

BACKGROUND

To evaluate the biological variation and prognostic value of brain natriuretic peptide (BNP) for stable outpatients with nonischemic chronic heart failure (NICHF).

METHODS AND RESULTS

Biological variation in BNP was evaluated using an automated assay system in 140 outpatients with NICHF. The stable clinical condition during the 2-month study period was defined as unchanged NYHA and unchanged left ventricular ejection fraction; therefore, 7 patients were excluded during the 2 months. Thereafter, 133 patients were prospectively followed and the relationship between cardiac events and the plasma BNP concentrations (at baseline and after 2 months) were evaluated as well as the changes in BNP. The biological variation in BNP (2-month interval) was calculated as 22.3%. During a mean follow-up period of 42 months, 26 patients had cardiac events. According to stepwise multivariate analyses, plasma BNP after 2 months (P=0.0002) and % change in BNP (P=0.0067) were significant independent predictors of cardiac events.

CONCLUSIONS

These findings indicated that a combination of the absolute value of BNP after 2 months and % increase in BNP (2-month interval) is useful for predicting cardiac events in stable outpatients with NICHF.

The value of serum N-terminal pro-brain natriuretic peptide levels in the differential diagnosis and follow-up of congestive cardiac failure and respiratory distress due to pulmonary aetiologies in infants and children

OBJECTIVE

We aimed to determine whether N-terminal pro-brain natriuretic peptide can differentiate between cardiac and pulmonary aetiologies of dyspnoea, if N-terminal pro-brain natriuretic peptide can be used for evaluating the effect of treatment in cardiac failure, and for predicting severe pulmonary diseases that are complicated by cardiac failure.

METHODS

In all, 76 children with dyspnoea were enrolled; 41 of them suffered cardiac failure - 25 caused by cardiac disease, 16 caused by pulmonary disease - and 35 had dyspnoea due to pulmonary disease. The control group consisted of 32 children. We calculated Ross scores, analysed N-terminal pro-brain natriuretic peptide levels, and evaluated left ventricular systolic functions by echocardiography.

RESULTS

N-terminal pro-brain natriuretic peptide levels were significantly higher in children with cardiac failure than in those with pulmonary disease and in controls (medians 7321, 241, 87.71 picograms per millilitre, respectively), were higher in children with cardiac failure due to pulmonary disease than in those with only pulmonary disease (medians 2728, 241 picograms per millilitre, respectively), and were higher in children who died from cardiac failure than in survivors (p < 0.05). After treatment of cardiac failure, N-terminal pro-brain natriuretic peptide levels decreased significantly (p < 0.001). The cut-off level of N-terminal pro-brain natriuretic peptide for differentiating cardiac failure from pulmonary disease was 726.8 picograms per millilitre, sensitivity 100%, specificity 94.3%.

CONCLUSIONS

N-terminal pro-brain natriuretic peptide levels can differentiate dyspnoea due to cardiac failure from pulmonary diseases. It can also be used to monitor the effects of treatment of cardiac failure and to estimate the prognosis, as well as to predict pulmonary diseases that are complicated with cardiac failure.

Combination of uric acid and NT-ProBNP: a more useful prognostic marker for short-term clinical outcomes in patients with acute heart failure

BACKGROUND/AIMS

In patients with heart failure (HF), N-terminal prohormone brain natriuretic peptide (NT-ProBNP) is a standard prognostic indicator. In addition, uric acid (UA) was recently established as a prognostic marker for poor outcome in chronic HF. The aim of this study was to determine the combined role of UA and NT-ProBNP as prognostic markers for short-term outcomes of acute heart failure (AHF).

METHODS

The levels of UA and NT-ProBNP were determined in 193 patients (age, 69 ± 13 years; 76 males) admitted with AHF. Patients were followed for 3 months and evaluated for cardiovascular events, defined as cardiac death and/or readmission for HF.

RESULTS

Of the 193 patients, 23 (11.9%) died and 20 (10.4%) were readmitted for HF during the 3-month follow-up period. Based on univariate analysis, possible predictors of short-term cardiovascular events were high levels of UA and NT-ProBNP, low creatinine clearance, no angiotensin converting enzyme inhibitors or angiotensin receptor blockers, and old age. Multivariate Cox hazard analysis showed that UA levels were independently associated with increased incidence of cardiovascular events (hazard ratio, 1.115; 95% confidence interval, 1.006 to 1.235; p = 0.037). Kaplan-Meier survival analysis revealed that patients with UA levels > 8.0 mg/dL and NT-ProBNP levels > 4,210 pg/mL were at highest risk for cardiac events (p = 0.01).

CONCLUSIONS

The combination of UA and NT-ProBNP levels appears to be more useful than either marker alone as an independent predictor for short-term outcomes in patients with AHF.

The cardiopulmonary continuum systemic inflammation as 'common soil' of heart and lung disease

Coronary artery disease (CAD), chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) occur commonly in the presence of each other and are associated with similar systemic inflammatory reactions. Inflammation plays a central role in the pathogenesis of these diseases. C-reactive protein (CRP) could represent the sentinel biomarker to all chronic diseases. Also, interleukin (IL)-6 may play a causal role in systemic inflammatory diseases. These complex interactions between heart and lung can be denoted as 'cardiopulmonary continuum'. Common risk factors induce systemic inflammatory processes which lead to progression of atherosclerotic diseases as well as COPD.

Comparison of the utility of preoperative versus postoperative B-type natriuretic peptide for predicting hospital length of stay and mortality after primary coronary artery bypass grafting

BACKGROUND

Preoperative B-type natriuretic peptide (BNP) is known to predict adverse outcomes after cardiac surgery. The value of postoperative BNP for predicting adverse outcomes is less well delineated. The authors hypothesized that peak postoperative plasma BNP (measured postoperative days 1-5) predicts hospital length of stay (HLOS) and mortality in patients undergoing primary coronary artery bypass grafting, even after adjusting for preoperative BNP and perioperative clinical risk factors.

METHODS

This study is a prospective longitudinal study of 1,183 patients undergoing primary coronary artery bypass grafting surgery. Mortality was defined as all-cause death within 5 yr after surgery. Cox proportional hazards analyses were conducted to separately evaluate the associations between peak postoperative BNP and HLOS and mortality. Multivariable adjustments were made for patient demographics, preoperative BNP concentration, and clinical risk factors. BNP measurements were log10 transformed before analysis.

RESULTS

One hundred fifteen deaths (9.7%) occurred in the cohort (mean follow-up = 4.3 yr, range = 2.38-5.0 yr). After multivariable adjustment for preoperative BNP and clinical covariates, peak postoperative BNP predicted HLOS (hazard ratio [HR] = 1.28, 95% CI = 1.002-1.64, P = 0.049) but not mortality (HR = 1.62, CI = 0.71-3.68, P = 0.25), whereas preoperative BNP independently predicted HLOS (HR = 1.09, CI = 1.01-1.18, P = 0.03) and approached being an independent predictor of mortality (HR = 1.36, CI = 0.96-1.94, P = 0.08). When preoperative and peak postoperative BNP were separately adjusted for within the clinical multivariable models, each independently predicted HLOS (preoperative BNP HR = 1.13, CI = 1.05-1.21, P = 0.0007; peak postoperative BNP HR = 1.44, CI = 1.15-1.81, P = 0.001) and mortality (preoperative BNP HR = 1.50, CI = 1.09-2.07, P = 0.01; peak postoperative BNP HR = 2.29, CI = 1.11-4.73, P = 0.02).

CONCLUSIONS

Preoperative BNP may be better than peak postoperative BNP for predicting HLOS and longer term mortality after primary coronary artery bypass grafting surgery.

Microglia activation in the hypothalamic PVN following myocardial infarction

Following a myocardial infarction (MI), inflammatory cytokines are elevated in the brain, as well as in plasma, indicating that inflammation is occurring in the brain in addition to the periphery. Microglia are the immune cells in the central nervous system and can produce cytokines when they are activated by an insult or injury. In the present study, we investigated whether MI in rats induces activation of microglia in the brain. We used immunohistochemistry to detect CD11b (clone OX-42) and morphological changes to identify activated microglia. Compared to control rats that had undergone sham surgical procedures, there was a significant increase in activated microglia in the hypothalamic paraventricular nucleus (PVN) following myocardial infarction. Activated microglia were not observed in the ventral hypothalamus, adjacent to the PVN, nor in the cortex, indicating the response was not the result of a generalized inflammatory reaction in the brain. Echocardiography and haemodynamic parameters after myocardial infarction indicated that reduced left ventricular function but congestive heart failure had not developed. In conclusion, microglia are activated in the PVN but not in the adjacent hypothalamus following myocardial infarction. The activated microglia may contribute to the increased local production of pro-inflammatory cytokines observed in the PVN after myocardial infarction and resulting in reduced left ventricular function.

Relationship of interleukin-6 with regional and global left-ventricular function in asymptomatic individuals without clinical cardiovascular disease: insights from the Multi-Ethnic Study of Atherosclerosis

AIMS

We sought to examine the relationship between circulating interleukin-6 (IL-6) level and regional left-ventricular (LV) function among apparently healthy individuals free of cardiovascular disease.

METHODS AND RESULTS

Using magnetic resonance myocardial tagging, we determined peak systolic circumferential strain (Ecc) as a measure of regional systolic function in 894 asymptomatic participants in the Multi-Ethnic Study of Atherosclerosis. Ecc was analysed by harmonic phase imaging separately in the LV anterior wall, septum, lateral wall, and inferior wall. Global Ecc was calculated as the average of Ecc in all myocardial segments. We performed multivariable linear regression to evaluate the independent associations between log IL-6 and Ecc, after adjusting for demographic features, cardiovascular risk factors, and markers of subclinical atherosclerosis. The inverse relationships between IL-6 and absolute Ecc were similar in both genders. In multivariable analysis, higher IL-6 level was independently associated with reduced systolic function (less negative Ecc) in the septum [regression coefficient = 1.03 per unit higher log IL-6, 95% confidence interval (CI) 0.26-1.79, P = 0.008] and inferior wall (regression coefficient = 1.65, 95% CI 0.74-2.56, P < 0.001), but not in the anterior wall (P = 0.27) or lateral wall (P = 0.52). Overall, there was an independent inverse association between IL-6 and global Ecc (regression coefficient = 0.94, 95% CI 0.37-1.51, P = 0.001). Compared with C-reactive protein, higher IL-6 level demonstrates a stronger independent association with reduced regional systolic function.

CONCLUSION

In asymptomatic men and women without documented cardiovascular disease, there is a strong, independent, inverse relationship between IL-6 and regional LV systolic function. These findings suggest that IL-6 may underlie the pathogenetic link between inflammation, LV dysfunction and incipient heart failure. The observed variable relationships between IL-6 and systolic function across different LV regions warrant further investigations.

Prognostic role of highly sensitive cardiac troponin I in patients with systolic heart failure

BACKGROUND

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are useful biomarkers in patients with chronic heart failure (CHF). However, the clinical use has limitations due to the low sensitivity of a conventional commercial assay system. Recently, a high sensitive-cTnI (hs-cTnI) commercial assay has become available.

METHODS

To compare the prognostic value of cTnT and hs-cTnI, we measured hemodynamic parameters and serum levels of cTnT, hs-cTnI and N-terminal pro-brain natriuretic peptide (NT-proBNP)in 258 consecutive CHF patients and then followed these patients for a mean period of 2.6 years. In both assays of cTnT and hs-cTnI, the lowest concentration at which the coeffi cient of variation was < or =10% were 0.03 ng/mL, respectively. Therefore, in the present study, an elevated cTnT or cTnI test was defined as a level of > or =0.03 ng/mL.

RESULTS

During long-term follow up, there were 20 cardiac deaths. In 258 CHF patients, serum cTnT were elevated (> or =0.03 ng/mL) in 32 patients (12%) and serum hs-cTnI was elevated (> or =0.03 ng/mL) in 112 patients (43%). On stepwise multivariate analyses, high plasma NT-proBNP (> or =627 pg/mL, P = .0063) and hs-cTnI (> or =0.03 ng/mL) (P = .016) were independent significant prognostic predictors but cTnT (> or =0.03 ng/mL) was not. The hazard ratio for mortality of patients with high plasma NT-proBNP (> or =627 pg/mL) and hs-cTnI (> or =0.03 ng/mL) was 5.74 (95% CI, 2.33-14.28, P < .0001) compared to that of those with low NT-proBNP (<627 pg/mL) or hs-cTnI (<0.03 ng/mL).

CONCLUSIONS

These findings indicate that a high plasma concentration of hs-cTnI is an independent and useful prognostic predictor in patients with CHF.

gp130-mediated pathway and heart failure

Binding of ligands to gp130 activates at least three different downstream signaling pathways: the signal transducer and activator of transcription (STAT), the Src-homology tyrosine phosphatase 2-ras-MAPK and the PI3K/Akt pathways. Cardiac-specific disruption of gp130 was shown to result in heart failure in response to mechano-stress accompanied by an increase in apoptosis of cardiac myocytes. Inactivation of STAT3 resulting from the loss of gp130 may be a key event in the transition from cardiac hypertrophy to heart failure. Proper vascular growth would be essential for normal cardiac development and the remodeling process. In addition to various factors, such as bcl-xL, inducible nitric oxide synthase and reactive oxygen species-scavenging proteins, VEGF has also been identified as a target gene of STAT3 and together can promote cardiac myocyte survival by preventing apoptosis and restoration of energy deprivation. In this regard, the gp130-receptor system and its main downstream mediator, STAT3, play a key role in the prevention of heart failure. In this review, current knowledge of the IL-6 family of cytokines relating to human cardiac disease is summarized, in addition to the potential role of gp130-mediated signaling systems in various models of experimental heart failure.

Interleukin-6 and tumor necrosis factor-alpha as biochemical markers of heart failure: a head-to-head clinical comparison with B-type natriuretic peptide

BACKGROUND

The reliability of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) as biochemical markers of heart failure in comparison to B-type natriuretic peptide (BNP) has not been investigated in depth.

AIM

To compare the correlations between IL-6, TNF, BNP plasma concentrations and some clinical and instrumental variables and their prognostic value in heart failure patients.

METHODS

In 79 patients with heart failure, the correlations between IL-6, TNF and BNP plasma concentrations and a series of 18 variables were studied. Outcome events were death from any cause and combined death and heart transplantation.

RESULTS

At univariate analysis, BNP and IL-6 plasma concentrations correlated with each other (r = 0.4828; P < 0.0001), with New York Heart Association class, fluid retention, left ventricular ejection fraction, mean right atrial pressure, mean pulmonary pressure and cardiac index. All these correlations were stronger with BNP. TNF plasma concentration correlated only with New York Heart Association class and left ventricular ejection fraction.During follow-up, 1-32 months, 14 patients died and nine underwent heart transplantation. At univariate analysis, both BNP and IL-6 plasma concentrations were predictors of death and heart transplantation, but only BNP was a predictor of death; however, only creatinine plasma level was an independent predictor of prognosis.

CONCLUSION

IL-6 and TNF are less reliable biochemical markers than BNP in heart failure patients.

Pump failure death and sudden cardiac death in patients with cardiac dysfunction: a search for prognostic predictive factors--a long-term follow-up study

BACKGROUND

There have been few reports that have analyzed the predictive factors for heart failure death, which is sub-divided into pump failure death and sudden cardiac death, in the long term.

METHODS AND RESULTS

We followed 186 consecutive patients with myocardial infarction (MI) and 115 consecutive patients with non-ischemic heart failure (NIHF) during 73+/-3 months. In the MI group, 26 died from pump failure and 12 died from sudden cardiac death. In the NIHF group, 21 died from pump failure and 9 died from sudden cardiac death. Multivariate analysis revealed that the log B-type natriuretic peptide (BNP) was an independent predictor for pump failure death in both groups. In the MI group, the estimated glomerular filtration rate (eGFR) was an independent predictor for sudden cardiac death. Kaplan-Meier analysis revealed that a high BNP level was a risk factor for pump failure death in either MI or NIHF patients. On the other hand, the sudden cardiac death rate was significantly higher in the MI patients with low eGFR than in those with high eGFR.

CONCLUSIONS

The plasma BNP level is an independent predictor for pump failure death in both MI and NIHF patients. The eGFR is an independent predictor for sudden cardiac death in MI patients.

Cytokines and matrix metalloproteinases as potential biomarkers in chronic heart failure

Heart failure (HF) is accompanied by the upregulation of bioactive signaling molecules, known as cytokines, and a family of downstream proteases, matrix metalloproteinases (MMPs). It is now apparent that these molecules contribute to adverse myocardial remodeling during HF. Elevated levels of cytokines and MMPs exist in the myocardium and can subsequently spill over into the systemic circulation. The purpose of this article is to examine clinical studies of HF that have quantified levels of different types of cytokines, MMPs and endogenous tissue inhibitors of MMPs in relation to this disease process. HF is a complex syndrome that can develop from various etiologies and can be characterized into two distinct phenotypes: systolic and diastolic. This article will present recent clinical studies that have identified significant differences between the cytokine and MMP circulating profile of systolic and diastolic HF patients. In general, elevated levels of cytokines and MMPs exist in systolic HF patients when compared with diastolic HF patients, whereas diastolic HF patients have elevated levels of cytokines and MMPs when compared with controls. Therefore, future studies distinguishing between HF phenotypes may provide more consistent results in determining possible analytes to be used as biomarkers. Furthermore, this article will emphasize why standardization of analytical techniques and establishment of referent cytokine and MMP levels are necessary if these analytes are to be used as biomarkers for the diagnosis, prognosis and evaluation of treatment in the context of HF.

Comparison of the cardiac markers B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide

B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide have emerged as powerful biomarkers for heart failure and other cardiovascular conditions. B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide are synthesized on the basis of myocardial stress and hypertrophy and are detectable in serum by several commercially available assays. Although both markers display wide similarities in their predictive values for acute and chronic heart failure, important differences exist regarding cutoff values and influence of noncardiac variables. The similarities and differences between B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide will be reviewed and illustrated in detail regarding preanalytics and analytics, predictive properties for acute and chronic heart failure and prognosis as well as the influence of noncardiac parameters.

Cardiac sympathetic activity is associated with inflammation and neurohumoral activation in patients with idiopathic dilated cardiomyopathy

BACKGROUND

Idiopathic dilated cardiomyopathy (IDC) is characterized by sympathetic nervous overactivity, inflammation and neurohumoral activation; however, their interrelationships are poorly understood.

METHODS AND RESULTS

We studied 99 patients with IDC (age 54 +/- 1 years, left ventricular ejection fraction (EF) 40 +/- 1%, maximum oxygen uptake (VO(2)max) 20 +/- 1 ml kg(-1) min(-2), mean +/- SEM) by using (123)I-metaiodobenzylguanidine (MIBG) imaging. MIBG washout and MIBG heart/mediastinum (H/M)-ratio at 4 h postinjection were calculated. In addition, the plasma levels of interleukin (IL)-6 and N-terminal B-type natriuretic peptide (NT-proBNP) were measured. MIBG washout and MIBG H/M ratio had a significant correlation with IL-6 (r = 0.42, P<0.001 and r = -0.31, P<0.01) and NT-proBNP (r = 0.48, P<0.001 and r = -0.40, P<0.001). During a median follow-up of 4.1 years, 20 patients (20%) had an adverse cardiac event (death, heart transplantation or application of biventricular pacemaker or implantable cardioverter-defibrillator). In these patients, MIBG washout was higher (53 +/- 4 versus 40 +/- 2%, P = 0.01) and H/M ratio lower (1.38 +/- 0.04 versus 1.51 +/- 0.02, P = 0.01) than in patients without an event.

CONCLUSIONS

In dilated cardiomyopathy, myocardial sympathetic innervation and activity are related to inflammation and neurohumoral activation. These relationships are at least partly independent of left ventricular function and exercise capacity.

Relation of baseline plasma phospholipid transfer protein (PLTP) activity to left ventricular systolic dysfunction in patients referred for coronary angiography

Phospholipid transfer protein (PLTP) is an important modulator of phospholipid transfer and exchange among proteins. It also plays a role in inflammation and oxidative stress. Accordingly, PLTP has been implicated in the development of atherosclerosis. Left ventricular (LV) systolic dysfunction is common in patients with atherosclerosis, and both inflammation and oxidative stress have also been implicated in its development and progression. The goal of the present study was to examine the relation between plasma PLTP activity and LV systolic function. Baseline plasma PLTP activity was measured in 389 male patients referred for coronary angiography for a variety of indications. Detailed clinical, angiographic and laboratory characteristics were available for the patients. Compared to those patients with normal LV function (defined as an ejection fraction of >or=55% on ventriculography), patients with any degree of LV dysfunction had elevated PLTP activity (median PLTP 17.8 pmol/microl/h versus 15.9 pmol/microl/h, p=0.0038). Using multivariate analysis, and adjusting for a variety of confounding variables known to affect both LV function and PLTP activity, PLTP activity was an independent predictor of the presence of any left ventricular systolic dysfunction in the entire population (OR 1.47, 95% CI 1.12-1.93, p=0.0052). Furthermore, PLTP activity was an independent predictor of the presence of LV dysfunction in both patients with and without myocardial infarction on presentation (OR 2.39, 95% CI 1.18-4.86, p=0.0161 and OR 1.41, 95% CI 1.05-1.89, p=0.0206, respectively). In conclusion, PLTP activity may represent a novel marker of LV systolic dysfunction in patients with known or suspected coronary artery disease.