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Rist A, Sevre K, Wachtell K, Devereux RB, Aurigemma GP, Smiseth OA, Kjeldsen SE, Julius S, Pitt B, Burnier M, Kreutz R, Oparil S, Mancia G, Zannad F. The current best drug treatment for hypertensive heart failure with preserved ejection fraction. Eur J Intern Med 2024; 120:3-10. [PMID: 37865559 DOI: 10.1016/j.ejim.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
More than 90 % of patients developing heart failure (HF) have hypertension. The most frequent concomitant conditions are type-2 diabetes mellitus, obesity, atrial fibrillation, and coronary disease. HF outcome research focuses on decreasing mortality and preventing hospitalization for worsening HF syndrome. All drugs that decrease these HF endpoints lower blood pressure. Current drug treatments for HF are (i) angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors, (ii) selected beta-blockers, (iii) steroidal and non-steroidal mineralocorticoid receptor antagonists, and (iv) sodium-glucose cotransporter 2 inhibitors. For various reasons, these drug treatments were first studied in HF patients with a reduced ejection fraction (HFrEF). Subsequently, they have been investigated in HF patients with a preserved left ventricular ejection fraction (LVEF, HFpEF) of mostly hypertensive etiology, and with modest benefits largely assessed on top of background treatment with the drugs already proven effective in HFrEF. Additionally, diuretics are given on symptomatic indications. Patients with HFpEF may have diastolic dysfunction but also systolic dysfunction visualized by lack of longitudinal shortening. Considering the totality of evidence and the overall need for antihypertensive treatment and/or treatment of hypertensive complications in almost all HF patients, the principal drug treatment of HF appears to be the same regardless of LVEF. Rather than LVEF-guided treatment of HF, treatment of HF should be directed by symptoms (related to the level of fluid retention), signs (tachycardia), severity (NYHA functional class), and concomitant diseases and conditions. All HF patients should be given all the drug classes mentioned above if well tolerated.
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Affiliation(s)
- Aurora Rist
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kaja Sevre
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristian Wachtell
- Weill-Cornell Medicine, Division of Cardiology, New York City, NY, USA
| | | | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan School of Medicine, Worcester, MA, USA
| | - Otto A Smiseth
- Institute for Surgical Research and Department of Cardiology, University of Oslo, Rikshospitalet, Oslo, Norway
| | - Sverre E Kjeldsen
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Ullevaal Hospital, Oslo, Norway; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Stevo Julius
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Bertram Pitt
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michel Burnier
- Centre Hospitalier Universitaire Vaudois, Service of Nephrology and Hypertension, Lausanne, Switzerland
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | | | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques-1433 and F-CRIN INI CRCT, Universite de Lorraine, Nancy, France
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Sevre K, Rist A, Wachtell K, Devereux RB, Aurigemma GP, Smiseth OA, Kjeldsen SE, Julius S, Pitt B, Burnier M, Kreutz R, Oparil S, Mancia G, Zannad F. What Is the Current Best Drug Treatment for Hypertensive Heart Failure With Preserved Ejection Fraction? Review of the Totality of Evidence. Am J Hypertens 2024; 37:1-14. [PMID: 37551929 PMCID: PMC10724525 DOI: 10.1093/ajh/hpad073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND More than 90% of patients developing heart failure (HF) have an epidemiological background of hypertension. The most frequent concomitant conditions are type 2 diabetes mellitus, obesity, atrial fibrillation, and coronary disease, all disorders/diseases closely related to hypertension. METHODS HF outcome research focuses on decreasing mortality and preventing hospitalization for worsening HF syndrome. All drugs that decrease these HF endpoints lower blood pressure. Current drug treatments for HF are (i) angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors, (ii) selected beta-blockers, (iii) steroidal and nonsteroidal mineralocorticoid receptor antagonists, and (iv) sodium-glucose cotransporter 2 inhibitors. RESULTS For various reasons, these drug treatments were first studied in HF patients with a reduced ejection fraction (HFrEF). However, subsequently, they have been investigated and, as we see it, documented as beneficial in HF patients with a preserved left ventricular ejection fraction (LVEF, HFpEF) and mostly hypertensive etiology, with effect estimates assessed partly on top of background treatment with the drugs already proven effective in HFrEF. Additionally, diuretics are given on symptomatic indications. CONCLUSIONS Considering the totality of evidence and the overall need for antihypertensive treatment and/or treatment of hypertensive complications in almost all HF patients, the principal drug treatment of HF appears to be the same regardless of LVEF. Rather than LVEF-guided treatment of HF, treatment of HF should be directed by symptoms (related to the level of fluid retention), signs (tachycardia), severity (NYHA functional class), and concomitant diseases and conditions. All HF patients should be given all the drug classes mentioned above if well tolerated.
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Affiliation(s)
- Kaja Sevre
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
| | - Aurora Rist
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
| | - Kristian Wachtell
- Weill-Cornell Medicine, Division of Cardiology, New York City, New York, USA
| | - Richard B Devereux
- Weill-Cornell Medicine, Division of Cardiology, New York City, New York, USA
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, UMassChan School of Medicine, Worcester, Massachusetts, USA
| | - Otto A Smiseth
- University of Oslo, Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo, Norway
| | - Sverre E Kjeldsen
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
- Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Stevo Julius
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Bertram Pitt
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Reinhold Kreutz
- Charité – Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Suzanne Oparil
- University of Alabama at Birmingham, Vascular Biology and Hypertension Program, Department of Medicine, Birmingham, Alabama, USA
| | | | - Faiez Zannad
- Universite de Lorraine, Inserm, Centre d’Investigations Cliniques-1433 and F-CRIN INI CRCT, Nancy, France
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Chaikijurajai T, Rincon-Choles H, Tang WHW. Natriuretic peptide testing strategies in heart failure: A 2023 update. Adv Clin Chem 2023; 118:155-203. [PMID: 38280805 DOI: 10.1016/bs.acc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.
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Affiliation(s)
- Thanat Chaikijurajai
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hernan Rincon-Choles
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States.
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Lee KK, Doudesis D, Anwar M, Astengo F, Chenevier-Gobeaux C, Claessens YE, Wussler D, Kozhuharov N, Strebel I, Sabti Z, deFilippi C, Seliger S, Moe G, Fernando C, Bayes-Genis A, van Kimmenade RRJ, Pinto Y, Gaggin HK, Wiemer JC, Möckel M, Rutten JHW, van den Meiracker AH, Gargani L, Pugliese NR, Pemberton C, Ibrahim I, Gegenhuber A, Mueller T, Neumaier M, Behnes M, Akin I, Bombelli M, Grassi G, Nazerian P, Albano G, Bahrmann P, Newby DE, Japp AG, Tsanas A, Shah ASV, Richards AM, McMurray JJV, Mueller C, Januzzi JL, Mills NL. Development and validation of a decision support tool for the diagnosis of acute heart failure: systematic review, meta-analysis, and modelling study. BMJ 2022; 377:e068424. [PMID: 35697365 PMCID: PMC9189738 DOI: 10.1136/bmj-2021-068424] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2012] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics. DESIGN Individual patient level data meta-analysis and modelling study. SETTING Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies. PARTICIPANTS Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated. MAIN OUTCOME MEASURE Adjudicated diagnosis of acute heart failure. RESULTS Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure. CONCLUSIONS In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach. STUDY REGISTRATION PROSPERO CRD42019159407.
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Affiliation(s)
- Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Mohamed Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Federica Astengo
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Yann-Erick Claessens
- Department of Emergency Medicine, Princess Grace Hospital Center, Monaco, Principality of Monaco
| | - Desiree Wussler
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ivo Strebel
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Zaid Sabti
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Stephen Seliger
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gordon Moe
- University of Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Carlos Fernando
- University of Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, CIBERCV, Spain
| | | | - Yigal Pinto
- University of Amsterdam, Amsterdam, Netherlands
| | - Hanna K Gaggin
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jan C Wiemer
- BRAHMS, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Martin Möckel
- Department of Emergency and Acute Medicine with Chest Pain Units, Charité - Universitätsmedizin Berlin, Campus Mitte and Virchow, Berlin, Germany
| | - Joost H W Rutten
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Anton H van den Meiracker
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, Singapore
| | - Alfons Gegenhuber
- Department of Internal Medicine, Krankenhaus Bad Ischl, Bad Ischl, Austria
| | - Thomas Mueller
- Department of Laboratory Medicine, Hospital Voecklabruck, Voecklabruck, Austria
| | - Michael Neumaier
- Institute for Clinical Chemistry, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michele Bombelli
- University of Milan Bicocca, ASST-Brianza, Pio XI Hospital of Desio, Internal Medicine, Desio, Italy
| | - Guido Grassi
- Clinica Medica, University Milan Bicocca, Milan, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Albano
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Philipp Bahrmann
- Department of Internal Medicine III, Division of Cardiology, University Hospital of Heidelberg, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alan G Japp
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
- Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Christian Mueller
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - James L Januzzi
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Bertolino L, Ursi MP, Iossa D, Karruli A, D’Amico F, Zampino R, Dialetto G, De Feo M, Durante-Mangoni E, Durante-Mangoni E, Iossa D, Bertolino L, Ursi MP, D’Amico F, Karruli A, Ramadan M, Andini R, Zampino R, Bernardo M, Ruocco G, Dialetto G, Covino FE, Manduca S, Della Corte A, De Santo LS, Carozza A, De Feo M, De Vivo MD S, De Rimini ML, Galdieri N. Dissecting the correlates of N-terminal prohormone brain natriuretic peptide in acute infective endocarditis. Infection 2022; 50:1465-1474. [PMID: 35430641 PMCID: PMC9705495 DOI: 10.1007/s15010-022-01813-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/22/2022] [Indexed: 11/05/2022]
Abstract
Abstract
Purpose
To explore the prognostic value and the correlates of NT-proBNP in patients with acute infective endocarditis, a life-threatening disease, with an often unpredictable outcome given by the lack of reliable prognostic parameters.
Methods
We retrospectively studied 337 patients admitted to our centre between January 1, 2006 and September 30, 2020 with available NT-proBNP level at admission. Our analyses were performed considering NT-proBNP as both a categorical variable, using the median value as the cut-off level, and numerical variable. Study end points were in-hospital mortality, cardiac surgery and 1 year survival.
Results
NT-proBNP was an independent predictor of in-hospital mortality (OR 14.9 [95%C.I. 2.46–90.9]; P = .003). Levels below 2926 pg/mL were highly predictive of a favorable in-hospital outcome (negative predictive value 96.6%). Patients with higher NT-proBNP levels showed a significantly lower survival rate at 1 year follow-up (log-rank P = .005). NT-proBNP was strongly associated with chronic kidney disease (P < .001) and significantly higher in patients with prior chronic heart failure (P = .001). NT-proBNP was tightly related to staphylococcal IE (P = .001) as well as with higher CRP and hs-troponin I (P = 0.023, P < .001, respectively).
Conclusion
Our results confirm the remarkable prognostic role of NT-proBNP in patients with IE and provide novel evidences of its multifaceted correlates in this unique clinical setting. Our data strongly support the incorporation of NT-proBNP into the current diagnostic work-up of IE.
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6
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Jiang H, Holm J, Friberg Ö, Vanky F, Vidlund M, Tajik B, Yang Y, Svedjeholm R. Utility of NT-proBNP as an objective marker of postoperative heart failure after coronary artery bypass surgery: a prospective observational study. Perioper Med (Lond) 2021; 10:21. [PMID: 34253255 PMCID: PMC8275184 DOI: 10.1186/s13741-021-00194-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/04/2021] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative heart failure (PHF) is the main cause for mortality after cardiac surgery but unbiased evaluation of PHF is difficult. We investigated the utility of postoperative NT-proBNP as an objective marker of PHF after coronary artery bypass surgery (CABG). Methods Prospective study on 382 patients undergoing isolated CABG for acute coronary syndrome. NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A blinded Endpoints Committee used prespecified criteria for PHF. Use of circulatory support was scrutinized. Results After adjusting for confounders PHF was associated with 1.46 times higher NT-proBNP on POD1 (p = 0.002), 1.54 times higher on POD3 (p < 0.0001). In severe PHF, NT-proBNP was 2.18 times higher on POD1 (p = 0.001) and 1.81 times higher on POD3 (p = 0.019). Postoperative change of NT-proBNP was independently associated with PHF (OR 5.12, 95% CI 1.86–14.10, p = 0.002). The use of inotropes and ICU resources increased with incremental quartiles of postoperative NT-proBNP. Conclusions Postoperative NT-proBNP can serve as an objective marker of the severity of postoperative myocardial dysfunction. Due to overlap in individuals, NT-proBNP is useful mainly for comparisons at cohort level. As such, it provides a tool for study purposes when an unbiased assessment of prevention or treatment of PHF is desirable. Trial registration ClinicalTrials.gov Identifier: NCT00489827https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00194-4.
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Affiliation(s)
- Huiqi Jiang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Jonas Holm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Farkas Vanky
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bashir Tajik
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Yanqi Yang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Rolf Svedjeholm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.
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7
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Ibrahim NE, Burnett JC, Butler J, Camacho A, Felker GM, Fiuzat M, O'Connor C, Solomon SD, Vaduganathan M, Zile MR, Januzzi JL. Natriuretic Peptides as Inclusion Criteria in Clinical Trials: A JACC: Heart Failure Position Paper. JACC-HEART FAILURE 2020; 8:347-358. [PMID: 32171762 DOI: 10.1016/j.jchf.2019.12.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/06/2019] [Accepted: 12/19/2019] [Indexed: 12/17/2022]
Abstract
This study investigated the use of natriuretic peptides as inclusion criteria and to develop recommendations regarding their use. B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are commonly used as inclusion criteria for heart failure (HF) clinical trials, but no consensus exists regarding their optimal use for this purpose. A comprehensive search of the Aggregate Analysis of ClincalTrials.gov database identified 3,446 HF trials. Of these, 365 recently completed or ongoing HF clinical trials (10.6%) used either BNP or NT-proBNP as inclusion criteria. A panel of experts discussed current practices and a path forward for the use of natriuretic peptides as inclusion criteria for HF trials. Significant variations existed across trials regarding which natriuretic peptide and which cutoff value were used. Overall, 43% used both natriuretic peptides, 33% used only NT-proBNP, and 24% used only BNP in determining eligibility. Studies using BNP and NT-proBNP concentrations as inclusion criteria had higher cardiovascular event rates and higher concentrations for study entry and were generally associated with higher event rates. Areas of uncertainty included use in certain patient populations in which natriuretic peptides are historically lower (e.g., black patients, obese patients, patients with HF with preserved ejection fraction) or higher (older patients, patients with atrial fibrillation). This paper discusses best practices regarding use of BNP or NT-proBNP in clinical trials and identification of gaps in medical literature, including importance of documentation in ClinicalTrials.gov studies to inform future research efforts.
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Affiliation(s)
- Nasrien E Ibrahim
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Javed Butler
- Cardiology Division, University of Mississippi, Jackson, Mississippi
| | - Alexander Camacho
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Mona Fiuzat
- Cardiology Division, Duke University, Durham, North Carolina
| | - Christopher O'Connor
- Cardiology Division, Duke University, Durham, North Carolina; Inova Heart and Vascular Institute, Fairfax, Virginia
| | - Scott D Solomon
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael R Zile
- Medical University of South Carolina, Charleston, South Carolina, and Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
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8
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van den Kerkhof JJ, Van der Sande FM, Leunissen K, Kooman JP. Are Natriuretic Peptides Useful Biomarkers in Dialysis Patients? Perit Dial Int 2020. [DOI: 10.1177/089686080702700606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jos J. van den Kerkhof
- Division of Nephrology Department of Internal Medicine University Hospital Maastricht Maastricht, The Netherlands
| | - Frank M. Van der Sande
- Division of Nephrology Department of Internal Medicine University Hospital Maastricht Maastricht, The Netherlands
| | - Karel Leunissen
- Division of Nephrology Department of Internal Medicine University Hospital Maastricht Maastricht, The Netherlands
| | - Jeroen P. Kooman
- Division of Nephrology Department of Internal Medicine University Hospital Maastricht Maastricht, The Netherlands
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Thanh BD, Son NH, Pho DC, Bac ND, Nga VT, Dung QA, Anh DD, Linh DD, Viet HTB, Anh BDT, Tan HT, Hung PN. The Role of Serial NT-ProBNP Level in Prognosis and Follow-Up Treatment of Acute Heart Failure after Coronary Artery Bypass Graft Surgery. Open Access Maced J Med Sci 2019; 7:4411-4415. [PMID: 32215104 PMCID: PMC7084009 DOI: 10.3889/oamjms.2019.872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: After coronary artery bypass graft (CABG) surgery, heart failure is still major problem. The valuable marker for it is needed. AIM: Evaluating the role of serial NT-proBNP level in prognosis and follow-up treatment of acute heart failure after CABG surgery. METHODS: The prospective, analytic study evaluated 107 patients undergoing CABG surgery at Ho Chi Minh Heart Institute from October 2012 to June 2014. Collecting data was done at pre- and post-operative days with measuring NT-proBNP levels on the day before operation, 2 hours after surgery, every next 24 h until the 5th day, and in case of acute heart failure occurred after surgery. RESULTS: On the first postoperative day (POD1), the NT-proBNP level demonstrated significant value for AHF with the cut-off point = 817.8 pg/mL and AUC = 0.806. On the second and third postoperative day, the AUC value of NT- was 0.753 and 0.751. It was statistically significant in acute heart failure group almost at POD 1 and POD 2 when analyzed by the doses of dobutamine, noradrenaline, and adrenaline (both low doses and normal doses). CONCLUSION: Serial measurement of NT-proBNP level provides useful prognostic and follow-up treatment information in acute heart failure after CABG surgery.
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Affiliation(s)
- Bui Duc Thanh
- Intensive Care Unit, 175 Military Hospital, Ho Chi Minh City, Vietnam
| | | | - Dinh Cong Pho
- Faculty of Medicine, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Duy Bac
- Department of Training, Vietnam Military Medical University, Hanoi, Vietnam
| | - Vu Thi Nga
- Institute for Research and Development, Duy Tan University, 03 Quang Trung, Danang, Vietnam
| | - Quan Anh Dung
- Faculty of Medicine, Vietnam Military Medical University, Hanoi, Vietnam
| | - Do Duc Anh
- Faculty of Medicine, University of Medical Sciences of Revolutionary Armed Force (UCIMED de Las FAR), Marianao, Havana, Cuba
| | - Do Dieu Linh
- Faculty of Medicine, Hai Phong Medical University, 72A Nguyen Binh Khiem, Hai Phong, Vietnam
| | - Hoang Thi Bich Viet
- Department of Occupational Lung Disease, National Lung Hospital, 463 Hoang Hoa Tham, Ba Dinh, Ha Noi, Vietnam
| | - Bui Dang The Anh
- Department of Epidemiology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Ha The Tan
- Department of Epidemiology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Pham Ngoc Hung
- Department of Training, Vietnam Military Medical University, Hanoi, Vietnam.,Department of Epidemiology, Vietnam Military Medical University, Hanoi, Vietnam
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McCullough PA, Kluger AY. Interpreting the Wide Range of NT-proBNP Concentrations in Clinical Decision Making. J Am Coll Cardiol 2019; 71:1201-1203. [PMID: 29544602 DOI: 10.1016/j.jacc.2018.01.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Peter A McCullough
- Baylor University Medical Center, Dallas, Texas; Baylor Heart and Vascular Institute, Dallas, Texas; Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; Baylor Scott & White Research Institute, Dallas, Texas.
| | - Aaron Y Kluger
- Baylor Heart and Vascular Institute, Dallas, Texas; Baylor Scott & White Research Institute, Dallas, Texas
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Otaki Y, Watanabe T, Sato N, Shirata T, Kato S, Tamura H, Nishiyama S, Arimoto T, Takahashi H, Shishido T, Morikane K, Watanabe M. Brain Natriuretic Peptide (BNP) and N-Terminal-proBNP in Cardio-Renal Anemia Syndrome ― Difference in Prognostic Ability ―. Circ Rep 2019. [DOI: 10.1253/circrep.cr-18-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Naohito Sato
- Division of Clinical Laboratory, Yamagata University Hospital
| | - Toru Shirata
- Division of Clinical Laboratory, Yamagata University Hospital
| | - Shigehiko Kato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsuro Shishido
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Keita Morikane
- Division of Clinical Laboratory and Infection Control, Yamagata University Hospital
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
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Pervez MO, Winther JA, Brynildsen J, Strand H, Christensen G, Høiseth AD, Myhre PL, Røysland R, Lyngbakken MN, Omland T, Røsjø H. Prognostic and diagnostic significance of mid-regional pro-atrial natriuretic peptide in acute exacerbation of chronic obstructive pulmonary disease and acute heart failure: data from the ACE 2 Study. Biomarkers 2018; 23:654-663. [PMID: 29733687 DOI: 10.1080/1354750x.2018.1474258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the diagnostic and prognostic value of mid-regional pro-ANP (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with acute dyspnea. METHODS MR-proANP and NT-proBNP were measured with commercial immunoassays at hospital admission (n = 313), on day 2 (n = 234), and before discharge (n = 91) and compared for diagnosing acute heart failure (HF; n = 143) and to predict mortality among patients with acute HF and acute exacerbation of chronic obstructive pulmonary disease (AECOPD; n = 84) separately. RESULTS The correlation coefficient between MR-proANP and NT-proBNP was 0.89 (p < 0.001) and the receiver-operating area under the curve (AUC) was 0.85 (95% CI 0.81-0.89) for MR-proANP and 0.86 (0.82-0.90) for NT-proBNP to diagnose acute HF. During a median follow-up of 816 days, mortality rates were 46% in acute HF patients and 42% in AECOPD patients. After adjustment for other risk variables by multivariate Cox regression analysis, MR-proANP and NT-proBNP concentrations were associated with mortality in patients with acute HF, but only MR-proANP were associated with mortality among patients with AECOPD: hazard ratio (lnMR-proANP) 1.98 (95% CI 1.17-3.34). CONCLUSION MR-proANP and NT-proBNP concentrations provide similar diagnostic and prognostic information in patients with acute HF. In contrast to NT-proBNP, MR-proANP measurements also provided independent prognostic information in AECOPD patients.
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Affiliation(s)
- Mohammad Osman Pervez
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Jacob A Winther
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Jon Brynildsen
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Heidi Strand
- c Multidiciplinary Laboratory Medicine and Medical Biochemistry , Akershus University Hospital , Lørenskog , Norway
| | - Geir Christensen
- d Institute for Experimental Medical Research, Oslo University Hospital, Ullevål , Oslo , Norway.,e Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Arne Didrik Høiseth
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Peder L Myhre
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Ragnhild Røysland
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Magnus Nakrem Lyngbakken
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Torbjørn Omland
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
| | - Helge Røsjø
- a Division of Medicine , Akershus University Hospital , Lørenskog , Norway.,b Norway and Center for Heart Failure Research, University of Oslo , Oslo , Norway
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Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery. PLoS One 2018; 13:e0192503. [PMID: 29420603 PMCID: PMC5805306 DOI: 10.1371/journal.pone.0192503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/24/2018] [Indexed: 12/14/2022] Open
Abstract
Objective The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality. Methods A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures. Results Preoperative NT-proBNP was 1.67 times (p<0.0001) and 1.41 times (p<0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders. NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95%CI 0.73–0.85, p<0.0001), MR (AUC = 0.80, 95%CI 0.72–0.87, p<0.0001) and AS (AUC = 0.66, 95%CI 0.51–0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95%CI 0.71–0.85, p<0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD. Conclusions Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.
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Zencirci E, Yeşilaltay A, Yağız V, Değirmencioğlu A, Zencirci AE, Buturak A. Myocardial functional abnormalities and serum N-terminal pro-brain natriuretic peptide in type II diabetes mellitus patients with cardiovascular autonomic neuropathy. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-016-0484-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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15
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Martindale JL, Wakai A, Collins SP, Levy PD, Diercks D, Hiestand BC, Fermann GJ, deSouza I, Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:223-42. [PMID: 26910112 DOI: 10.1111/acem.12878] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/31/2015] [Accepted: 09/16/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. OBJECTIVES The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. METHODS PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. RESULTS Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). CONCLUSIONS Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.
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Affiliation(s)
| | - Abel Wakai
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University School of Medicine; Detroit MI
| | - Deborah Diercks
- The Department of Emergency Medicine; University of Texas Southwestern; Dallas TX
| | - Brian C. Hiestand
- The Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
| | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Ian deSouza
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
| | - Richard Sinert
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
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Schaub JA, Coca SG, Moledina DG, Gentry M, Testani JM, Parikh CR. Amino-Terminal Pro-B-Type Natriuretic Peptide for Diagnosis and Prognosis in Patients With Renal Dysfunction: A Systematic Review and Meta-Analysis. JACC. HEART FAILURE 2015; 3:977-89. [PMID: 26671676 PMCID: PMC4683413 DOI: 10.1016/j.jchf.2015.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVES This study sought to determine if amino-terminal pro-B-type natriuretic peptide (NT-proBNP) has different diagnostic and prognostic utility in patients with renal dysfunction. BACKGROUND Patients with renal dysfunction have higher NT-proBNP, which may complicate interpretation for diagnosis of acute decompensated heart failure (ADHF) or prognosis. METHODS We searched MEDLINE and EMBASE through August 2014 for studies with a subgroup analysis by renal function of the diagnostic or prognostic ability of NT-proBNP. RESULTS For diagnosis, 9 studies were included with 4,287 patients and 1,325 ADHF events. Patients were mostly divided into subgroups with and without renal dysfunction by an estimated glomerular filtration rate of 60 ml/min/1.73 m(2). In patients with renal dysfunction, the area under the curve (AUC) for NT-proBNP ranged from 0.66 to 0.89 with a median cutpoint of 1,980 pg/ml, while the AUC ranged from 0.72 to 0.95 with a cutpoint of 450 pg/ml in patients with preserved renal function. For prognosis, 30 studies with 32,203 patients were included, and mortality in patients with renal dysfunction (25.4%) was twice that of patients with preserved renal function (12.2%). The unadjusted pooled risk ratio for NT-proBNP and mortality was 3.01 (95% confidence interval [CI]: 2.53 to 3.58) in patients with preserved renal function and was similar in patients with renal dysfunction (3.25; 95% CI: 2.45 to 4.30). Upon meta-regression, heterogeneity was partially explained if patients with heart failure or coronary artery disease were enrolled. CONCLUSIONS NT-proBNP retains utility for diagnosis of ADHF in patients with renal dysfunction with higher cutpoints. Elevated NT-proBNP confers a worse prognosis regardless of renal function.
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Affiliation(s)
- Jennifer A Schaub
- Department of Internal Medicine and Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Steven G Coca
- Ichan School of Medicine at Mount Sinai, New York, New York
| | - Dennis G Moledina
- Department of Internal Medicine and Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Mark Gentry
- John Cushing/John Hay Whitney Medical Library, Yale University School of Medicine, New Haven
| | - Jeffrey M Testani
- Department of Internal Medicine and Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Chirag R Parikh
- Department of Internal Medicine and Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut.
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Ibrahim N, Januzzi JL. The potential role of natriuretic peptides and other biomarkers in heart failure diagnosis, prognosis and management. Expert Rev Cardiovasc Ther 2015. [DOI: 10.1586/14779072.2015.1071664] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Roberts E, Ludman AJ, Dworzynski K, Al-Mohammad A, Cowie MR, McMurray JJV, Mant J. The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta-analysis in the acute care setting. BMJ 2015; 350:h910. [PMID: 25740799 PMCID: PMC4353288 DOI: 10.1136/bmj.h910] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine and compare the diagnostic accuracy of serum natriuretic peptide levels (B type natriuretic peptide, N terminal probrain natriuretic peptide (NTproBNP), and mid-regional proatrial natriuretic peptide (MRproANP)) in people presenting with acute heart failure to acute care settings using thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure. DESIGN Systematic review and diagnostic meta-analysis. DATA SOURCES Medline, Embase, Cochrane central register of controlled trials, Cochrane database of systematic reviews, database of abstracts of reviews of effects, NHS economic evaluation database, and Health Technology Assessment up to 28 January 2014, using combinations of subject headings and terms relating to heart failure and natriuretic peptides. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible studies evaluated one or more natriuretic peptides (B type natriuretic peptide, NTproBNP, or MRproANP) in the diagnosis of acute heart failure against an acceptable reference standard in consecutive or randomly selected adults in an acute care setting. Studies were excluded if they did not present sufficient data to extract or calculate true positives, false positives, false negatives, and true negatives, or report age independent natriuretic peptide thresholds. Studies not available in English were also excluded. RESULTS 37 unique study cohorts described in 42 study reports were included, with a total of 48 test evaluations reporting 15 263 test results. At the lower recommended thresholds of 100 ng/L for B type natriuretic peptide and 300 ng/L for NTproBNP, the natriuretic peptides have sensitivities of 0.95 (95% confidence interval 0.93 to 0.96) and 0.99 (0.97 to 1.00) and negative predictive values of 0.94 (0.90 to 0.96) and 0.98 (0.89 to 1.0), respectively, for a diagnosis of acute heart failure. At the lower recommended threshold of 120 pmol/L, MRproANP has a sensitivity ranging from 0.95 (range 0.90-0.98) to 0.97 (0.95-0.98) and a negative predictive value ranging from 0.90 (0.80-0.96) to 0.97 (0.96-0.98). At higher thresholds the sensitivity declined progressively and specificity remained variable across the range of values. There was no statistically significant difference in diagnostic accuracy between plasma B type natriuretic peptide and NTproBNP. CONCLUSIONS At the rule-out thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure, plasma B type natriuretic peptide, NTproBNP, and MRproANP have excellent ability to exclude acute heart failure. Specificity is variable, and so imaging to confirm a diagnosis of heart failure is required. There is no statistical difference between the diagnostic accuracy of plasma B type natriuretic peptide and NTproBNP. Introduction of natriuretic peptide measurement in the investigation of patients with suspected acute heart failure has the potential to allow rapid and accurate exclusion of the diagnosis.
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Affiliation(s)
- Emmert Roberts
- Maudsley Hospital, South London and the Maudsley Mental Health Trust, London, UK
| | - Andrew J Ludman
- Royal Devon & Exeter NHS Foundation Trust, Wonford, Exeter EX2 5DW, UK
| | | | - Abdallah Al-Mohammad
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London (Royal Brompton Hospital), London, UK
| | - John J V McMurray
- British Heart Foundation (BHF) Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health & Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK
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Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence. Heart Fail Rev 2014; 19:421-38. [DOI: 10.1007/s10741-014-9447-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Morello AM, Januzzi JL. Amino-terminal pro-brain natriuretic peptide: a biomarker for diagnosis, prognosis and management of heart failure. Expert Rev Mol Diagn 2014; 6:649-62. [PMID: 17009901 DOI: 10.1586/14737159.6.5.649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There is a substantial need for a diagnostic tool to aid in the early diagnosis of heart failure and in the recognition of those at risk for its development, as well as in guidance of therapy. Testing for amino-terminal pro-brain natriuretic peptide (NT-proBNP) has been recognized to have utility in the diagnosis, prognosis and management of heart failure. In addition, numerous other applications for NT-proBNP testing are now recognized, such as evaluation of patients with heart disease in the absence of heart failure, as well as the diagnostic and prognostic evaluation of patients with acute coronary syndromes or pulmonary thromboembolism.
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Affiliation(s)
- Angela M Morello
- Massachusetts General Hospital and Harvard Medical School, Department of Medicine, Boston, MA 02114, USA.
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21
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Velibey Y, Golcuk Y, Golcuk B, Oray D, Atilla OD, Colak A, Kurtulmus Y, Erbay AR, Yilmaz A, Eren M. Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure. Am J Emerg Med 2013; 31:1634-7. [PMID: 24055249 DOI: 10.1016/j.ajem.2013.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. METHODS NT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. RESULTS The mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs 72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). CONCLUSION Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.
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Affiliation(s)
- Yalcin Velibey
- Bitlis State Hospital, Department of Cardiology, Bitlis, Turkey.
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Nir A, Luchner A, Rein AJ. The natriuretic peptides as biomarkers for adults with congenital heart disease. Biomark Med 2012; 6:827-37. [PMID: 23227849 DOI: 10.2217/bmm.12.73] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Thanks to improved treatment of congenital heart disease early in life, many such patients reach adulthood. Adults with congenital heart disease are an increasing population, which will continue to grow in the future. The clinical state of these patients is affected by their complex heart diseases, as well as the consequence of past corrective or palliative interventions. The natriuretic peptides are important markers for the presence, severity and prognosis of heart disease. The majority of the current knowledge is on patients with acquired heart disease. This article reviews the present knowledge regarding the role of the natriuretic peptides in adults with various forms of congenital heart disease.
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Affiliation(s)
- Amiram Nir
- Department of Pediatric Cardiology, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
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Gruson D, Thys F, Verschuren F. Diagnosing destabilized heart failure in the emergency setting: current and future biomarker tests. Mol Diagn Ther 2011; 15:327-40. [PMID: 22188636 DOI: 10.1007/bf03256468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute or destabilized heart failure (DHF) is characterized by new or worsening signs and symptoms of heart failure leading to admission to an emergency department. Biomarkers may support the diagnosis, the prognosis and the management of DHF patients. The aim of this review article is to discuss and evaluate the clinical usefulness of both recognized and potential new biomarker tests for use in heart failure.
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Affiliation(s)
- Damien Gruson
- Pôle de Recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium.
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Andreu A, Guglin M. Exaggerated NT-proBNP Production in Patients With Hematologic Malignancies: A Case Series. ACTA ACUST UNITED AC 2011; 18:333-6. [DOI: 10.1111/j.1751-7133.2011.00258.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Tobias JD. B-type Natriuretic Peptide: Diagnostic and Therapeutic Applications in Infants and Children. J Intensive Care Med 2011; 26:183-195. [DOI: 10.1177/0885066610387993] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The natriuretic peptide system plays an active role in the regulation of fluid balance and systemic vascular resistance. Peptides of the natriuretic system produced through recombinant DNA technology are now available for clinical use including both atrial natriuretic peptide (ANP) and brain-type natriuretic peptide (BNP). Assays of BNP are available and may be used for both diagnostic and prognostic purposes in various clinical scenarios. The basic physiology of the natriuretic peptide system is presented, applications of BNP monitoring as a diagnostic tool are reviewed, and reports regarding the use of recombinant BNP in the pediatric population are discussed.
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Affiliation(s)
- Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine Nationwide Children's Hospital, Columbus, Ohio, The Ohio State University, Columbus, Ohio,
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Thygesen K, Mair J, Mueller C, Huber K, Weber M, Plebani M, Hasin Y, Biasucci LM, Giannitsis E, Lindahl B, Koenig W, Tubaro M, Collinson P, Katus H, Galvani M, Venge P, Alpert JS, Hamm C, Jaffe AS. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2011; 33:2001-6. [PMID: 21292681 DOI: 10.1093/eurheartj/ehq509] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kristian Thygesen
- Department of Medicine and Cardiology, Aarhus University Hospital, Tage-Hansens Gade 2, Aarhus C DK-8000, Denmark.
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Chenevier-Gobeaux C, Guerin S, André S, Ray P, Cynober L, Gestin S, Pourriat JL, Claessens YE. Midregional pro-atrial natriuretic peptide for the diagnosis of cardiac-related dyspnea according to renal function in the emergency department: a comparison with B-type natriuretic peptide (BNP) and N-terminal proBNP. Clin Chem 2010; 56:1708-17. [PMID: 20813917 DOI: 10.1373/clinchem.2010.145417] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although renal dysfunction influences the threshold values of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in diagnosis of cardiac-related dyspnea (CRD), its effects on midregional pro-atrial natriuretic peptide (MR-proANP) threshold values are unknown. We evaluated the impact of renal function on MR-proANP concentrations and compared our results to those of BNP and NT-proBNP. METHODS MR-proANP, BNP, and NT-proBNP concentrations were measured in blood samples collected routinely from dyspneic patients admitted to the emergency department. Patients were subdivided into tertiles based on their estimated glomerular filtration rate [eGFR, in mL · min(-1) · (1.73 m(2))(-1)]: tertiles 1 (<44.3), 2 (44.3-58.5), and 3 (≥58.6). RESULTS Of 378 patients studied, 69% (n = 260) had impaired renal function [<60 mL · min(-1) · (1.73 m(2))(-1)] and 30% (n = 114) had CRD. MR-proANP, BNP, and NT-proBNP concentrations were significantly increased in patients with impaired renal function. In each tertile, all peptides remained significantly increased in CRD patients by comparison with non-CRD patients. By ROC analysis, MR-proANP, BNP, and NT-proBNP threshold values for the diagnosis of CRD increased as eGFR decreased from tertile 3 to tertile 1. Areas under the ROC curve for all peptides were significantly lower in tertile 1. Using adapted thresholds, MR-proANP, BNP, and NT-proBNP remained independently predictive of CRD, even in tertile 1 patients. CONCLUSIONS Renal function influences optimum cutoff points of MR-proANP for the diagnosis of CRD. With use of an optimum threshold value adapted to the eGFR category, MR-proANP remains as effective as BNP and NT-proBNP in independently predicting a diagnosis of CRD in the emergency department.
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Affiliation(s)
- Camille Chenevier-Gobeaux
- Department of Clinical Chemistry, Hôpital Cochin-Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Luchner A, Weidemann A, Willenbrock R, Philipp S, Heinicke N, Rambausek M, Mehdorn U, Frankenberger B, Heid IM, Eckardt KU, Holmer SR. Improvement of the cardiac marker N-terminal-pro brain natriuretic peptide through adjustment for renal function: a stratified multicenter trial. Clin Chem Lab Med 2010; 48:121-8. [PMID: 20047532 DOI: 10.1515/cclm.2010.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND N-terminal-pro brain natriuretic peptide (NT-proBNP) is a useful cardiac marker that is also influenced by renal dysfunction. It was our objective to assess the relationship between NT-proBNP concentrations in plasma and worsening renal function, and to attempt adjustment of NT-proBNP for renal dysfunction in a prospective, stratified multi-center study. METHODS We stratified 203 male patients according to their cardiac status and the estimated glomerular filtration rate (eGFR). Cardiac disease was assessed by medical history, physical examination and standardized echocardiography. Patients were stratified according to the following: absence of cardiac history and abnormalities (control, CTRL, n=66), cardiac history without left ventricular hypertrophy (LVH) or left ventricular systolic dysfunction (LVD) (history, n=30), LVH without systolic dysfunction (LVH, n=68), and LVD [ejection fraction (EF) <40%, LVD, n=39]. Renal disease was stratified according to the eGFR: 15-30 mL/min (n=52), 31-75 mL/min (n=99), and >75 mL/min (n=52). RESULTS NT-proBNP was correlated with eGFR in the entire study population and for all levels of cardiac disease (all p<0.01). Regression analysis allowed adjustment of NT-proBNP for eGFR in a continuous manner, and this adjustment significantly improved the predictive value (receiver operating characteristic curve for symptomatic LVD from 0.80 to 0.86, p<0.01; sensitivity from 74% to 83% and specificity from 68% to 79%). CONCLUSIONS NT-proBNP correlates inversely and significantly with eGFR throughout all levels of cardiac strata. We propose for the first time a continuous adjustment algorithm which markedly improves the predictive values of NT-proBNP in male patients with impaired renal function.
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Affiliation(s)
- Andreas Luchner
- Klinik und Poliklinik für Innere Medizin II, Klinikum der Universität Regensburg, Regensburg, Germany.
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Salem M, El Behery S, Adly A, Khalil D, El Hadidi E. Early predictors of myocardial disease in children and adolescents with type 1 diabetes mellitus. Pediatr Diabetes 2009; 10:513-21. [PMID: 19708908 DOI: 10.1111/j.1399-5448.2009.00517.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The spectrum of diabetic heart disease involves a progression from normal heart to preclinical left ventricular diastolic and systolic dysfunction followed by overt echocardiographic evidence of left ventricular (LV) dysfunction and finally symptomatic heart failure. OBJECTIVE To compare the value of tissue Doppler imaging (TDI) over the conventional echocardiography in the assessment of early myocardial dysfunction in type 1 diabetics in correlation with serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP), state of metabolic control, and diabetes duration. METHODS Sixty subjects were included; 40 type 1 diabetics (aged 12-18 years). Twenty matched subjects served as controls. They were subjected to clinical examination with assessment of cardiovascular reflexes for autonomic neuropathy. Laboratory investigations included mean random blood sugar (MRBS), hemoglobin A1c (HbA1c), urinary microalbumin, and serum determination of NT-pro-BNP. Echocardiography for chamber dimensions, systolic and diastolic function, Tie index, and longitudinal myocardial global biventricular function by pulsed TDI of 6 LV walls and right ventricle (RV) free wall. RESULTS All diabetics and controls had normal LV dimensions, LV mass index and systolic functions except for higher left ventricular posterior wall (LVPW) in diabetics (P < 0.05). LV and RV diastolic dysfunction diagnosed in 25% of diabetics by conventional Doppler with higher peak A (P < 0.05, P < 0.05) and lower E/A (P < 0.05, P < 0.05) compared to controls. Diabetics had larger Tie index (P < 0.05). TDI showed delayed myocardial relaxation in 52.5% of diabetics with lower LV and RV peak Em (P < 0.05, P < 0.01) and Em/Am (P < 0.01, P < 0.001) compared to controls. NT-pro-BNP was elevated in diabetics (P < 0.01) with best cut-off value = 62.5 Fmol/mL, sensitivity (82%), and specificity (95%) for detection of isolated diastolic dysfunction in diabetics. It was correlated negatively with LV Em (P < 0.05), Em/Am (P < 0.01) and positively with Am (P < 0.01), impaired diastolic velocities were associated with higher HbA1c. CONCLUSION Asymptomatic diabetics had evidence of subtle right and LV dysfunction with delayed myocardial relaxation which was related to metabolic control. Tissue Doppler (TD) has an additional value in evaluating ventricular filling. NT-pro-BNP is considered a sensitive, specific, and predictive marker for diastolic dysfunction.
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Affiliation(s)
- Mona Salem
- Paediatrics Department, Ain Shams University, Cairo, Egypt.
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Teixeira A, Legrain S, Ray P. Diagnostic étiologique de la dyspnée aiguë du sujet âgé : place des biomarqueurs en urgence. Presse Med 2009; 38:1506-15. [DOI: 10.1016/j.lpm.2008.12.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 10/29/2008] [Accepted: 12/18/2008] [Indexed: 11/28/2022] Open
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Buchner S, Jungbauer C, Birner C, Debl K, Riegger GA, Luchner A. Comparison of the cardiac markers B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide. Biomark Med 2009; 3:465-81. [DOI: 10.2217/bmm.09.47] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Stefan Buchner
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
| | - Carsten Jungbauer
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
| | - Christoph Birner
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
| | - Kurt Debl
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
| | - Günter A Riegger
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
| | - Andreas Luchner
- Klinik und Poliklinik für Innere Medizin II, Kardiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
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Jourdain P, Lefèvre G, Oddoze C, Sapin V, Dievart F, Jondeau G, Meune C, Galinier M. [NT-proBNP in practice: from chemistry to medicine]. Ann Cardiol Angeiol (Paris) 2009; 58:165-179. [PMID: 19457468 DOI: 10.1016/j.ancard.2009.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 03/03/2009] [Indexed: 05/27/2023]
Abstract
Since the introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This literature review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.
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Affiliation(s)
- P Jourdain
- Cardiologie, Centre Hospitalier René-Dubos, Pontoise, France
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Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, Capp R, Noble VE. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med 2009; 16:201-10. [PMID: 19183402 DOI: 10.1111/j.1553-2712.2008.00347.x] [Citation(s) in RCA: 198] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used. METHODS This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). RESULTS One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP. CONCLUSIONS Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.
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Affiliation(s)
- Andrew S Liteplo
- Department of Emergency Medicine, Division of Emergency Ultrasound, Massachusetts General Hospital, Boston, MA, USA.
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Ray P, Delerme S, Jourdain P, Chenevier-Gobeaux C. Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department. QJM 2008; 101:831-43. [PMID: 18664534 DOI: 10.1093/qjmed/hcn080] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.
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Affiliation(s)
- P Ray
- Service d'Accueil des Urgences, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Szadkowska I, Goch JH, Kawiński J, Chizyński K. N-terminal pro-brain natriuretic peptide in the elderly with myocardial infarction. Clin Cardiol 2008; 31:443-7. [PMID: 18781605 DOI: 10.1002/clc.20278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The myocardial infarction (MI) results in the change of the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) in blood. In addition, attention is paid to the dependence of NT-proBNP levels on the patients' age. However, the behavior of natriuretic peptide levels has not been recognized well enough in the elderly with MI treated with invasive methods. HYPOTHESIS The aim of the study was to estimate the effect of age on NT-proBNP levels in patients with first MI, and treated with primary percutaneous coronary intervention (PCI) with complete coronary revascularization. METHODS One hundred and sixty-one consecutive patients with first ST-elevation MI, and treated with primary PCI with stent implantation (occlusion in infarct-related artery was the patient's only lession) were included. Determination of NT-proBNP level and echocardiography were performed on the 4th-5th day of MI. RESULTS Thirty-seven patients (23%) aged>or=65 y were considered as a study group. The NT-proBNP levels were nearly 4-fold higher in older patients than in younger patients. Only systolic and diastolic dysfunction, mitral regurgitation, troponin T levels, and glomerular filtration rate (GFR) were independent risk factors of the occurrence of elevated NT-proBNP concentration above median. CONCLUSIONS The patients' age was not a factor independently affecting the increase of NT-proBNP level above the median in patients with first MI and treated successfully with primary PCI. Independently associated elevated levels of NT-proBNP were as follows: presence of diastolic dysfunction, mitral regurgitation, left ventricular systolic dysfunction, troponin T concentration, and GFR.
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Affiliation(s)
- Iwona Szadkowska
- Invasive Cardiology Unit, Department of Cardiology, Medical University of Lodz, Lodz, Poland.
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Chenevier-Gobeaux C, Delerme S, Allo JC, Arthaud M, Claessens YE, Ekindjian OG, Riou B, Ray P. B-type natriuretic peptides for the diagnosis of congestive heart failure in dyspneic oldest-old patients. Clin Biochem 2008; 41:1049-54. [DOI: 10.1016/j.clinbiochem.2008.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 11/25/2022]
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Fox AA, Shernan SK, Collard CD, Liu KY, Aranki SF, DeSantis SM, Jarolim P, Body SC. Preoperative B-type natriuretic peptide is as independent predictor of ventricular dysfunction and mortality after primary coronary artery bypass grafting. J Thorac Cardiovasc Surg 2008; 136:452-61. [PMID: 18692657 DOI: 10.1016/j.jtcvs.2007.12.036] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 12/10/2007] [Accepted: 12/27/2007] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Elevated B-type natriuretic peptide is associated with increased morbidity and mortality in ambulatory patients with congestive heart failure or acute coronary syndromes. Its utility in predicting adverse cardiac surgical outcomes is less certain. We hypothesized that preoperative plasma B-type natriuretic peptide would independently predict in-hospital postoperative ventricular dysfunction, hospital stay, and up to 5-year mortality after primary coronary artery bypass grafting. METHODS This is a prospective, longitudinal study of 1023 patients at two institutions undergoing primary coronary artery bypass grafting with cardiopulmonary bypass. Ventricular dysfunction was defined as requirement for at least two inotropes or new intra-aortic balloon pump or ventricular assist device support after coronary artery bypass grafting. Multivariable analyses assessed independent roles of preoperative B-type natriuretic peptide in predicting postoperative ventricular dysfunction, hospital stay, and 5-year all-cause mortality. RESULTS Preoperative plasma B-type natriuretic peptide concentration predicted ventricular dysfunction, hospital stay, and mortality in univariate and multivariable analyses. Logistic regression demonstrated preoperative B-type natriuretic peptide to independently predict ventricular dysfunction (odds ratio 1.92, 95% confidence interval 1.12-3.29, P = .018), after adjustment for preoperative left ventricular ejection fraction, congestive heart failure severity, and other clinical predictors. Multivariable Cox proportional hazards models showed preoperative B-type natriuretic peptide to independently predict hospital stay (hazard ratio 1.42, 95% confidence interval 1.18-1.72, P = .0002) and mortality (hazard ratio 1.89, 95% confidence interval 1.08-3.33, P = .026). CONCLUSION Preoperative plasma B-type natriuretic peptide independently predicted in-hospital ventricular dysfunction, hospital stay, and up to 5-year all-cause mortality after primary coronary artery bypass grafting.
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Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Verdiani V, Ognibene A, Rutili MS, Lombardo C, Bacci F, Terreni A, Nozzoli C. NT-ProBNP reduction percentage during hospital stay predicts long-term mortality and readmission in heart failure patients. J Cardiovasc Med (Hagerstown) 2008; 9:694-9. [DOI: 10.2459/jcm.0b013e3282f447ae] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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N-Terminal pro B-type natriuretic peptide testing for short-term prognosis in breathless older adults. Am J Emerg Med 2008; 26:555-60. [DOI: 10.1016/j.ajem.2007.08.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 08/23/2007] [Accepted: 08/23/2007] [Indexed: 11/21/2022] Open
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Steiner J, Guglin M. BNP or NTproBNP? A clinician's perspective. Int J Cardiol 2008; 129:5-14. [PMID: 18378336 DOI: 10.1016/j.ijcard.2007.12.093] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 12/27/2007] [Accepted: 12/29/2007] [Indexed: 10/22/2022]
Abstract
Existing literature on two natriuretic peptides--B-type natriuretic peptide (BNP) and amino terminal pro-brain natriuretic peptide (NTproBNP)--is overwhelming. Both peptides are acknowledged markers for cardiac dysfunction. Most of the sources present data on either BNP or NTproBNP making the comparison difficult. This paper focuses on reviewing studies directly comparing two peptides in the setting of chronic and acute heart failure (HF) and coronary artery disease. Many concomitant diseases influence these two peptides to varying extent. These characteristics should be taken into consideration when interpreting results. For most practical purposes, BNP and NTproBNP are interchangeable, and can be used based on local preferences and availability. NTproBNP seems to be more advantageous for diagnosing mild HF or asymptomatic left ventricular dysfunction.
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. The Diagnostic Value of B Natriuretic Peptide in Elderly Patients with Acute Dyspnea. Clin Med Cardiol 2008. [DOI: 10.4137/cmc.s525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- S. Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpětrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
| | - C. Chenevier-Gobeaux
- Department of Biochemistry A, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France
| | - B. Doumenc
- Department of Emergency Medicine, Centre Hospitalo-Universitaire de Bicetre, Assistance-Publique Hôpitaux de Paris (AP-HP), 94270 Kremlin-Bicetre, Université Paris Sud 11, France
| | - P. Ray
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpětrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine. Biomark Insights 2008; 3:203-217. [PMID: 19578505 PMCID: PMC2688345 DOI: 10.4137/bmi.s499] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.
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Affiliation(s)
- S Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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Mekontso Dessap A, Leon R, Habibi A, Nzouakou R, Roudot-Thoraval F, Adnot S, Godeau B, Galacteros F, Brun-Buisson C, Brochard L, Maitre B. Pulmonary hypertension and cor pulmonale during severe acute chest syndrome in sickle cell disease. Am J Respir Crit Care Med 2008; 177:646-53. [PMID: 18174543 DOI: 10.1164/rccm.200710-1606oc] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Steady-state mild pulmonary hypertension is a risk factor for death in adults with sickle cell disease. Acute pulmonary hypertension has been reported during exercise and vasoocclusive pain crisis in these patients. OBJECTIVES The aim of the present study was to evaluate changes in pulmonary pressures and cardiac biomarkers during severe acute chest syndrome and their associations with mortality. METHODS We prospectively evaluated 70 consecutive adults who received standardized treatment in our intensive care unit for a total of 84 episodes. At admission, cardiac biomarkers were measured. Transthoracic echocardiography was performed for pulmonary hypertension assessment via measurement of tricuspid regurgitant jet velocity and was repeated when possible after resolution. MEASUREMENTS AND MAIN RESULTS Tricuspid jet velocity was less than 2.5 m/second in 34 (40%) of the 84 episodes, 2.5 to 2.9 m/second in 19 (23%), and 3 m/second or greater in 31 episodes (37%). Cor pulmonale occurred in 11 (13%) episodes. Tricuspid jet velocity showed significant positive correlations with B-type natriuretic peptide (rho = 0.54, P < 0.01) and cardiac troponin I (rho = 0.42, P < 0.01). Pulmonary pressures increased compared with steady state then decreased after resolution. All five patients who required invasive ventilation and all four patients who died during the immediate hospital course had jet velocity values of 3 m/second or greater. Overall mortality was 12.9% (9 patients) and survival was significantly lower in patients whose jet velocity was 3 m/second or greater during at least one episode, compared with the other patients (P < 0.01). CONCLUSIONS Pulmonary pressures increase during severe acute chest syndrome, and pulmonary hypertension is associated with cardiac biomarker elevation and a higher risk of death.
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Affiliation(s)
- Armand Mekontso Dessap
- Service de Réanimation Médicale, Centre Hospitalo-Universitaire Henri Mondor, 51 avenue du M de Lattre de Tassigny, 94010 Créteil Cedex, France.
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Boswood A, Dukes-McEwan J, Loureiro J, James RA, Martin M, Stafford-Johnson M, Smith P, Little C, Attree S. The diagnostic accuracy of different natriuretic peptides in the investigation of canine cardiac disease. J Small Anim Pract 2007; 49:26-32. [PMID: 18005104 DOI: 10.1111/j.1748-5827.2007.00510.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aimed to validate and determine the accuracy of a new sandwich ELISA for canine N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the discrimination of canine patients with cardiac disease from those with respiratory disease and to determine the effect of confounding variables on NT-proBNP concentrations. METHODS Validation studies for the new assay were undertaken. Concentrations of N-terminal atrial natriuretic peptide (NT-proANP) and NT-proBNP in both ethylenediaminetetraacetic acid (EDTA) plasma and serum were estimated in samples from 77 dogs at a laboratory blinded to the clinical status of the patient. The diagnostic accuracy of the each sample type and test was evaluated using receiver operating characteristic curves. The effect of age, gender and indicators of renal function was evaluated using a multivariate regression analysis. RESULTS Concentrations of NT-proBNP in both serum and plasma accurately discriminated dogs with respiratory disease from those with cardiac disease, with an optimum cut-off concentration of 210 pmol/l. NT-proBNP concentrations were unaffected by sample type. Increasing creatinine concentration is associated with increasing concentration of NT-proBNP. Age and gender were not found to have significant effects on natriuretic peptide concentrations in this population. CLINICAL SIGNIFICANCE Canine NT-proBNP appears to be a useful marker of the presence of cardiac disease, although concentrations must be interpreted in the light of the patient's renal function.
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Affiliation(s)
- A Boswood
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK
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Collins S, Storrow AB, Kirk JD, Pang PS, Diercks DB, Gheorghiade M. Beyond pulmonary edema: diagnostic, risk stratification, and treatment challenges of acute heart failure management in the emergency department. Ann Emerg Med 2007; 51:45-57. [PMID: 17868954 DOI: 10.1016/j.annemergmed.2007.07.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 06/26/2007] [Accepted: 07/09/2007] [Indexed: 02/06/2023]
Abstract
The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach.
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Affiliation(s)
- Sean Collins
- University of Cincinnati, Department of Emergency Medicine, Cincinnati, OH 45267, USA.
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Hogenhuis J, Voors AA, Jaarsma T, Hoes AW, Hillege HL, Kragten JA, van Veldhuisen DJ. Anaemia and renal dysfunction are independently associated with BNP and NT-proBNP levels in patients with heart failure. Eur J Heart Fail 2007; 9:787-94. [PMID: 17532262 DOI: 10.1016/j.ejheart.2007.04.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 12/22/2006] [Accepted: 04/05/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anaemia may affect B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) levels, but this has not been well described in heart failure (HF) patients without the exclusion of patients with renal dysfunction. AIMS To study the influence of both anaemia and renal function on BNP and NT-proBNP levels in a large group of hospitalised HF patients. METHODS AND RESULTS We studied 541 patients hospitalised for HF (mean age 71+/-11 years, 62% male, and left ventricular ejection fraction 0.33+/-0.14). Of these patients, 30% (n=159) were anaemic (women: Hb<7.5 mmol/l, men: Hb<8.1 mmol/l). Of the 159 anaemic patients, 73% had renal dysfunction (eGFR<60 ml/min/1.73 m2) and of the non-anaemic patients, 57% had renal dysfunction. BNP and NT-proBNP levels were measured in all patients before discharge. In multivariable analyses both plasma haemoglobin and eGFR were independently related to the levels of BNP and NT-proBNP (standardised beta's of -0.16, -0.14 [BNP] and -0.19, -0.26 [NT-proBNP] respectively, P-values<0.01). CONCLUSION Anaemia and renal dysfunction are related to increased BNP and NT-proBNP levels, independent of the severity of HF. These results indicate that both anaemia and renal dysfunction should be taken into consideration during the interpretation of BNP and NT-proBNP levels in HF patients.
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Affiliation(s)
- Jochem Hogenhuis
- Department of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Abstract
The natriuretic peptide system plays an active role in the regulation of fluid balance and systemic vascular resistance. Assays of these peptides are now available and may be used for both diagnostic and prognostic purposes. Despite its primary use in adults, it may have a diagnostic role in the Pediatric ICU as well. The basic physiology of the natriuretic system is discussed and the potential applications of B-type natriuretic peptide (BNP) monitoring as a diagnostic tool in various clinical scenarios in infants and children in the Pediatric ICU setting is reviewed.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology, University of Missouri, Columbia, MO 65212, USA.
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Angermann C, Hoyer C, Ertl G. [Differential diagnosis of dyspnea - significance of clinic aspects, imaging and biomarkers for the diagnosis of heart failure]. Clin Res Cardiol 2007; 95 Suppl 4:57-70; quiz 71. [PMID: 16598607 DOI: 10.1007/s00392-006-2009-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Dyspnea is a frequent reason for emergency consultations in hospitals or community medical facilities. Besides heart failure, a wide variety of other disorders may cause this symptom. Thus, early and accurate differential diagnosis is mandatory in order to facilitate rapid institution of appropriate therapy. This CME article elaborates on the specific usefulness of traditional diagnostic tools as history, symptomatology and physical signs along with chest X-ray and ECG and the more recently introduced natriuretic peptides to discriminate heart failure from other causes of dyspnea in the emergency setting. According to a systematic search and meta-analysis of the respective literature, several features from history and physical examination as well as pulmonary congestion on chest X-ray, atrial fibrillation and a high level of confidence of the initial clinical judgment indicate a cardiac cause of dyspnea with high specificity, but less sensitivity. Thus, in patients presenting with one or several of these characteristic features, little further diagnostic yield is to be expected from natriuretic peptides. If, however, the suspicion of heart failure remains unsettled by these means, determination of biomarkers may be helpful, although it needs to be considered that moderately elevated levels have only a limited specificity in particular in elderly patients with comorbidities. As also recognized by the European Guidelines for diagnosis and treatment of chronic heart failure, a BNP level of <100 pg/ml has proven particularly useful for excluding heart failure. Thus, a directed history, symptoms, physical findings, chest-X-ray and ECG remain the diagnostic mainstay. If the diagnosis cannot be established by these traditional tools, BNP or NT-proBNP testing may be very helpful, especially for ruling out heart failure.
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Affiliation(s)
- C Angermann
- Medizinische Klinik und Poliklinik I, Herz- und Kreislaufzentrum der Universität Würzburg, Klinikstrasse, Würzburg.
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Emdin M, Passino C, Prontera C, Fontana M, Poletti R, Gabutti A, Mammini C, Giannoni A, Zyw L, Zucchelli G, Clerico A. Comparison of brain natriuretic peptide (BNP) and amino-terminal ProBNP for early diagnosis of heart failure. Clin Chem 2007; 53:1289-97. [PMID: 17495021 DOI: 10.1373/clinchem.2006.080234] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND We compared the diagnostic accuracy of brain natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) for diagnosis of preclinical and mild heart failure (HF). METHODS We assayed plasma NT-proBNP and BNP in 182 healthy controls and in a prospective cohort of 820 HF patients divided according to the American Heart Association/American College of Cardiology classification. These included 86 patients in stage A [mean (SE) ejection fraction 61% (1%); mean (SE) age 47 (2) years], 255 in stage B [65% (2%); 62 (1) years], 420 patients in stage C [35% (1%); 68 (1) years] and 59 in stage D [25% (1%); 74 (1) years]. Diagnostic accuracies of BNP and NT-proBNP were evaluated by ROC analysis, and a multivariate linear regression model was applied to predict HF staging. RESULTS Median BNP and NT-proBNP concentrations increased from stage A to D 57-fold and 107-fold, respectively. Both assays were accurate (P <0.001) in separating stage B from controls or stage A, and stage C from controls or stage A or B. NT-proBNP was more accurate (P <0.001) than BNP in differentiating stage C from stages A and B patients and controls and was a better predictor of HF classification in a model including age, sex, and renal function (P <0.001). CONCLUSIONS Monitoring BNP or NT-proBNP enabled identification of asymptomatic patients at risk for the development of HF. NT-proBNP showed better accuracy than BNP for identifying mild HF.
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Affiliation(s)
- Michele Emdin
- CNR Institute of Clinical Physiology, Cardiovascular Medicine Department and Cardiovascular Endocrinology Laboratory, Pisa, Italy.
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Clerico A, Fontana M, Zyw L, Passino C, Emdin M. Comparison of the Diagnostic Accuracy of Brain Natriuretic Peptide (BNP) and the N-Terminal Part of the Propeptide of BNP Immunoassays in Chronic and Acute Heart Failure: A Systematic Review. Clin Chem 2007; 53:813-22. [PMID: 17384013 DOI: 10.1373/clinchem.2006.075713] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background: We used evidence-based laboratory medicine principles to compare the diagnostic accuracy of brain natriuretic peptide (BNP) and the N-terminal part of the propeptide of BNP (NT-proBNP) assays for the diagnosis of heart failure.
Methods: In May 2006, we performed a computerized literature search of the online National Library of Medicine to select studies specifically designed to compare the diagnostic accuracy of BNP and NT-proBNP assays. The comparison took into account the area under the curve and diagnostic odds ratio (DOR) derived from ROC analysis of original studies.
Results: Both BNP and NT-proBNP assays were found to be clinically useful for the diagnosis of heart failure. Metaanalysis of these data was difficult because of the heterogeneity of data regarding patient population, diagnostic criteria, end-points, and immunoassay methods for both BNP and NT-proBNP. Separate metaanalyses were performed for acute and chronic heart failure. In chronic heart failure, the diagnostic DOR for BNP (8.44, 95% CI 4.66–15.30) was not significantly different from that of NT-proBNP (23.36, 95% CI 9.38–58.19). In patients with acute heart failure, the mean DOR for BNP (16.46, 95% CI 10.65–25.43) was not significantly different from that of NT-proBNP (18.61, 95% CI 12.99–26.65).
Conclusion: Our results indicate that both BNP and NT-proBNP assays have a high degree of diagnostic accuracy and clinical relevance for both acute and chronic heart failure.
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Affiliation(s)
- Aldo Clerico
- Laboratory of Cardiovascular Endocrinology, Department of Cardiovascular Medicine, Consiglio Nazionale delle Ricerche Institute of Clinical Physiology, Pisa, Italy.
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