Amino-terminal pro-B-type natriuretic peptide testing to assist the diagnostic evaluation of heart failure in symptomatic primary care patients

To support the use of NT-proBNP to better detect heart failure in patients with type 2 diabetes

PURPOSE

Heart failure (HF) is a chronic disease that causes approximately 300,000 and 250,000 deaths per year in Europe and United States, respectively. Type 2 Diabetes Mellitus (T2DM) is one the major risk factors of HF, and the investigation of NT-proBNP might support the early identification of HF in T2DM sufferers. Nevertheless, this parameter is poorly investigated. Thus, we aimed to demographically and clinically characterize diabetic patients which were prescribed with NT-proBNP in the primary care setting.

METHODS

Using a primary care database, we formed a cohort of patients aged ≥18 years diagnosed with T2DM between 2002 and 2021. A multivariate Cox model was adopted to assess the determinants associated with the prescription of NT-proBNP.

RESULTS

Among 167,961 T2DM patients, 7558 (4.5%, 95% CI: 4.4-4.6) were prescribed with NT-proBNP. Males and increasing age were expectedly associated with a higher propensity to be prescribed with NT-proBNP. In addition, a significant association was found for those suffering from obesity, ischemic cardiomyopathy, stroke, atrial fibrillation, hypertension, and with a Charlson Index of 2+.

CONCLUSION

These determinants might contribute to investigate the NT-proBNP in T2DM sufferers. A decision support system to appropriately ease the prescription of NT-proBNP might be therefore implemented in primary care settings.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Biomarkers in the clinical management of patients with atrial fibrillation and heart failure

Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.

Interdisciplinary assessment and diagnostic algorithm: The role of the cardiologist

Patients with diabetes have an increased risk of developing heart failure and those with heart failure are at higher risk of developing diabetes. In patients with diabetes antidiabetic medications and the metabolic alterations of diabetes increase the risk of developing heart failure. In diabetic patients with heart failure and in those with an increased likelihood of developing the disease a stepwise approach based on the use of natriuretic peptides and echocardiography to rule out the presence of heart failure should be used. Once the diagnosis of heart failure is established it will be important to define the phenotype according to the left ventricular function and, where appropriate, use additional tests to identify possible additional underlying causes of heart failure like coronary artery disease. A multidisciplinary heart failure management programs is recommended in all patients with diabetes mellitus and heart failure to enable appropriate investigations, accurate diagnosis, and appropriate agreed evidence-based therapy and care plan. The implementation of a multidisciplinary heart failure management program requires a multidisciplinary team that will have to follow the patients throughout the whole heart failure trajectory and that should consider a holistic approach to the diabetic patient with heart failure rather than focussing merely on either heart failure or diabetes.

Association between NT-proBNP and nocturia among community-dwelling elderly males and females: A cross-sectional analysis of the HEIJO-KYO study

AIMS

To investigate the association between B-type natriuretic peptide (BNP) and nocturia among community-dwelling males and females.

METHODS

A total of 1096 participants (mean age 71.9 ± 7.1 years, 518 [47.2%] males) were included in the study. The number of nocturnal voids was recorded in a self-reported urination diary, and nocturia was defined as two or more voids per night. Daytime serum concentration of the N-terminal fragment of BNP precursor (NT-proBNP) was measured. Multivariable logistic regression analysis was performed to determine the association between NT-proBNP and nocturia.

RESULTS

Nocturia was observed in 23.5% of females and 37.1% of males. Higher NT-proBNP (log pg/ml) was associated with nocturia in both gender groups (females: odds ratio [OR]: 1.67, 95% confidence interval [95% CI], 1.21-2.34, p = .002; males: OR: 1.26, 95% CI, 1.01-1.59, p = .046), independent of confounding variables including night-time blood pressure, mean voided volume, and chronic kidney disease. Although the increase in prevalence of nocturia with higher NT-proBNP was equivalent in both genders, some effect of gender on the relationship between NT-proBNP and nocturia was observed (p = .037). Nocturnal urine volume was also significantly and independently associated with NT-proBNP level (females: β = 32.9 ml, 95% CI, 5.63-60.2, p = .018; males: β = 34.6 ml, 95% CI, 9.40-59.9, p = .007).

CONCLUSIONS

This study revealed higher serum NT-proBNP is significantly and independently associated with the prevalence of nocturia in both males and females. This is an exploratory cross-sectional study and the analyses are post hoc, so further research works are needed to clarify the causality and clinical value.

Elevated N-terminal prohormone of brain natriuretic peptide among persons living with HIV in a South African peri-urban township

AIMS

Efforts to improve access to antiretroviral therapy (ART) have shifted morbidity and mortality among persons living with HIV (PLWH) from AIDS to non-communicable diseases, such as cardiovascular disease (CVD). However, contemporary data on CVD among PLWH in sub-Saharan Africa in the current ART era are lacking. The aim of this study was to assess the burden of cardiac stress among PLWH in South Africa via measurement of N-terminal prohormone of brain natriuretic peptide (NT-proBNP).

METHODS AND RESULTS

NT-proBNP was measured at baseline in 224 PLWH enrolled in a sub-study of a tuberculosis vaccine trial in Khayelitsha township near Cape Town, South Africa. Thresholds were applied at the assay's limit of detection (≥137 pg/mL) and a level indicative of symptomatic heart failure in the acute setting (>300 pg/mL). Mean (SD) age of participants was 39 (6) years, 86% were female, and 19% were hypertensive. Mean (SD) duration of HIV diagnosis was 8.3 (3.9) years and CD4 + count was 673 (267) with 79% prescribed ART for a duration of 5.6 (2.7) years. Thirty-one percent of participants had NT-proBNP > 300 pg/mL. Elevated vs. undetectable NT-proBNP level was associated with older age (P = 0.04), no ART (P = 0.03), and higher plasma tumour necrosis factor-α (P = 0.01).

CONCLUSIONS

Among South African PLWH largely free of known CVD and on ART with high CD4 + counts and few comorbidities, we observed a high proportion with elevated NT-proBNP levels, suggesting the burden of cardiac stress in this population may be high. This observation underscores the need for more in-depth research, including the current effect of HIV on heart failure risk among a growing ART-treated population in sub-Saharan Africa.

Prognostic Role of NT-proBNP for in-Hospital and 1-Year Mortality in Patients with Acute Exacerbations of COPD

Background and objective

The association between N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations and in-hospital and 1-year mortality in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients is largely unknown. Our objective was to explore the usefulness of NT-proBNP concentrations in AECOPD patients as a prognostic marker for in-hospital and 1-year mortality.

Methods

NT-proBNP levels were measured in patients upon admission and laboratory and clinical data were also recorded. The cut-point for the NT-proBNP concentration level for in-hospital death was obtained using the receiver operating characteristic (ROC) curve. Univariate and multivariate logistic regression and Cox regression were used in the analyses of factors of in-hospital and 1-year mortality.

Results

A total of 429 patients were enrolled. Twenty-nine patients died during hospitalization and 59 patients died during the 1-year follow-up. Patients who died in-hospital compared with those in-hospital survivors were older (80.14±6.56 vs 75.93±9.45 years, p=0.003), had a higher percentage of congestive heart failure (65.52% vs 33.75%, p<0.001), had higher NT-proBNP levels (5767.00 (1372.50–12,887.00) vs 236.25 (80.03–1074.75) ng/L, p<0.001), higher neutrophil counts (10.52±5.82 vs 7.70±4.31, p=0.016), higher D-dimer levels (1231.62±1921.29 vs 490.11±830.19, p=0.048), higher blood urea nitrogen levels (9.91±6.33 vs 6.51±4.01 mmol/L, p=0.001), a lower body mass index (19.49±3.57 vs 22.19±4.76, p=0.003), and higher hemoglobin levels (122.34±25.36 vs 130.57±19.63, p=0.034). The area under the ROC curve (AUC) for NT-proBNP concentration was 0.88 (95% confidence interval [CI], 0.84–0.93). NT-proBNP concentrations ≥551.35 ng/L were an independent prognostic factor for both in-hospital and 1-year mortality after adjustment for relative risk (RR) (RR=29.54, 95% CI 3.04–286.63, p=0.004 for the multivariate logistic regression analysis) and hazard ratio (HR) (HR=4.47, 95% CI, 2.38–8.41, p <0.001 for the multivariate cox regression analysis).

Conclusion

NT-proBNP was a strong and independent predictor of in-hospital and 1-year mortality in AECOPD patients.

Clinical Applications of Natriuretic Peptides in Heart Failure and Atrial Fibrillation

Natriuretic peptides (NPs) have become important diagnostic and prognostic biomarkers in cardiovascular diseases, particularly in heart failure (HF). Diagnosis and management of coronary artery disease and atrial fibrillation (AF) can also be guided by NP levels. When interpreting NP levels, however, the caveat is that age, sex, body mass index, renal dysfunction, and race affect the clearance of NPs, resulting in different cut-off values in clinical practice. In AF, NP levels have been associated with incident AF in the general population, recurrences after catheter ablation, prediction of clinical prognosis, and the risk of stroke. In this article, we first review and summarize the current evidence and the roles of B-type NP and atrial NP in HF and coronary artery disease and then focus on the increasing utility of NPs in the diagnosis and management of and the research into AF.

Preliminary Results: Can Dual-Energy Computed Tomography Help Distinguish Cardiogenic Pulmonary Edema and Acute Interstitial Lung Disease?

OBJECTIVE

We compared iodine concentration in pulmonary ground-glass opacity on iodine density images of contrast-enhanced chest dual-energy computed tomography (DECT) between patients with cardiogenic pulmonary edema (CPE) and acute interstitial lung disease (AILD).

METHODS

Five of 12 patients who underwent contrast-enhanced chest DECT to exclude pulmonary embolism were clinically diagnosed with CPE and 7, with AILD. We compared the mean CT value on monochromatic images at 65 keV and iodine concentration on iodine density images between the affected and normal areas.

RESULTS

The mean iodine concentrations were comparable between the affected and normal areas (P = 0.3048) in patients with CPE and were significantly higher in the affected than in the normal areas in those with AILD (P < 0.0001).

CONCLUSIONS

Measurement of iodine concentration in pulmonary ground-glass opacity of contrast-enhanced chest DECT has the potential to help distinguish CPE and AILD.

The association of N-terminal pro-brain-type natriuretic peptide with hemodynamics and functional capacity in therapy-naive precapillary pulmonary hypertension: results from a cohort study

Background

N-terminal pro-brain-type natriuretic peptide (NT-proBNP) is currently used as a surrogate marker for disease severity in pulmonary hypertension (PH). However, NT-proBNP tends to have a high variability and may insufficiently correlate with hemodynamics and exercise capacity.

Methods

To investigate the association of NT-proBNP with hemodynamics and cardio-pulmonary exercise testing (CPET) in 84 therapy-naive patients with precapillary PH.

Results

NT-proBNP levels were significantly correlated with hemodynamics and CPET parameters except for cardiac index, diffusion capacity, PaO₂ at peak exercise, and peak minute ventilation. NT-proBNP correlated best with hemodynamics and CPET in women and patients >65 years. NT-proBNP correlated better with CPET in pulmonary arterial hypertension compared to chronic thromboembolic PH (CTEPH).

Conclusion

NT-proBNP is associated with disease severity in precapillary PH. The association might be age- and gender-dependent. NT-proBNP may insufficiently correlate with disease severity in CTEPH, possibly due to comorbidity.

The ratio of D-dimer to brain natriuretic peptide may help to differentiate between cerebral infarction with and without acute aortic dissection

BACKGROUND

Previous studies reported that the plasma d-dimer level reflects the activity of thrombus formation in the left atrium of patients with acute cerebral infarction and acute aortic dissection (AAD). Brain natriuretic peptide (BNP) is considered to be a marker of chronic heart failure. The differential diagnosis in the emergency room between stroke due to cardioembolism and AAD is difficult but important for early treatment especially in patients requiring intravenous thrombolysis with a recombinant tissue-type plasminogen activator. We aimed to investigate the association between the plasma d-dimer and BNP levels in patients with cerebral infarction and AAD.

METHODS

We identified 115 consecutive patients with ischemic stroke who were admitted within 72 h of symptom onset and 15 consecutive patients with AAD and measured the level of plasma d-dimer and BNP and the d-dimer:BNP ratio.

RESULTS

In patients with AAD the d-dimer level was significantly higher than that in patients with any other stroke subtypes and their BNP level was significantly lower than that in patients with cardioembolic stroke. The d-dimer:BNP ratio was significantly higher in patients with AAD than in those with any other stroke subtype. Compared to patients with a cardioembolic stroke subtype they manifested significantly higher d-dimer levels and d-dimer:BNP ratios suggesting that this ratio may help to diagnose cerebral infarction due to AAD (sensitivity 80%, specificity 93.5%, cut-off 0.074). When the population was limited to patients within 6h of onset, the ratio had higher sensitivity and specificity at the same cut-off value (sensitivity 81.8%, specificity 96.4%).

CONCLUSION

We found that the d-dimer:BNP ratio may be helpful in distinguishing between cerebral infarction with and without AAD.

Effect of enhanced external counterpulsation treatment on renal function in cardiac patients

Background

Enhanced external counterpulsation (EECP) enhances coronary perfusion and reduces left ventricular afterload. However, the role of EECP on renal function in cardiac patients is unknown. Our aim was to assess renal function determined by serum cystatin C in cardiac patients before and after EECP treatment.

Methods

A prospective observational longitudinal study was conducted in order to evaluate renal function using serum cystatin C (Cys C) and estimated glomerular filtration rate (GFR) after 35 sessions of EECP treatment in 30 patients with chronic stable angina and/or heart failure. The median (IQR) time for follow-up period after starting EECP treatment was 16 (10–24) months.

Results

Cys C significantly declined from 1.00 (0.78-1.31) to 0.94 (0.77-1.27) mg/L (p < 0.001) and estimated GFR increased from 70.47 (43.88-89.41) to 76.27 (49.02-91.46) mL/min/1.73 m² (p = 0.006) after EECP treatment. Subgroup analysis showed that patients with baseline GFR <60 mL/min/1.73 m² or NT-proBNP >125 pg/mL had a significant decrease in Cys C when compared to other groups (p < 0.01).

Conclusions

The study demonstrated that EECP could improve long-term renal function in cardiac patients especially in cases with declined renal function or with high NT-proBNP.

Trial registration

The study was registered in the clinical trial as International Standard Randomized Controlled Trial Number ISRCTN11560035.

Utility of biomarkers in the differential diagnosis of heart failure in older people: findings from the heart failure in care homes (HFinCH) diagnostic accuracy study

Background

The performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF).

Methods

This is the first diagnostic accuracy study in this population to assess the differential diagnostic performance and acceptability of a range of biomarkers against a clinical diagnosis using portable echocardiography. A total of 405 residents, aged 65–100 years (mean 84.2), in 33 UK long-term care facilities were enrolled between April 2009 and June 2010.

Results

For undifferentiated HF, BNP or NT-proBNP were adequate rule-out tests but would miss one in three cases (BNP: sensitivity 67%, NPV 86%, cut-off 115 pg/ml; NT-proBNP: sensitivity 62%, NPV 87%, cut-off 760 pg/ml). Using higher test cut-offs, both biomarkers were more adequate tests of LVSD, but would still miss one in four cases (BNP: sensitivity 76%, NPV 97%, cut-off 145 pg/ml; NT-proBNP: sensitivity 73%, NPV 97%, cut-off 1000 pg/ml). At these thresholds one third of subjects would test positive and require an echocardiogram. Applying a stricter ‘rule out’ threshold (sensitivity 90%), only one in 10 cases would be missed, but two thirds of subjects would require further investigation. Biomarkers were less useful for HFpEF (BNP: sensitivity 63%, specificity 61%, cut-off 110 pg/ml; NT-proBNP: sensitivity 68%, specificity 56%, cut-off 477 pg/ml). Novel biomarkers (Copeptin, MR-proADM, and MR-proANP) and common signs and symptoms had little diagnostic utility.

Conclusions

No test, individually or in combination, adequately balanced case finding and rule-out for heart failure in this population; currently, in-situ echocardiography provides the only adequate diagnostic assessment.

Trial Registration

Controlled-Trials.com ISRCTN19781227

Rapid point-of-care NT-proBNP optimal cut-off point for heart failure diagnosis in primary care

INTRODUCTION AND OBJECTIVES

Measurement of natriuretic peptides may be recommended prior to echocardiography in patients with suspected heart failure. Cut-off point for heart failure diagnosis in primary care is not well established. We aimed to assess the optimal diagnostic cut-off value of N-terminal pro-B-type natriuretic peptide on a community population attended in primary care.

METHODS

Prospective diagnostic accuracy study of a rapid point-of-care N-terminal pro-B-type natriuretic peptide test in a primary healthcare centre. Consecutive patients referred by their general practitioners to echocardiography due to suspected heart failure were included. Clinical history and physical examination based on Framingham criteria, electrocardiogram, chest X-ray, N-terminal pro-B-type natriuretic peptide measurement and echocardiogram were performed. Heart failure diagnosis was made by a cardiologist blinded to N-terminal pro-B-type natriuretic peptide value, using the European Society of Cardiology diagnosis criteria (clinical and echocardiographic data).

RESULTS

Of 220 patients evaluated (65.5% women; median 74 years [interquartile range 67-81]). Heart failure diagnosis was confirmed in 52 patients (23.6%), 16 (30.8%) with left ventricular ejection fraction <50% (39.6 [5.1]%). Median values of N-terminal pro-B-type natriuretic peptide were 715 pg/mL [interquartile range 510.5-1575] and 77.5 pg/mL [interquartile range 58-179.75] for patients with and without heart failure respectively. The best cut-off point was 280 pg/mL, with a receiver operating characteristic curve of 0.94 (95% confidence interval, 0.91-0.97). Six patients with heart failure diagnosis (11.5%) had N-terminal pro-B-type natriuretic peptide values <400 pg/mL. Measurement of natriuretic peptides would avoid 67% of requested echocardiograms.

CONCLUSIONS

In a community population attended in primary care, the best cut-off point of N-terminal pro-B-type natriuretic peptide to rule out heart failure was 280 pg/mL. N-terminal pro-B-type natriuretic peptide measurement improve work-out diagnoses and could be cost-effectiveness.

Practical use of natriuretic peptide measurement: questionnaire results from general practitioners and cardiologists

AIMS

To elucidate the knowledge regarding B-type natriuretic peptide (BNP)/N-terminal proBNP (NT-proBNP) measurement among doctors using this biomarker.

MATERIALS & METHODS

We performed a questionnaire-based study on the use of BNP/NT-proBNP measurement among doctors; 21 general practitioners and 23 randomly chosen doctors at cardiology departments were interviewed.

RESULTS

12 general practitioners (57%) answered 'yes', eight (38%) answered 'no' and one (5%) was 'undecided' for use of BNP/NT-proBNP measurement to exclude a diagnosis of heart failure. Among cardiologists, 11 (48%) answered 'yes', ten (43%) answered 'no' and two (9%) were 'undecided' (no difference between groups, p = 0.56). The majority of doctors were familiar with BNP/NT-proBNP being affected by age but were unaware of the impact of gender and obesity.

CONCLUSION

We propose that BNP/NT-proBNP measurement results should be supplied with age- and gender-related cut-off values, along with a notion of the negative predictive value and other parameters affecting the concentration in plasma.

Effects of rosuvastatin on progression of stenosis in adult patients with congenital aortic stenosis (PROCAS Trial)

Recent trials have failed to show that statin therapy halts the progression of calcific aortic stenosis (AS). We hypothesized that statin therapy in younger patients with congenital AS would be more beneficial, because the valve is less calcified. In the present double-blind, placebo-controlled trial, 63 patients with congenital AS (age 18 to 45 years) were randomly assigned to receive either 10 mg of rosuvastatin daily (n = 30) or matched placebo (n = 33). The primary end point was the progression of peak aortic valve velocity. The secondary end points were temporal changes in the left ventricular mass, ascending aortic diameter, and N-terminal pro-brain natriuretic peptide (NT-proBNP). The median follow-up was 2.4 years (interquartile range 1.9 to 3.0). The mean increase in peak velocity was 0.05 ± 0.21 m/s annually in the rosuvastatin group and 0.09 ± 0.24 m/s annually in the placebo group (p = 0.435). The annualized change in the ascending aorta diameter (0.4 ± 1.7 mm with rosuvastatin vs 0.5 ± 1.6 mm with placebo; p = 0.826) and left ventricular mass (1.1 ± 15.8 g with rosuvastatin vs -3.7 ± 30.9 g with placebo; p = 0.476) were not significantly different between the 2 groups. Within the statin group, the NT-proBNP level was 50 pg/ml (range 19 to 98) at baseline and 21 pg/ml (interquartile range 12 to 65) at follow-up (p = 0.638). NT-proBNP increased from 40 pg/ml (interquartile range 20 to 92) to 56 pg/ml (range 26 to 130) within the placebo group (p = 0.008). In conclusion, lipid-lowering therapy with rosuvastatin 10 mg did not reduce the progression of congenital AS in asymptomatic young adult patients. Interestingly, statins halted the increase in NT-proBNP, suggesting a potential positive effect of statins on cardiac function in young patients with congenital AS.

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.

High N-terminal pro-B-type natriuretic peptide: a biomarker of lung cancer?

BACKGROUND

The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is affected by many known factors. Our study aimed to evaluate whether other factors, in particular lung cancer, could be responsible for an increase in NT-proBNP levels in a population with no known risk factors for elevated NT-proBNP.

PATIENTS AND METHODS

This study was based on the RIABO (Recueil de l'Ischémie au Bloc Opératoire) database, a single-center registry that prospectively records in elective noncardiac surgery. Patients aged > 75 years and those presenting with 1 or more known risk factors for high NT-proBNP were excluded. Patients were divided into 2 groups according to preoperative NT-proBNP levels: (≥ 125 pg/mL or < 125 pg/mL).

RESULTS

Between October 2005 and February 2007, 439 patients were eligible for inclusion. Among 35 patients with lung cancer, 26 (74%) had elevated NT-proBNP (≥ 125 pg/mL), versus 9 (26%) with NT-proBNP < 125 pg/mL (P < .0001). By multivariate analysis, the presence of lung cancer was an independent risk factor for a level of NT-proBNP ≥ 125 pg/mL (odds ratio, 7; 95% CI, 2.9-17; P < .0001). We also observed an independent relationship between NT-proBNP ≥ 125 pg/mL and age, female sex, smoking status, and C-reactive protein levels.

CONCLUSION

In our study, patients with lung cancer were 7 times more likely to have elevated NT-proBNP (≥ 125 pg/mL). The presence of lung cancer should therefore be taken into account when interpreting NT-proBNP levels. Further studies are warranted to explore the diagnostic value of this marker in lung cancer and to identify the cause of the elevation.

Effectiveness of thrombolysis in patients with intermediate-risk pulmonary embolism: influence on length of hospital stay

INTRODUCTION

The effects of thrombolysis on the clinical outcome of patients with intermediate-risk pulmonary embolism (PE) are still under debate. The effect of thrombolysis on the length of stay (LOS) in hospital is unknown. The aim of this study was to identify factors associated with LOS and to investigate whether LOS is suitable to assess effectiveness of thrombolysis in patients with intermediate-risk PE.

METHODS

Data were reviewed from December 2005 until October 2009. The LOS in the intensive care unit (ICU) was expressed in hours, and total LOS was recorded in days. Total LOS was not noted in case of preterm withdrawal of therapy or death.

RESULTS

Of a total of 202 patients, 84 received alteplase plus heparin and 118 patients were treated with anticoagulants alone. Total median LOS was significantly shorter (10 vs. 12 days) in the alteplase group (P=0.005), while there was no difference in the LOS in the ICU. Age above 65 years (P=0.036) and comorbidity (P<0.001) were independent predictors for a prolonged hospital stay, whereas thrombolysis independently predicted a shorter total LOS in multivariate analysis (P=0.001). Thrombolysis has shown to be able to independently predict home discharge (P=0.029).

CONCLUSION

LOS is influenced by patient-related factors such as age and comorbidity. Thrombolysis may lead to a reduction of total median LOS for patients with intermediate-risk PE, possibly indicating that it is more effective than anticoagulant therapy alone in this group of patients.

Age-dependent values of N-terminal pro-B-type natriuretic peptide are superior to a single cut-point for ruling out suspected systolic dysfunction in primary care

AIMS

The study evaluated the use of age-related decision limits for N-terminal pro-B-type natriuretic peptide (NT-proBNP), for ruling out suspected systolic dysfunction in symptomatic patients in primary care, compared with the present standards.

METHODS AND RESULTS

Data were obtained from 5508 patients from 10 studies in the UK, New Zealand, Europe, and USA. All have had NT-proBNP analysis and echocardiography. The median age was 62 years (range 18-100 years) with a prevalence of reduced left ventricular systolic function (left ventricular ejection fraction < or =40%) of 18%. In a receiver operating characteristic curve analysis, overall area under the curve (AUC) was 0.89. When looking at different age groups, AUC was highest (0.95) for <50 years, intermediate (0.90) for 50-75 years, and lowest (0.82) for >75 years. Using optimized decision limits, sensitivity, specificity, and negative predictive values (NPVs) were: <50 years (50 ng/L): 99.2, 57.2, and 99.7%; 50-75 years (75 ng/L): 95.9, 51.0, and 96.8%; and >75 years (250 ng/L): 87.9, 53.7, and 92.4%, respectively. Using only a single decision value (125 ng/L for all ages) gave sensitivities of 89.1, 91.9, and 94.3%; specificities of 84.0, 69.1, and 29.3% and NPVs of 97.7, 97.6, and 93.4%. A decision value of 400 ng/L for all ages gave much lower sensitivities.

CONCLUSION

In a large population of patients in primary care, the use of age-stratified NT-proBNP decision limits considerably improves performance over current standards, with an excellent NPV for exclusion of reduced left ventricular systolic function.

Amino-terminal pro-B-type natriuretic peptide testing in patients with diabetes mellitus and with systemic hypertension

Although the current value of amino-terminal pro-B-type natriuretic peptides (NT-proBNP) to generally screen populations of "apparently well patients" remains promising but still undefined, the use of NT-proBNP to screen patients at high risk for heart disease (such as elderly patients, or patients with diabetes mellitus, hypertension, or known coronary artery disease) appears logical and is supported by data. NT-proBNP has strong prognostic value in such at-risk patients. However, the exact implications for clinical management after detection of an elevated NT-proBNP value should be driven by clinical judgment. At present, data suggest that when an elevated NT-proBNP is detected in an at-risk patient, it is a high-risk finding. In this context, consideration for a more in-depth cardiovascular workup, as well as initiation or intensification of medical therapies with proven benefits might be indicated.