Evidence based application of BNP/NT-proBNP testing in heart failure

Plastic-based lateral flow immunoassay device for electrochemical detection of NT-proBNP

Here we report an easily fabricated, plastic-based lateral flow device for carrying out metalloimmunoassays. The device is called ocFlow to emphasize the open-channel design. We have shown that the ocFlow is capable of magnetic microbead (MμB)-based metalloimmunoassays for the detection of two types of immunoconjugates: a model composite (MC) and a sandwich immunoassay for the heart failure marker NT-proBNP. In both assays, Ag nanoparticles (AgNPs) were used as electrochemically detectable labels. NT-proBNP and MC concentrations as low as 750.0 pM and 10.0 pM, respectively, could be detected using the ocFlow device. Four key conclusions can be drawn from the results presented herein. First, immunoconjugates attached to the MμBs can be transported in the flow channel using combined hydrodynamic and capillary pressure passive pumping. Second, the ocFlow device is capable of on-chip storage, resolvation, and conjugate formation of both the MC and NT-proBNP composites. Third, electrochemical detection can be conducted on analytes suspended in serum by rinsing the electrodes with a wash buffer. Finally, and perhaps most significantly, the assay is quantitative and has a detection limit for NT-proBNP in the high picomolar range when the necessary reagents are stored on the device in a dry form.

Detection Efficiency of Ag Nanoparticle Labels for a Heart Failure Marker Using Linear and Square-Wave Anodic Stripping Voltammetry

In this article, we compare linear sweep anodic stripping voltammetry (LASV) and square-wave anodic stripping voltammetry (SWASV) for detection of a nano metalloimmunoassay. Two separate immunoassays were examined: a model assay, based on interactions between antibodies, and a sandwich assay for the heart failure marker NT-proBNP. In both cases, one antibody is linked to a magnetic microbead, and one is linked to a spherical Ag nanoparticle label. Electrochemical detection is carried out on a paper device. The three analytical figures of merit studied were the precision of the measurements, the calibration sensitivity, and the limit of detection (LOD). For the NT-proBNP assay, the results show that after optimization of the pulse amplitude and frequency of the potential input for SWASV, the detection efficiency is substantially higher compared to LASV. Specifically, the calibration sensitivity increased by up to ~40 fold, the average coefficient of variation decreased by ~40%, and the (LOD) decreased to 300.0 pM. Finally, for a model immunoassay, a ~10-fold decrease in the LOD was observed for SWASV compared to LASV.

Relationship of uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide with acute cerebral infarction

OBJECTIVE

The objective was to study the relationship of serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels with acute cerebral infarction.

METHODS

A total of 96 acute cerebral infarction patients were divided into small, middle, and large infarct size groups based on the size of infarct focus and mild, moderate, and severe infarction groups based on the evaluation criteria of nerve defect degree. In addition, 75 healthy people were selected as the control group. The serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels of all subjects were detected.

RESULTS

The serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels in the acute cerebral infarction group were significantly higher than the control group (p<0.05). Compared with the small infarct size group, each index in middle and large infarct size groups was significantly increased (p<0.05). Compared with the middle infarct size group, each index in the large infarct size group was significantly increased (p<0.05). The serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels in moderate and severe infarction groups were significantly higher than the mild infarction group (p<0.05). Compared with the moderate infarction group, each index in the severe infarction group was significantly increased (p<0.05). The serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels were positively correlated with the infarct size and nerve defect degree (p<0.05).

CONCLUSIONS

The serum uric acid, C-reactive protein, and N-terminal pro-B-type natriuretic peptide levels are closely correlated with the occurrence and development of acute cerebral infarction. The detection of these indexes has significance for understanding the severity of acute cerebral infarction, guiding the individual treatment scheme, and evaluating the prognosis.

Electrochemical Detection of NT-proBNP Using a Metalloimmunoassay on a Paper Electrode Platform

In this paper, we demonstrate an electrochemical method for detection of the heart failure biomarker, N-terminal prohormone brain natriuretic peptide (NT-proBNP). The approach is based on a paper electrode assembly and a metalloimmunoassay; it is intended for eventual integration into a home-use sensor. Sensing of NT-proBNP relies on the formation of a sandwich immunoassay and electrochemical quantification of silver nanoparticle (AgNP) labels attached to the detection antibodies (Abs). There are four important outcomes reported in this article. First, compared to physisorption of the detection Abs on the AgNP labels, a 27-fold increase in signal is observed when a heterobifunctional cross-linker is used to facilitate this labeling. Second, the assay is selective in that it does not cross-react with other cardiac natriuretic peptides. Third, the assay forms in undiluted human serum (though the electrochemical analysis is carried out in buffer). Finally, and most important, the assay is able to detect NT-proBNP at concentrations between 0.58 and 2.33 nM. This performance approaches the critical NT-proBNP concentration threshold often used by physicians for risk stratification purposes: ∼0.116 nM.

An Empirical Study on the Effect of Short-Term Regular Vitamin D3 Supplement Therapy on Blood Pressure and Exercise Tolerance in Heart Failure Patients

The receptor of vitamin D is expressed in almost all body cells, including vascular endothelial cells and cardiomyocytes. Vitamin D deficiency has been observed widespread amongst heart failure (HF) patients, which could have harmful effects on their health condition. This study aims to investigate the effect of vitamin D supplements on blood pressure (BP) and physical activity of HF patients. Thirty-nine systolic HF patients with low ejection fraction (EF) < 50% and class III of New York Heart Association functional classification were randomly divided into 2 groups including intervention and placebo to enroll in an 8 weeks double-blind clinical trial. During the trial 6-minute walk test (6MWT), 25-hydroxyvitamin D (25[OH]D) level, BP, sodium and potassium intakes were assessed. The mean 25(OH)D level increased to 28.9 ± 11.7 ng/mL (p < 0.001) in the intervention group. There was a poor but non-significant reduction in systolic BP (-0.033 ± 4.71 mmHg, p = 0.531) in the intervention group. The BP also did not change in the placebo group at the end of the trial. A negligible decrease of 6MWT was observed in the intervention group (-6.6 ± 29.2 m) compared to the placebo (-14.1 ± 40.5 m). However, differences between the 2 groups were not statistically significant (p = 0.325). The results solely showed a slight positive correlation between 25(OH)D level and 6MWT. No significant improvements in BP and 6MWT were observed after vitamin D3 supplementation.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials Identifier: IRCT2016102113678N13.

Telmisartan and captopril ameliorate pregabalin-induced heart failure in rats

Pregabalin (PRG) is highly effective in the treatment of epilepsy, neuropathic pain and anxiety disorders. Despite its potential benefits, PRG administration has been reported to induce or exacerbate heart failure (HF). It has been previously documented that overactivation of the renin angiotensin system (RAS) is involved in HF pathophysiological mechanism. The target of the current study was to examine the possible cardioprotective effect of telmisartan (Tel), an angiotensin II type 1 receptor (AT1R) blocker, compared with that of captopril (Cap), an angiotensin converting enzyme (ACE) inhibitor, in ameliorating PRG-induced HF in rats by assessing morphometric, echocardiographic and histopathological parameters. Furthermore, to investigate the role of RAS blockade by the two drugs in guarding against PRG-induced changes in cardiac angiotensin 1-7 (Ang 1-7) and angiotensin II (Ang II) levels, in addition to myocardial expression of ACE2, ACE, Mas receptor (MasR) and AT1R. Results showed that PRG administration induced morphometric, echocardiographic and histopathological deleterious alterations and significantly elevated cardiac Ang II, ACE and AT1R levels, while reduced Ang 1-7, ACE2 and MasR cardiac levels. Concurrent treatment with either Tel or Cap reversed PRG-induced morphometric, echocardiographic and histopathological abnormalities and revealed prominent protection against PRG-induced HF via downregulation of ACE/Ang II/AT1R and upregulation of ACE2/Ang 1-7/MasR axes. These are the first findings to demonstrate that the potential benefits of Tel and Cap are mediated by counteracting the altered balance between the RAS axes induced by PRG. Hence; Tel and Cap may attenuate PRG-induced HF partially through stimulation of ACE2/Ang 1-7/MasR pathway.

NT-proBNP to exclude heart failure in primary care - a pragmatic, cluster-randomized study

Heart failure (HF) is difficult to recognize in primary care. N-terminal pro B-type natriuretic peptide (NT-proBNP) can be used as a rule-out test in HF due to its high negative predictive value. We aim to determine whether the number per 1000 patients of HF diagnoses increase among patients referred from primary care to an outpatient HF clinic, if general practitioners (GPs) were offered NT-proBNP in a real-life setting. All GP practices covered by Randers Regional Hospital were randomized to an intervention group (34 GP practices) and a control group (35 GP practices) in this pragmatic, cluster-randomized controlled trial. The main outcome was the number of patients referred to echocardiography and diagnosed with HF in each group. The number of patients per 1000 diagnosed with HF in the two groups was the same (0.09 (0.02-0.16) vs. 0.14 (0.07-0.21), p = .3541). A total of 700 NT-proBNP analyses, of which 611 were unique, were requested from 31 GP practices in 17.5 months. A total of 184 patients were referred to echocardiography on suspicion of HF. The number of patients per 1000 referred in the intervention group was significantly higher (p < .010). NT-proBNP was measured in 36.6% of referred patients in the intervention group. Significantly more women were diagnosed with HF in the intervention group (56.3% vs. 0%, p = .019). Hence, increased diagnostic effectiveness could not be shown in this real-life setting.

The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation

Background

The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT).

Patients and methods

A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency.

Results

The study population was largely male (68.3%), and the median age was 54 (49–59) years. The median model for end-stage liver disease score was 12 (6–22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations.

Conclusions

The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.

The role of plasma N-terminal brain natriuretic pro-peptide in diagnosing elderly patients with acute exacerbation of COPD concurrent with left heart failure

Introduction

Acute exacerbation of COPD (AECOPD) and left heart failure (LHF) commonly exist together in clinical practice. However, the identification of AECOPD concurrent with LHF is currently challenging. Our study aimed to investigate the role of plasma N-terminal brain natriuretic pro-peptide (NT-proBNP) in diagnosing elderly patients with AECOPD associated with LHF.

Methods and results

LHF was diagnosed in patients with AECOPD according to echocardiographic criteria, and the levels of NT-proBNP in plasma were measured by quantitative electrochemiluminescence assay. Among the 655 patients with AECOPD, 158 (24.1%) had comorbid LHF, whether systolic (n=108, 68.4%) or diastolic (n=50, 31.6%). The plasma concentrations of NT-proBNP in elderly patients with AECOPD associated with LHF were markedly elevated, compared with those with only AECOPD (4,542.5 and 763.0 ng/L, respectively, P<0.01). The receiver operating characteristic curve indicated a diagnostic cutoff value of 1,677.5 ng/L of NT-proBNP in plasma for ascertaining the presence of LHF in AECOPD, with a sensitivity of 87.9%, a specificity of 88.5%, and an accuracy of 88.4%.

Conclusion

The plasma level of NT-proBNP may be a useful indicator in diagnosing AECOPD associated with LHF.

Novel heart failure biomarkers: why do we fail to exploit their potential?

Plasma biomarkers are useful tools in the diagnosis and prognosis of heart failure (HF). In the last decade, numerous studies have aimed to identify novel HF biomarkers that would provide superior and/or additional diagnostic, prognostic, or stratification utility. Although numerous biomarkers have been identified, their implementation in clinical practice has so far remained largely unsuccessful. Whereas cardiac-specific biomarkers, including natriuretic peptides (ANP and BNP) and high sensitivity troponins (hsTn), are widely used in clinical practice, other biomarkers have not yet proven their utility. Galectin-3 (Gal-3) and soluble suppression of tumorigenicity 2 (sST2) are the only novel HF biomarkers that are included in the ACC/AHA HF guidelines, but their clinical utility still needs to be demonstrated. In this review, we will describe natriuretic peptides, hsTn, and novel HF biomarkers, including Gal-3, sST2, human epididymis protein 4 (HE4), insulin-like growth factor-binding protein 7 (IGFBP-7), heart fatty acid-binding protein (H-FABP), soluble CD146 (sCD146), interleukin-6 (IL-6), growth differentiation factor 15 (GDF-15), procalcitonin (PCT), adrenomedullin (ADM), microRNAs (miRNAs), and metabolites like 5-oxoproline. We will discuss the biology of these HF biomarkers and conclude that most of them are markers of general pathological processes like fibrosis, cell death, and inflammation, and are not cardiac- or HF-specific. These characteristics explain to a large degree why it has been difficult to relate these biomarkers to a single disease. We propose that, in addition to clinical investigations, it will be pivotal to perform comprehensive preclinical biomarker investigations in animal models of HF in order to fully reveal the potential of these novel HF biomarkers.

Elevated circulating IL-32 presents a poor prognostic outcome in patients with heart failure after myocardial infarction

BACKGROUND

Interleukin-32 (IL-32) is a newly discovered proinflammatory cytokine. However, there are limited data regarding IL-32 as a biomarker for heart failure (HF). In this study, we assessed the prognostic value of IL-32 in patients with chronic HF after myocardial infarction (MI).

METHODS AND RESULTS

Over a period of 1.8years, we prospectively enrolled 100 patients with chronic HF after MI. IL-32, NT-proBNP, Matrix metallopeptidase 9 (MMP-9), procollagen type I (PI) and type III (PIII) were measured at baseline. Study endpoint was adverse cardiac events. High IL-32 levels were associated with numerous factors that are related to deteriorate cardiac function and cardiac fibrosis. Strong expression of IL-32 was detected in human cardiomyocytes from HF tissue. ROC curve revealed the area under the curve of IL-32 for predicting negative outcome of HF was 0.72 (95% CI: 0.60-0.83, P<0.01). Kaplan-Meier statistics showed that the risk of adverse cardiac event was 5.75 fold (hazard ratio 5.75, 95% CI 1.53-21.58, P=0.009), which increased in the highest quartile (>296pg/mL). Cox regression analysis revealed IL-32 was an independent predictor for cardiac events (hazard ratio 2.78, 95% CI 1.02-7.57, P=0.046). Recombinant IL-32 significantly exacerbated infarct size in a mouse model of MI. IL-32 upregulated expression of MMP-9, PIII and transforming growth factor beta in rat fibroblasts.

CONCLUSION

IL-32 might be a novel predictor of adverse cardiac event in patients with HF after MI. The pro-fibrotic effect of IL-32 may contribute to adverse cardiac remodeling and progression to HF.

Global Longitudinal Strain and Strain Rate in Type Two Diabetes Patients with Chronic Heart Failure: Relevance to Osteoprotegerin

BACKGROUND

Biomechanical stress and inflammatory biomarkers relate to global contractility dysfunction; however, adding these biomarkers into a risk model constructed on clinical data does not improve its prediction value in chronic heart failure (CHF).

AIM

The aim of this study was to evaluate whether biomarkers predict declining of left ventricular global contractility function in diabetic patients with ischemia-induced CHF.

PATIENTS AND METHODS

The study retrospectively evolved 54 diabetic patients who had systolic or diastolic ischemia-induced CHF that was defined as left-ventricular ejection fraction (LVEF) ≤45% or 46-55% respectively assessed by quantitative echocardiography and other conventional criteria according to current clinical guidelines. Two-dimensional transthoracic echocardiography and tissue Doppler imaging were performed according to a conventional method. Radial, longitudinal, and circumferential strain and strain rate values were obtained by speckle-tracking Imaging analysis of both LV short axis and long axis views. Serum adiponectin, NT-pro brain natriuretic peptide (BNP), osteoprotegerin, and hs- C-reactive protein (CRP) were determined at baseline by ELISA.

RESULTS

We found lower global longitudinal strain and strain rate in diabetic patients with LVEF <45% than these in diabetic patients that did not have LVEF (Р=0.001 for all cases). Multivariate logistic regression analysis showed that NT-proBNP (r=0.432; P=0.001 and r=0.402; P=0.001, respectively), osteoprotegerin (r=0.422; P=0.001 and r=0.401; P=0.001, respectively), hs-CRP (r=0.408; P=0.001 and r=0.404; P=0.001, respectively) were independently inversely associated with global longitudinal strain and strain rate in CHF patients.

CONCLUSION

We suggest that osteoprotegerin may be useful in improving the NT-proBNP based model as predictor of decreased global contractility function in diabetic patients with CHF.

Cirrhotic cardiomyopathy: Implications for liver transplantation

The majority of patients on a waiting list for liver transplantation have end-stage liver disease. Because of the marked peripheral vasodilatation of end-stage cirrhosis that masks a latent myocardial dysfunction, cardiac abnormalities in the resting state are usually subclinical and escape the attention of physicians. However, when challenged, the systolic and diastolic contractile responses are attenuated. In addition to these contractile abnormalities, morphological changes, such as enlargement or hypertrophy of cardiac chambers, and electrophysiological repolarization changes, including a prolonged QT interval, can be observed. The constellation of these cardiac abnormalities is termed cirrhotic cardiomyopathy. Liver transplantation induces significant cardiovascular stress. Clamping of the inferior vena cava and portal vein, hemorrhage and blood/volume infusion, and ischemia/reperfusion all cause hemodynamic fluctuation. The changing cardiac preload and afterload status increases the cardiac workload, and thus, the previously subclinical ventricular dysfunction may manifest as overt heart failure during the operative and perioperative periods. Cardiac dysfunction contributes to morbidity and mortality associated with liver transplantation. Cardiovascular events are the third leading cause of death in liver recipients. However, because liver transplantation is the only definitive treatment for end-stage liver failure and also appears to reverse cardiac abnormalities, it is important to understand the challenges of the heart in liver transplantation. This review focuses on cardiac status before, during, and after liver transplantation. Liver Transplantation 23 826-835 2017 AASLD.

[New Heart Failure Guidelines: Update for Primary Care]

Zusammenfassung. Die Herzinsuffizienz ist definiert als klinisches Syndrom, charakterisiert durch typische Symptome, häufig begleitet von typischen klinischen Befunden in Assoziation mit strukturellen oder funktionellen kardialen Abnormitäten. Unterschieden wird die Herzinsuffizienz mit verminderter, erhaltener und neu «mid-range» Auswurffraktion. Es wird ein neuer Diagnose-Algorithmus basierend auf der klinischen Wahrscheinlichkeit für das Vorliegen einer Herzinsuffizienz bei nicht akutem Beginn vorgestellt. Die etablierte medikamentöse Therapie der Herzinsuffizienz mit verminderter Auswurffraktion umfasst ACE-Hemmer, Betablocker und Mineralokortikoidrezeptor-Antagonisten, ergänzt durch Diuretika bei Vorliegen einer Stauung. Eine neue Therapieoption steht mit dem Angiotensinrezeptor-Neprilysin-Inhibitor Valsartan/Sacubitril zur Verfügung. Neben der medikamentösen Therapie kommt der Device-Therapie, insbesondere der kardialen Resynchronisationstherapie (CRT) eine wichtige Rolle zu. Die entsprechende Indikationsstellung erfolgt durch Kardiologen. Für die Herzinsuffizienz mit erhaltener Auswurffraktion gibt es bisher keine evidenzbasierte Therapie zur Reduktion von Morbidität und Mortalität. Diuretika verbessern Symptome bei Flüssigkeitsretention. Auslösende Faktoren sowie kardiale und nicht-kardiale Komorbiditäten sollen gezielt gesucht und behandelt werden.

Predictive value of B-type natriuretic peptide (BNP) for adverse cardiac events in patients undergoing primary total knee arthroplasty (TKA)

BACKGROUND

B-type natriuretic peptide (BNP) is a well-known biomarker to predict cardiac events following orthopedic procedures. However, further information regarding BNP can be completed. The present study aims to determine which of preoperative, postoperative or the difference between them (DVPPB) can best predict adverse cardiac events following TKA procedure and detect possible risk factors of high level of BNP.

METHODS

Between Jan. 2012 and Jan. 2014. 1120 included patients in 3 institutions have a minimum of 2-years follow-up. All clinical characteristics related to TKA procedure were put in total joint arthroplasty registry system and analyzed finally. The cut-off value of BNP predicting patients at increased risks of cardiac events after TKA was evaluated by the Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Our results reveal DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA, and the optimal cut-off value was 825.5 pg/ml with the highest Youden index of 0.62. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml.

CONCLUSIONS

DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml. We hope these results could be helpful to optimize health care among patients undergoing primary TKA.

Prognostic value of transthoracic echocardiography and biomarkers of cardiac dysfunction in community-acquired pneumonia

The aim of this study was to determine the prognostic role of echocardiography and compare with admission N-terminal proB-type natriuretic peptide (NT-proBNP) levels in adult patients with community-acquired pneumonia (CAP). Consecutive adult patients hospitalized with CAP were prospectively enrolled and followed-up until hospital discharge or death. Echocardiography was performed within the first 48 hours. Complicated hospitalization (CH) was defined as intensive care unit admission, need for mechanical ventilation or in-hospital mortality. This study was registered with ClinicalTrials.gov, number NCT02441855. A total of 15 CH (13.5%) occurred among 111 patients with CAP. CAP patients with a CH compared with those without CH had significantly higher NT-proBNP values (1267.4±1146.1 vs. 305.6±545.7 pg/mL, p <0.001) and troponin I (23.8±24.3 vs. 10.3±6.3 ng/mL, p 0.02) but had lower left ventricle ejection fraction (52.7±8.7 vs. 60.5±6.7%, p <0.001) and tricuspid annular plane systolic excursion (TAPSE), which is a measure of right ventricular systolic function (17.1±4.4 vs. 21.8±4 mm; p 0.001). Patients with elevation of NT-proBNP and decreased TAPSE at presentation had a significantly higher probability of CH (60%) than patients with either elevated NT-proBNP or decreased TAPSE (40%). Patients with neither elevated NT-proBNP nor decreased TAPSE had a 0% probability of CH. This is the first study to demonstrate that decreased right ventricular systolic function is associated with increased rates of adverse events in patients with CAP.

Prognosis of heart failure with preserved ejection fraction treated with β-blockers: A propensity matched study in the community

BACKGROUND

The effect of treatment with β-blockers on the prognosis of patients newly diagnosed with heart failure with preserved ejection fraction (HFpEF) is unknown.

OBJECTIVE

To analyze the relationship of commencing treatment with the β-blockers bisoprolol or carvedilol (CT-βB) with the prognosis of newly diagnosed HFpEF.

METHODS

Prospective study over 10years on 2704 patients with HFpEF. Main outcomes were mortality (all-cause and cardiovascular), hospitalizations for HF worsening, and visits. The independent relationship between CT-βB and the prognosis, stratifying patients for cardiovascular co-morbidity after propensity score-matching (985 patients CT-βB vs. another 985 patients non-CT-βB), was analyzed.

RESULTS

During a median follow-up of 1877.4days (interquartile range, 1-3651.2) 1600 died (81.2%), and 1702 were hospitalized (86.4%). CT-βB was associated with a lower risk of mortality (all-cause: HR [CI 95%] 0.78 [0.71 to 0.85], and cardiovascular: 0.75 [0.69 to 0.82]), a lower hospitalization rate (per 100 persons-year), 15.8 vs. 19.2, and a lower 30-day readmission rate (per 100 persons-year), 4.0 vs. 5.8, (P<0.001 in all cases), even after adjustment for the propensity to take β-blockers or other medications, comorbidities, and other potential confounders. These effects of CT-βB were independent of gender, and were observed in both patients taking high dose βB (over the median dose) and lower dose βB (under or equal to the median dose).

CONCLUSIONS

In this propensity matched study, commencing treatment with bisoprolol or carvedilol, both at high and at lower doses, is associated with an improved prognosis of patients newly diagnosed with HFpEF.

Multimarker assessment for the prediction of renal function improvement after percutaneous revascularization for renal artery stenosis

BACKGROUND

Identifying patients likely to have improved renal function after percutaneous transluminal renal angioplasty and stenting (PTRA) for renal artery stenosis (RAS) is challenging. The purpose of this study was to use a comprehensive multimarker assessment to identify those patients who would benefit most from correction of RAS.

METHODS

In 127 patients with RAS and decreased renal function and/or hypertension referred for PTRA, quantification of hemodynamic cardiac stress using B-type natriuretic peptide (BNP), renal function using estimated glomerular filtration rate (eGFR), parenchymal renal damage using resistance index (RI), and systemic inflammation using C-reactive protein (CRP) were performed before intervention.

RESULTS

Predefined renal function improvement (increase in eGFR ≥10%) at 6 months occurred in 37% of patients. Prognostic accuracy as quantified by the area under the receiver-operating characteristics curve for the ability of BNP, eGFR, RI and CRP to predict renal function improvement were 0.59 (95% CI, 0.48-0.70), 0.71 (95% CI, 0.61-0.81), 0.52 (95% CI, 0.41-0.65), and 0.56 (95% CI, 0.44-0.68), respectively. None of the possible combinations increased the accuracy provided by eGFR (lower eGFR indicated a higher likelihood for eGFR improvement after PTRA, P=ns for all). In the subgroup of 56 patients with pre-interventional eGFR <60 mL/min/1.73 m(2), similar findings were obtained.

CONCLUSIONS

Quantification of renal function, but not any other pathophysiologic signal, provides at least moderate accuracy in the identification of patients with RAS in whom PTRA will improve renal function.

The prognostic value of the plasma N-terminal pro-brain natriuretic peptide level on all-cause death and major cardiovascular events in a community-based population

BACKGROUND

Despite growing evidence that N-terminal pro-brain natriuretic peptide (NT-proBNP) has an important prognostic value for patients with cardiovascular disease, chronic kidney disease, etc, the prognostic significance of NT-proBNP levels in the general population has not been established. The aim of this study was to evaluate the clinical significance of NT-proBNP in a community population.

METHODS

This is a community-based prospective survey of residents from two communities in Beijing conducted for a routine health status checkup. Out of 1,860 individuals who were eligible for inclusion from 2007 to 2009, 1,499 completed a follow-up and were assessed for the prognostic value of NT-proBNP in 2013. A questionnaire was used for end point events. Anthropometry and blood pressure were measured. Plasma NT-proBNP, creatinine, lipids, and glucose were determined.

RESULTS

A total of 1,499 subjects with complete data were included in the analysis. Participants were divided into four groups according to baseline NT-proBNP levels (quartile 1, <19.8 pg/mL; quartile 2, 19.8-41.6 pg/mL; quartile 3, 41.7-81.8 pg/mL; quartile 4, ≥81.9 pg/mL). During a median 4.8-year follow-up period, the all-cause mortality rate rose from 0.8% in the lowest concentration NT-proBNP group (<19.8 pg/mL) to 7.8% in the highest NT-proBNP group (≥81.9 pg/mL; P<0.001). The incidence of major adverse cardiovascular events (MACEs) increased from 3.1% in the lowest NT-proBNP group to 18.9% in the highest group (P<0.001). Individuals in the highest NT-proBNP group (≥81.9 pg/mL) were associated with higher risk of all-cause death and MACEs compared with the lowest NT-proBNP group using Kaplan-Meier survival curves and the Cox proportional hazard model after adjusting for age, sex, and traditional risk factors.

CONCLUSION

The plasma NT-proBNP level is a strong and independent prognosis factor for all-cause death and MACEs in the community population. The NT-proBNP cut-point for the prognostic value remains to be further studied. NT-proBNP is a strong and independent prognostic factor for all-cause death and MACEs in individuals older than 65 years and MACEs in individuals younger than 65 years.

Biomarkers of Heart Failure with Preserved and Reduced Ejection Fraction

Biomarkers are increaingly being used in the management of heart failure not only for the purpose of screening, diagnosis, and risk stratification, but also as a guide to evaluate the response to treatment in the individual patient and as an entry criterion and/or a surrogate marker of efficacy in clinical trials testing novel drugs. In this chapter, we review the role of established biomarkers for heart failure management, according to the main classification of HF phenotypes, based on the measurement of left ventricular ejection fraction, including heart failure with reduced (<40%), preserved (≥50%), and, as recently proposed, mid-range (40-49%) ejection fraction.