NT-proBNP as a marker for persistent cardiac disease in children with history of dilated cardiomyopathy and myocarditis

The Pulse of It: Dietary Inclusion of Up to 45% Whole Pulse Ingredients with Chicken Meal and Pea Starch in a Complete and Balanced Diet Does Not Affect Cardiac Function, Fasted Sulfur Amino Acid Status, or Other Gross Measures of Health in Adult Dogs

BACKGROUND

Pulses are an attractive alternative protein source for all mammals; however, recent reports suggest that these ingredients may be related to developing dilated cardiomyopathy in dogs.

OBJECTIVES

The primary objective of this study was to quantify the effects of dietary pulse intake by adult dogs on cardiac function using echocardiographic measurements and cardiac biomarkers N-terminal pro-B-type natriuretic peptide and cardiac troponin I (cTnI). Second, to investigate the effects of pulse consumption on plasma sulfur amino acid (SAA) concentrations as pulses are generally low in SAA and may limit taurine synthesis. Last, to assess the general safety and efficacy of feeding pulse-containing diets on canine body composition and hematological and biochemical indices.

METHODS

Twenty-eight privately-owned domestic Siberian Huskies (13 females; 4 intact, and 15 males; 6 intact) with a mean age of 5.3 ± 2.8 y (± SD) were randomly assigned to 1 of 4 dietary treatments (n = 7/treatment), with equal micronutrient supplementation and increasing whole pulse ingredient inclusion (0%, 15%, 30%, and 45%) with pea starch used to balance protein and energy.

RESULTS

After 20 wks of feeding, there were no differences (P > 0.05) in echocardiographic parameters, N-terminal pro-B-type natriuretic peptide, and cTnI concentrations among treatments or across time within treatment (P > 0.05), indicating no differences in cardiac function among treatments. Concentrations of cTnI remained below the safe upper limit of 0.2 ng/mL for all dogs. Plasma SAA status, body composition, and hematological and biochemical indices were similar among treatments and over time (P > 0.05).

CONCLUSIONS

The results from this study suggest that increasing the inclusion of pulses up to 45% with the removal of grains and equal micronutrient supplementation does not impact cardiac function concurrent with dilated cardiomyopathy, body composition, or SAA status and is safe for healthy adult dogs to consume when fed for 20 wks.

The Trend of Urinary N Terminal Probrain Natriuretic Peptide in Extremely Low Birth Weight Infants during the Neonatal Period

OBJECTIVE

N-terminal probrain natriuretic peptide (NT-proBNP) is a biomarker of interest in many cardiopulmonary diseases in extremely low birth weight (ELBW) Infants. However, there is a gap in knowledge about the trend of ELBW infant's urinary NT-proBNP during the neonatal period.

AIM

To determine the trend of urinary NT-proBNP during the first 4 weeks of life of an ELBW infant.

STUDY DESIGN

We analyzed prospectively enrolled 87 ELBW infants. Urinary NT-proBNP to creatinine ratios were measured on days 1 to 7, 14, and 28 of life. We plotted each study point's means to determine the trend of urinary NT-proBNP over the entire neonatal period. Data were analyzed using the Friedman analysis of variance for comparative analysis of study points.

RESULTS

Urinary NT-proBNP/creatinine ratios were significantly elevated on days 1 to 7 (mean 2,452, ± 1,518) than day 14 (mean 747, ± 176), and day 28 (mean 149, ± 54), p = 0.001. Overall, urinary NT-proBNP levels were highest during days 1 to 3 (mean 3,232, ± 1,255) and lowest on day 28 (mean 149, ± 54).

CONCLUSION

Urinary NT-proBNP levels are higher during the first week in ELBW infants with a downward trend during the neonatal period, the lowest values at 4 weeks postnatal age. More studies are required to determine the clinical utility of this trend during and beyond the neonatal period.

KEY POINTS

· NT-proBNP is a biomarker for monitoring cardiac disease in premature infants.. · The trend of urinary NT-proBNP is unknown in premature infants.. · A trend of urinary NT-proBNP was determined during the first 4 weeks in premature infants..

Acute Myocarditis in Children: An Overview of Treatment and Recent Patents

BACKGROUND

Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis.

METHODS

Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine.

RESULTS

Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking.

CONCLUSION

This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.

B-natriuretic peptide serum levels in neonates with persistent pulmonary hypertension

Background

Better management of persistent pulmonary hypertension of neonates (PPHN) required new markers that can predict the response of patient to treatment and thus influence the medical decision to avoid short-term and long-term adverse effects. Hence, we aimed to evaluate B-natriuretic peptide (BNP) serum levels in neonates with PPHN and to correlate its levels with disease severity and response to treatment.

Patients and methods

The study included 60 neonates (30 PPHN patients and 30 healthy subjects). BNP was assessed, using the ELISA technique, at admission and after 4 days of treatment.

Results

Initial serum BNP levels were significantly higher in patients compared to controls (p < 0.001). Patients with mild severity showed lower BNP levels compared to patients with moderate severity, while patients with moderate severity showed decreased levels in comparison to severe cases (p < 0.001). The group of patients who showed remission after 4 days of treatment had lower pre-treatment and post-treatment BNP levels, compared to patients who showed incomplete remission. Initial levels of BNP showed strong positive correlations with pulmonary artery pressure (PAP) and oxygenation index (OI) before treatment (r = 0.9, p < 0.001 and r = 0.85, p = 0.001), while BNP after treatment showed moderate positive correlations with PAP before treatment (r = 0.6, p = 0.001) and OI before treatment (r = 0.6, p = 0.001). Analysis of the ROC curve revealed an AUC of 0.83with CI = 0.7–0.98 and p = 0.003.

Conclusions

BNP may play a role in the pathogenesis of PPHN, and BNP serum level can be used as a marker to detect disease severity and predict response to treatment.

Characterization of arrhythmias, evaluation of cardiac biomarkers and their association with survival in calves suffering from foot-and-mouth disease

INTRODUCTION

Foot-and-mouth disease (FMD) causes mortality in calves due to myocarditis; however, the effects of FMD virus on cardiac arrhythmogenesis and Purkinje cells are unknown. Identifying diagnostic and prognostic markers in FMD-affected calves may be useful in disease management in the endemic countries.

MATERIALS AND METHODS

A total of 81 FMD-affected calves were prospectively monitored till death or recovery. Foot-and-mouth disease was diagnosed by serology and reverse transcriptase-polymerase chain reaction (RT-PCR). Electrocardiography was recorded and serum cardiac biomarkers were measured. Histopathological examination of the ventricular myocardium was carried out in the calves that died of FMD (n = 33). Apparently healthy calves (n = 15) served as control.

RESULTS

Serology and RT-PCR consistently revealed that the FMD was caused by serotype O virus. Arrhythmias occurred in 62 of 81 (76.5%) FMD-affected calves, of which, ventricular premature complexes (VPCs) were the most common type (22%). The combined mortality rate due to ventricular tachycardia, polymorphic VPCs, and atrial fibrillation was 27.6%. Receiver operating characteristic curve analysis revealed that cardiac troponin I (cTnI) concentrations of ≥1.3 ng/mL were diagnostic of myocarditis with a sensitivity and specificity of 90% and 100%, respectively. Similarly, serum cTnI concentrations of <6.4 ng/mL were a good predictor of survival [odds ratio of 263; 95% confidence interval: 29-2371]. Histopathology of the myocardium revealed hyaline degeneration, necrosis, edema, mononuclear cell infiltration, and disruption by fibroblasts. Atrophy of the Purkinje cells was also present.

CONCLUSIONS

FMD induces cardiac arrhythmias and Purkinje cell pathology in the calf. Portable ECG coupled with assay of serum cTnI would help in predicting survival in FMD-affected calves.

N-terminal pro-brain natriuretic peptide as a biomarker for predicting coronary artery lesion of Kawasaki disease

Coronary artery lesion (CAL) caused by Kawasaki disease (KD) is currently the most common acquired heart disease in children in many countries. Nevertheless, there is no single useful marker existing for predicting CAL of KD. Recently, many reports have noted that N-terminal pro-brain natriuretic peptide (NT-proBNP) can be utilized as a biomarker to predict CAL. Thus, we perform a meta-analysis to ascertain the diagnostic value of NT-proBNP in detecting CAL of KD in the acute phase. PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and China National Knowledge Infrastructure were searched to detect relevant publications. Finally, eight eligible studies were included. The overall diagnostic sensitivity and specificity were 0.84 (95% confidence interval [CI]: 0.78-0.89) and 0.71 (95% CI: 0.68-0.75), respectively. The area under the summary receiver operating characteristic curves value (SROC) curve was 0.8582 ± 0.0531. Moreover, the overall sensitivity and specificity across five studies adopted the threshold of approximately 900 ng/L were 0.82 (95% CI: 0.73-0.89) and 0.72 (95% CI: 0.68-0.76), respectively. SROC was 0.8868 ± 0.0486. This meta-analysis would be the first one to describe the role of NT-proBNP in detecting CAL of KD. We register this study with PROSPERO (CRD42019130083).

Alterations in cerebral blood flow in children with congestive heart failure due to ventricular septal defect

OBJECTIVE

We aimed to investigate the effect of ventricular septal defect (VSD) and heart failure on cerebral blood flow (CBF) in children, whether heart failure treatment improves CBF, and if there is any relationship between CBF and serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level.

METHOD

Forty children with VSD (13 with heart failure) aged between 1 and 36 months were studied. The control group comprised 25 healthy children in the same age group. Maximum, minimum, and mean blood flow velocities and pulsatility indices of the right and left middle cerebral arteries were assessed using transcranial Doppler ultrasonography. Measurements of CBF and serum NT-proBNP levels were repeated in patients with heart failure a month post-heart failure treatment initiation. The groups were also compared in terms of defect diameters, cardiac structural changes, left ventricular systolic function, and findings related to pulmonary hypertension determined by echocardiography. Correlations between echocardiographic measurements and CBF parameters were analyzed.

RESULTS

Although no significant difference was found between patient and control groups for CBF, right and left maximum CBF velocities significantly increased posttreatment in patients with heart failure (P = .04 and P = .01, respectively). Serum NT-proBNP levels in children with VSD associated with heart failure were significantly higher than those in children with VSD alone (P = .04) or in healthy children (P < .001). NT-proBNP levels were negatively correlated with right and left maximum CBF velocities (r = -0.39, P = .013 and r = -0.32, P = .043, respectively).

CONCLUSION

Although no significant difference was found in CBF velocity among the study groups, increase in the CBF velocity post heart failure treatment and negative correlations between CBF velocity and both the VSD diameter and NT-proBNP levels indicate that the hemodynamic status due to VSD associated with heart failure has an effect on CBF.

Comparison between procalcitonin, brain natriuretic peptide, and uric acid in children with cardiomyopathy and controls

Objective. This study was performed to determine the level of procalcitonin, Brain Natriuretic Peptide (BNP), and uric acid in children with cardiomyopathy in comparison with controls and the association with echocardiographic findings. Methods. The levels of BNP, procalcitonin, and serum uric acid were measured and the amounts of biomarkers compared with echocardiographic findings. Results. In this study mean age of participants was the same (p=0.321). The majority of echocardiographic indices in left and right heart have different means in case and controls (p<0.05). Means of BNP, procalcitonin, and uric acid were 213.814 ± 309.601, 9.326 ± 3.881, and 6.846 ± 1.814 for case group and 2.76 ± 1.013, 1.851 ± 1.466, and 3.317 ± 0.924 for control (p<0.001), respectively. In the patients group there was relationship of Ross classification with BNP (χ² = 15.845, p<0.05) and with age (χ² = 8.946, p<0.05). For uric acid and procalcitonin no significant relationships were observed. Conclusions. procalcitonin, uric acid, and BNP had significant relationship with many echocardiographic findings in participants. For patients, procalcitonin did not show correlation. The severity of illness based on the Ross classification showed significant correlation with BNP level and age in patients.

Myocarditis in drug rash with eosinophilia and systemic symptoms

Drug rash with eosinophilia and systemic symptoms is a drug hypersensitivity reaction. Hepatitis and nephritis are the most common visceral manifestations. Myocarditis is important to recognise, given the high mortality rate. We describe a child with drug rash with eosinophilia and systemic symptoms and discuss the role of N-terminal pro-hormone of basic natriuretic peptide in early recognition of associated myocarditis.

NT-proBNP as early marker of subclinical late cardiotoxicity after doxorubicin therapy and mediastinal irradiation in childhood cancer survivors

Background. Childhood cancer survivors treated with anthracyclines and mediastinal irradiation are at risk for late onset cardiotoxicity. Aims of the Study. To assess the role of N-terminal pro-brain natriuretic peptide (NT-proBNP) and tissue Doppler imaging (TDI) as early predictors of late onset cardiotoxicity in asymptomatic survivors of childhood cancer treated with doxorubicin with or without mediastinal irradiation. Methods. A cross-sectional study on 58 asymptomatic survivors of childhood cancer who received doxorubicin in their treatment protocols and 32 asymptomatic Hodgkin's lymphoma survivors who received anthracycline and mediastinal irradiation. Levels of NT-proBNP, TDI, and conventional echocardiography were determined. Results. Thirty percent of survivors had abnormal NT-proBNP levels. It was significantly related to age at diagnosis, duration of follow-up, and cumulative dose of doxorubicin. TDI detected myocardial affection in 20% more than conventional echocardiography. Furthermore, abnormalities in TDI and NT-pro-BNP levels were more common in Hodgkin lymphoma survivors receiving both chemotherapy and radiotherapy. Conclusions. TDI could detect early cardiac dysfunction even in those with normal conventional echocardiography. Measurement of NT-proBNP represents an interesting strategy for detecting subclinical cardiotoxicity. We recommend prospective and multicenter studies to validate the role of NT-proBNP as an early marker for late onset doxorubicin-induced cardiotoxicity.

Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines

Pediatric heart failure (HF) is an important cause of morbidity and mortality in childhood. This article presents guidelines for the recognition, diagnosis, and early medical management of HF in infancy, childhood, and adolescence. The guidelines are intended to assist practitioners in office-based or emergency room practice, who encounter children with undiagnosed heart disease and symptoms of possible HF, rather than those who have already received surgical palliation. The guidelines have been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and are accompanied by practical Recommendations for their application in the clinical setting, supplemented by online material. This work does not include Recommendations for advanced management involving ventricular assist devices, or other device therapies.

Use of cardiac markers for monitoring of doxorubixin-induced cardiotoxicity in children with cancer

The aim of this study was to evaluate N-terminal probrain natriuretic peptides (NT-pro-BNP), cardiac troponin T, and creatinine kinase, MB isoenzyme (CK-MB) in the determination of subclinical left ventricular (LV) dysfunction by echocardiography in patients treated with doxorubicin. We performed a cross-sectional case study of systolic, diastolic function and tissue Doppler imaging by echocardiography in children with cancer who received a certain cumulative dose of doxorubicin. Blood levels for NT-pro-BNP, cardiac troponin T, and CK-MB were analyzed within 6 hours of the cardiac study. Of 30 patients, 5 (16.7%) had LV dysfunction with an abnormally high NT-pro-BNP level of 363 ± 78 pg/mL, whereas patients with normal LV function had an NT-pro-BNP level of 148 ± 173 pg/mL (P = 0.012). The NT-pro-BNP level not only inversely correlated with fractional shortening (r = -0.43, P = 0.017) and ejection fraction (r = - 0.45, P = 0.013) but also correlated with mitral deceleration time ( r = 0.41, P = 0.021) and a cumulative dose of doxorubicin (r = 0.44, P = 0.014). For tissue Doppler imaging, NT-pro-BNP correlated with a peak systolic velocity at the myocardial segment (Sm) (r = -0.40, P = 0.027). NT-pro-BNP is a sensitive test and has a moderate relationship with the LV systolic and diastolic function, thus making it a useful cardiac marker for the monitoring of early anthracycline cardiotoxicity.

Growth differentiation factor 15: an additional diagnostic tool for the risk stratification of developing heart failure in patients with operated congenital heart defects?

BACKGROUND

Many young adults who have congenital heart defects develop heart failure despite corrective surgeries. Growth differentiation factor 15 (GDF-15) has an established role as a marker for risk stratification and mortality both in patients after acute myocardial infarction and in patients with heart failure. Our aim was to establish a role for GDF-15 for monitoring heart failure in operated congenital heart defects (ACHD). This potential biomarker was validated through comparison with maximal oxygen uptake (VO(2max)) and to another biomarker, N-terminal pro-brain natriuretic peptide (NT-proBNP).

METHODS

A total of 317 ACHD patients (129 females) with an average age of 26.5 ± 8.5 years (mean ± SD) enrolled in the study. We studied the relation between GDF-15 and NT-proBNP and VO(2max%) (percent predicted for age and gender). The cutoffs for the groups were as follows: NT-proBNP <100, 100 to 300, and >300 pg/mL; VO(2max%) <65%, 65% to 85%, and >85% of predicted normal.

RESULTS

Significant differences in mean GDF-15 levels were found between the NT-proBNP <100 and NT-proBNP >300 groups, as well as between the 100 to 300 and the >300 groups. For VO(2max%), significant differences were found in GDF-15 levels between <65% and >85% and between <65% and 65% to 85%, respectively. The lowest mean GDF-15 was found in groups with NT-proBNP <100 pg/mL and VO(2max%) >85%. The highest mean GDF-15 was found in the groups with NT-proBNP >300 pg/mL and VO(2max%) <65%. A subgroup analysis, including 82 patients with operated tetralogy of Fallot, showed that patients in the New York Heart Association I class have significantly lower NT-proBNP and GDF-15 level and markedly higher VO(2max) compared with the patients in higher New York Heart Association class.

CONCLUSION

Growth differentiation factor 15 might be used as a surrogate marker for latent heart failure and could help to identify patients with ACHD who are at risk for developing heart failure, even if they are clinically asymptomatic.

The evolving approach to paediatric myocarditis: a review of the current literature

Paediatric myocarditis remains challenging from the perspectives of diagnosis and management. Multiple aetiologies exist and the majority of cases appear to be related to viral illnesses. Enteroviruses are believed to be the most common cause, although cases related to adenovirus may be more frequent than suspected. The clinical presentation is extremely varied, ranging from asymptomatic to sudden unexpected death. A high index of suspicion is crucial. There is emerging evidence to support investigations such as serum N-terminal B-type natriuretic peptide levels, as well as cardiac magnetic resonance imaging as adjuncts to the clinical diagnosis. In the future, these may reduce the necessity for invasive methods, such as endomyocardial biopsy, which remain the gold standard. Management generally includes supportive care, consisting of cardiac failure medical management, with the potential for mechanical support and cardiac transplantation. Treatments aimed at immunosuppression remain controversial. The paediatric literature is extremely limited with no conclusive evidence to support or refute these strategies. This article summarises the current literature regarding aetiology, clinical presentation, diagnosis, and management of myocarditis in paediatric patients.

Plasma B-type natriuretic peptides in children with cardiovascular diseases

Natriuretic peptides (NP) are released from the heart in response to pressure and volume overload. The biologic properties of NPs include counterregulation of the rennin-angiotensin-aldosterone pathway and a decrease in sympathetic tone resulting in diuresis, natriuresis, and vasodilation. Natriuretic peptides help to maintain fluid balance and blood pressure in a healthy physiologic range. The B-type natriuretic peptide (BNP) and its N-terminal precursor (NTpBNP) have become important diagnostic biomarkers of cardiovascular diseases (CVDs) in adults. Although many studies suggest that BNP also is a reliable test for diagnosing significant CVDs in children, data are lacking on whether additional use of BNP increases diagnostic accuracy and predicts prognosis. This comprehensive review describes the utility of BNP and NTpBNP for various CVDs of the neonatal and pediatric age groups. Because BNP is not a stand-alone test, it should not replace history, physical examination, or clinical judgment, but it has a clear value in adding details to the whole story for children, thus enabling the front-line physicians to make a diagnosis, especially in the acute care setting.

Clinical course and risk profile in adolescents with idiopathic dilated cardiomyopathy

We sought to analyze the prevalence, clinical course, and risk profile of left ventricular systolic dysfunction in adolescents with idiopathic dilated cardiomyopathy. Patients with clinical onset at <13 years (n = 18) or >19 years (n = 14) of age and/or patients followed up for <12 months were excluded. Clinical and biochemical markers were evaluated during 4 +/- 3 years of follow-up to determinate predictors of adverse outcome. A composite end point (hospitalization for worsening heart failure, cardiac transplantation, and death) was investigated. The final cohort consisted of 48 patients (median age 17 years) with idiopathic dilated cardiomyopathy. During follow-up, 11 patients required hospitalization for heart failure (21%) and 6 patients entered the transplantation list (4 underwent orthotopic cardiac transplantation, 8%). A Cox multivariate model evidenced N-terminus pro-brain natriuretic peptide (NT-pro-BNP; odds ratio 1, confidence interval 1 to 1.1, p = 0.001), New York Heart Association (NYHA) classes III to IV (odds ratio 2.5, confidence interval 1 to 5.9, p = 0.04), and electrocardiographic atrial enlargement (odd ratios 6.7, confidence interval 1.8 to 25, p = 0.005) as predictors of adverse events (composite end point) at 60 months. The association of NYHA classes III to IV, electrocardiographic atrial enlargement, and NT-pro-BNP value > or =250 pg/ml (are under the curve 0.88) showed 100% sensitivity, 77% specificity, 62% positive predictive value, and 100% negative predictive value. In conclusion, compared to other clinical, echocardiographic, and biochemical parameters, the combination of advanced NYHA class, electrocardiographic atrial enlargement, and NT-pro-BNP > or =250 pg/ml seem to better predict the risk of adverse events in adolescent with long-term systolic dysfunction.

The Use of N-Terminal-Pro-BNP in Preterm Infants

The use of natriuretic peptides in the neonatal population is emerging. B-type Natriuretic Peptide (BNP) and N-terminal-Pro-BNP (NTpBNP) are used in the adult population to assess myocardial function and volume loading. Their role in prognosis following cardiac surgery has also been identified. In preterm infants NTpBNP is becoming increasingly recognised as a potential screening tool for patent ductus arteriosus (PDA), and a marker for myocardial performance. In addition, NTpBNP may provide prognostic information in preterm infants and term infants with congenital diaphragmatic hernia (CDH). In this paper, the role of NTpBNP in the preterm population will be discussed.

Gated myocardial perfusion scintigraphy in children with myocarditis: can it be considered as an indicator of clinical outcome?

PURPOSE

Myocarditis is an inflammation of the heart muscle and represents a challenge for diagnosis and treatment. On account of the lack of sensitivity and specificity of routine cardiac tests, there is a need for accurate diagnostic imaging. The aim of this study is to review the role of gated 99Tc-methoxyisobutylisonitrile myocardial perfusion scintigraphy (G-MPS) in the diagnosis and follow-up of the patients with myocarditis in comparison with gallium scintigraphy.

MATERIALS AND METHODS

Thirteen patients with a clinical diagnosis of myocarditis were included in the study. All underwent rest G-MPS and the images were then evaluated by quantitative perfusion single-photon emission computed tomography and quantitative gated single photon emission computed tomography software program. Visual evaluation of perfusion was performed as well as analysis of motion with thickening function [expressed as summed rest score, summed motion score, and summed thickening score (STS)] with calculation of ejection fraction (EF) and lung-to-heart (L/H) ratio. Eight patients underwent 67Ga scintigraphy. Clinical, echocardiography, and cardiac enzymes (creatinine kinase-MB, myoglobulin, troponin T, brain natriuretic peptide) data were gathered from the patients' charts. Clinical outcome was grouped according to prognosis. Spearman's correlation (SC) test was used for comparison analysis.

RESULTS

Myocardial perfusion defects were observed in eight patients. Perfusion defects in the left ventricle involve a mean of 7.25% (range: 1-11%), whereas wall motion abnormality on G-MPS was more prominent, which showed to be a better marker for myocardial inflammation and necrosis. The 67Ga scintigraphy findings were normal in all, but two. The G-MPS EF (33+/-21%) was slightly lower than the echocardiography EF (40+/-15%), but with close correlation (SC coefficient: 0.635). Comparison of scintigraphic findings with clinical parameters showed that summed motion score with G-MPS EF and STS with L/H ratios were highly correlated (0.932 and 0.622, respectively). The maximum brain natriuretic peptide and L/H ratio with STS were highly correlated with the patients' outcomes (SC coefficient: -0.621, 0.821, and 0.579, respectively), as well.

CONCLUSION

Tc-methoxyisobutylisonitrile G-MPS is therefore helpful in providing additional diagnostic and prognostic information in patients with myocarditis.

Elevation of brain natriuretic peptide levels in children with septic shock

OBJECTIVES

1) To compare brain natriuretic peptide levels in pediatric patients with septic shock with both children admitted to the pediatric intensive care unit without infection and with healthy subjects; and 2) to evaluate the correlation between brain natriuretic peptide with severity of illness and with myocardial dysfunction in children with septic shock.

DESIGN

: Prospective, observational study.

SETTING

Children's Hospital pediatric intensive care unit.

PATIENTS

Children from age 2 wks to 18 yrs. Thirteen children with septic shock requiring inotropic support, 12 healthy controls, and five critically ill patients without infection or heart disease were evaluated.

INTERVENTIONS

For patients with septic shock, brain natriuretic peptide was measured within 6 hrs of admission and throughout the pediatric intensive care unit course. Echocardiograms were performed within 12 hrs of admission and then repeated if the patient continued to require inotropic support. For controls, one measurement was performed.

MEASUREMENTS AND MAIN RESULTS

Children with septic shock had an elevated (p < 0.0001) brain natriuretic peptide on admission (median 115 pg/mL [range 26-2960]) when compared with healthy (9 pg/mL [5-30]) and pediatric intensive care unit controls (10 pg/mL [5-30]). In patients with septic shock, brain natriuretic peptide at 12 hrs correlated directly with Pediatric Risk of Mortality III score (rs = .80, p = 0.002) and inversely with fractional shortening (rs = -.66, p = 0.014). In children with cold shock, brain natriuretic peptide at 12 hrs (718 pg/mL) [63-1530] was higher (p = 0.007) than in those with warm shock (208 pg/mL [20-366]). There was no pattern (p > 0.05) observed for brain natriuretic peptide over time.

CONCLUSIONS

Brain natriuretic peptide measured early after admission is increased in children with septic shock, especially in those with cold shock. In addition, the level at 12 hrs correlates with both severity of illness and myocardial dysfunction. Brain natriuretic peptide may be useful in assessing myocardial dysfunction from septic shock, particularly in identifying children with cold shock. Further studies are warranted to determine whether this measurement will be helpful in guiding therapy in pediatric septic shock.

Amino-terminal pro-B-type natriuretic peptide testing in neonatal and pediatric patients

Concentrations of amino-terminal pro-B-type natriuretic peptides (NT-proBNP) are often markedly elevated immediately after birth and typically decrease to normal concentrations after the first week of life. Despite these early life elevations (which likely reflect activity of the natriuretic peptide system to assist in mobilization of fluid in the neonatal period), NT-proBNP has been shown to be useful for the diagnosis or exclusion of heart failure (HF) in the neonate, infant, adolescent, and older child. After the resolution of the normative early-life elevations of NT-proBNP, it is reasonable to use age-adjusted cut points suggested for younger adults (<50 years), namely levels <300 ng/L to "rule out" HF, and >450 ng/L to "rule in" HF. In children with congenital heart disease with or without symptoms of HF, NT-proBNP concentrations are typically elevated and may be prognostically useful. Furthermore, NT-proBNP may be useful for the identification of patients treated with cardiotoxic chemotherapy at risk for the subsequent development of cardiomyopathy. Knowledge of expected concentrations of NT-proBNP at varying stages of life is important to optimally utilize this assay in the pediatrics setting.

Are B-type natriuretic peptide (BNP) and N-terminal-pro-BNP useful in neonates?

B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NTpBNP) have a major role in screening and diagnosis of cardiac disease and monitoring of the treatment response in children and adults. This review discusses the evidence underpinning the potential benefits of these natriuretic peptides in neonatology. They may serve as a useful adjunct to echocardiography in the diagnosis of patent ductus arteriosus and its response to treatment and the diagnosis of persistent pulmonary hypertension of the newborn. However, more work is needed to explore the possible roles of BNP/NTpBNP in the management of sepsis and monitoring of cardiac performance in neonates.

Utility of N-terminal pro-B-type natriuretic peptide to differentiate cardiac diseases from noncardiac diseases in young pediatric patients

BACKGROUND

Previous studies comparing children with cardiac disease with children with lung disease or healthy children indicated that natriuretic peptides are promising markers in pediatric patients. The aim of this study was to further clarify the diagnostic usefulness of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements in a less preselected population of children younger than 3 years, a population in which clinical symptoms are frequently unspecific.

METHODS

NT-proBNP concentrations (Roche Diagnostics) were measured in sera of 142 pediatric patients (age range, 33-1070 days) presenting at the Gynaecologic and Pediatric Hospital (Linz, Austria) between January 2003 and January 2004. ROC curve analysis for the diagnostic performance of NT-proBNP, the Mann-Whitney U-test for group comparison, and linear regression analysis for influencing factors were performed.

RESULTS

NT-proBNP concentrations were significantly increased in infants with cardiac diseases [median (25th-75th percentile), 3681 (1045-13557) ng/L; n = 23] compared with infants with other diseases [241 (116-542) ng/L; n = 119], and ROC analysis revealed good performance for NT-proBNP in differentiating between infants with and without cardiac diseases [mean area under the curve (AUC) with 95% confidence interval (CI), 0.87 (0.76-0.94)]. A subgroup analysis of exactly age- and sex-matched infants was performed, which revealed results comparable to those for the whole study population [mean (95% CI) AUC, 0.84 (0.68-0.93)].

CONCLUSION

In a heterogeneous group of pediatric patients < 3 years of age, NT-proBNP showed good diagnostic performance to distinguish between cardiac diseases and various noncardiac diseases.