Brain natriuretic peptide and cardiac autonomic function in type 2 diabetic patients

SARS-CoV-2 Aiming for the Heart: A Multicenter Italian Perspective About Cardiovascular Issues in COVID-19

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the high fatality rate of coronavirus disease 2019 (COVID-19) have been putting a strain on the world since December 2019. Infected individuals exhibit unpredictable symptoms that tend to worsen if age is advanced, a state of malnutrition persists, or if cardiovascular comorbidities are present. Once transmitted, the virus affects the lungs and in predisposed individuals can elicit a sequela of fatal cardiovascular consequences. We aim to present the pathophysiology of COVID-19, emphasizing the major cellular and clinical manifestations from a cardiological perspective. As a roaming viral particle or more likely via the Trojan horse route, SARS-CoV-2 can access different parts of the body. Cardiovascular features of COVID-19 can count myocardial injuries, vasculitis-like syndromes, and atherothrombotic manifestations. Deviations in the normal electrocardiogram pattern could hide pericardial effusion or cardiac inflammation, and dispersed microthrombi can cause ischemic damages, stroke, or even medullary reflex dysfunctions. Tailored treatment for reduced ejection fraction, arrhythmias, coronary syndromes, macrothrombosis and microthrombosis, and autonomic dysfunctions is mandatory. Confidently, evidence-based therapies for this multifaceted nevertheless purely cardiological COVID-19 will emerge after the global assessment of different approaches.

N-Terminal Pro-B-Type Natriuretic Peptide Levels Inversely Correlated With Heart Rate Variability in Patients With Unstable Angina Pectoris

We explored the relationships between heart rate variability (HRV) and levels of N-terminal Pro-B-type natriuretic peptide (NT-proBNP) in patients with unstable angina pectoris (UA).A total of 90 consecutive patients admitted < 48 hours for UA were included. Serum levels of NT-proBNP were measured from blood samples. The cohort was divided into tertiles according to NT-proBNP levels. HRV parameters including SDNN, RMSSD, LF, HF, TP, and VLF were assessed by 24-hour Holter ECG monitoring.The median (IQR) NT-proBNP level was 177.02 (64.76, 740.70) pg/mL. Patients with SDNN < 100 ms had higher levels of NT-proBNP than those with SDNN > 100 ms (P = 0.003). With increasing levels of NT-proBNP, both the 24hour monitoring HRV and night-monitoring HRV showed that SDNN and VLF gradually decreased (P < 0.01), and patients in the NT-proBNP lowest tertile group had higher LF values than the other two groups (P < 0.05); however, no difference was found in RMSSD, HF, and TP. During the daytime, the LF, VLF, and TP values were lower in the NTproBNP highest group compared with the lowest tertile group (P < 0.05). NT-proBNP levels correlated negatively with SDNN (r = -0.314, P = 0.003) and VLF (r = -0.397, P < 0.001) but not with other HRV parameters. Multiple regression analysis showed that serum levels of NT-proBNP remained predictive of SDNN (β = -0.060, P = 0.001) and VLF (β = -0.145, P < 0.001), even after adjustment for confounders.Our study showed that the elevated serum levels of NT-proBNP predict reduced HRV parameters, and the increased NT-proBNP levels combined with decreased HRV represent the degree of neurohormonal dysfunction and may be better prognostic predictors for risk stratification in UA patients.

NT-proBNP values in elderly heart failure patients with atrial fibrillation and diabetes

AIM

To evaluate N-terminal pro-BNP-type natriuretic peptide (NT-proBNP) plasmatic levels in heart failure patients with/without atrial fibrillation (AFib) and with/without diabetes (DM).

METHODS

The study enrolled 120 patients with heart failure, age 71.26±9.14, 48.3% AFib and 30.8% with DM. The patients were divided into 4 groups according to the presence or absence of AFib and DM: group 1, 46 patients in sinus rhythm (SR) without DM; group 2, 16 patients in SR with DM; group 3, 37 patients with AFib and without DM; group 4, 21 patients with both AFib and DM.

RESULTS

The patients in SR with DM displayed lower NT-proBNP levels than those with AFib without DM (1196.75±1183.11 vs 1940.59±963.665, p=0.02). We recorded no significant difference in comparison with the patients who had both AFib and DM (1196.75±1183.11 vs 1452.67±1257.94, p=NS). There was no significant difference between groups 3 and 4. Statistically significant correlations between ejection fraction, namely NYHA class and NT-proBNP levels were recorded only in the patients in SR-group 1 (r=-0.42, p<0.01) and group 2 (r=-0.66, p<0.01).

CONCLUSIONS

Correlations between plasma NT-proBNP levels and ejection fraction, namely NYHA class, were evinced only in patients in SR.

Concomitant diabetes mellitus and heart failure

The prevalence of patients with concomitant diabetes mellitus (DM) and heart failure (HF) is growing exponentially. Patients with HF and DM show specific metabolic, neurohormonal, and structural heart abnormalities, which potentially contribute to worse HF outcomes than seen in patients without comorbid DM. Subgroup analysis of recent trials suggest that patients with HF and DM may respond differently to standard therapy, and data are emerging on the possible increase in the risk of hospitalizations for HF in patients with DM treated with specific class of antidiabetic agents, pointing to the need of developing specific medications to be tested in dedicated future studies to address the unique metabolic and hemodynamic alterations seen in these patients.

Plasma norepinephrine is an independent predictor of adverse cerebral and cardiovascular events in type 2 diabetic patients without structural heart disease

BACKGROUND

Resting plasma norepinephrine (NE) level was reportedly related to high mortality in patients with heart failure. The current study investigated whether resting NE could predict long-term major adverse cerebral and cardiovascular events (MACCEs) in Japanese type 2 diabetic patients without heart disease.

METHODS AND SUBJECTS

We evaluated resting NE in 95 patients with type 2 diabetes who did not have severe complications. Based on the ROC curves, high NE was defined as ≥333pg/ml. Accurate follow-up information during a mean of 3.6±1.9 years was obtained in 27 high NE patients (13 female, mean age 64±12 years) and 68 low NE patients (29 female, 60±12 years).

ESSENTIAL RESULTS

The Kaplan-Meier curves revealed that MACCE-free ratio was significantly lower in the high NE patients than in the low NE patients (log-rank 10.3, p=0.0013). Cox proportional hazards regression analysis revealed that female gender (hazard ratio 7.75), low baroreflex sensitivity (hazard ratio 6.66), and high NE (hazard ratio 5.40) were independently associated with the incidence of MACCE.

PRINCIPAL CONCLUSIONS

Our results suggest that resting NE is comparably useful to identify the high-risk patients for MACCE to baroreflex sensitivity in type 2 diabetic patients. The results also suggest that pathogenic sympathetic activation leading to MACCE may be identified by the assessment of resting NE, more easily and less expensively compared to cardiac iodine 123 metaiodobenzylguanidine scintigraphy in this population.

Levels of B-type natriuretic peptide in chronic heart failure patients with and without diabetes mellitus

The current study aimed to observe the value of B-type natriuretic peptide (BNP) in chronic heart failure (CHF) patients with and without diabetes mellitus (DM). The study consisted of 559 CHF patients, including 276 patients with coronary heart disease, 234 with hypertensive heart disease and 49 with dilated cardiomyopathy. The subjects were divided into non-DM and DM groups which included 384 and 175 patients, respectively. Their New York Heart Association (NYHA) cardiac function degree and BNP levels were detected following admission. Other blood parameters, including fasting blood glucose and serum creatinine, were also collected. Left ventricular ejection fraction (LVEF) and the average thickness of the left ventricular wall (LVW) were detected by echocardiography. The total score of the heart failure (HF)-related parameters was evaluated for each patient according to age, hypertension, LVEF, LVW and NYHA degree. Additionally, BNP-score relation curves were constructed. The levels of BNP were significantly higher in the DM group compared with the non-DM group (1143.73±94.0 vs. 884.34±57.0 ng/l, P<0.05). Positive BNP-score relation curves were obtained for the DM and non-DM groups, but the curve of the DM group was notably steeper. As the patients with DM have significantly higher BNP levels at a similar HF score, DM history and fasting blood glucose should be taken into consideration when evaluating the value of BNP in HF.

Gender difference in baroreflex sensitivity to predict cardiac and cerebrovascular events in type 2 diabetic patients

BACKGROUND

Cardiovascular autonomic neuropathy is a major complication in patients with diabetes mellitus (DM), and baroreflex sensitivity (BRS) reportedly can predict cardiovascular prognosis in type 2 DM patients. The hypothesis that cardiovascular events are associated with gender differences in BRS was tested in the present study.

METHODS AND RESULTS

From 1998, we have evaluated BRS by phenylephrine methods in 185 consecutive type 2 DM patients. The long-term prognostic value of BRS was compared between 91 female (5812 years) and 94 male patients (5811 years). There was no significant difference in age or severity and duration of DM between the 2 groups. When compared to male, the BRS value in female patients was significantly lower (9.266.0 vs. 5.975.0 ms/mmHg, P < 0.0001). During a mean of 62.7 months of follow-up, 16 female patients developed cardiovascular events (17.6%) including stroke, acute myocardial infarction, angina pectoris requiring percutaneous coronary intervention or coronary artery bypass grafting and congestive heart failure requiring admission, while only 4 male patients developed events (4.3%, P < 0.005). In females, the Kaplan-Meier curves revealed that those with depressed BRS (< 6 ms/mmHg) had a higher incidence of cardiovascular events than those with preserved BRS (P < 0.05), but this relationship was not observed in male patients.

CONCLUSIONS

Although the reason why females had a more depressed BRS remains unclear, our findings demonstrated that a depressed BRS value can accurately predict cardiovascular events, especially in female patients with type 2 DM.

Baroreflex sensitivity predicts cardiovascular events in patients with type 2 diabetes mellitus without structural heart disease

BACKGROUND

Cardiovascular autonomic neuropathy is a major complication in patients with diabetes mellitus (DM). However, the relationship between cardiovascular autonomic neuropathy and the incidence of cardiovascular events has been poorly investigated in type 2 DM. The present study aimed to assess the long-term cardiovascular predictive value of baroreflex sensitivity (BRS) in Japanese patients with type 2 DM without structural heart disease.

METHODS AND RESULTS

BRS was evaluated using the phenylephrine method in 210 patients with type 2 DM who did not have structural heart disease or other severe complications. BRS was considered depressed if <6 ms/mmHg. Accurate follow-up information for 3-10 years (mean 4.7 years) was obtained in 184 patients (90 females, 94 males; mean age 58+/-12 years). The initial onset of a major adverse cardiovascular event (MACE) was investigated. During follow-up, 19 patients presented with a MACE (4 cardiovascular deaths, 3 nonfatal myocardial infarctions, 4 coronary revascularizations, 5 strokes, 2 congestive heart failures). Cox proportional hazards regression analysis revealed that depressed BRS was independently associated with the incidence of MACE (hazard ratio 1.93, 95% confidence interval 1.09-3.82, P=0.0236).

CONCLUSIONS

Depressed BRS at baseline has long-term cardiovascular predictive value in Japanese patients with type 2 DM without structural heart disease.

The relationship between heart rate recovery and brain natruretic Peptide in patients with chest discomfort: a study for relationship between heart rate recovery and pre-exercise, post-exercise levels of brain natruretic Peptide in patients with normal systolic function and chest discomfort

Background and Objectives

The correlation between brain natruretic peptide (BNP) level and cardiac autonomic function has been studied in type 2 diabetic patients. However, there is limited data from patients with normal systolic function. We evaluated the association between heart rate recovery (HRR) representing autonomic dysfunction and three plasma BNP levels: pre-exercise, post-exercise, and change during exercise in patients with normal systolic function.

Subjects and Methods

Subjects included 105 patients with chest pain and normal systolic function. HRR was defined as the difference between the peak heart rate and the rate measured two minutes after completion of a treadmill exercise test. We measured plasma BNP levels before exercise, 5 minutes after completion of exercise, and during exercise (absolute value of difference between pre- and post-exercise BNP levels).

Results

Patients with abnormal HRR values (≤24 beats for the first 2 minutes of HRR) had lower high-density lipoprotein, lower peak heart rates, and higher pre- and post-exercise BNP levels than patients with normal HRR values. The patients with coronary artery disease (CAD) had abnormal HRR. However, no significant differences were found between the two groups in terms of history of hypertension (HTN), diabetes, and peak systolic blood pressure (SBP) and diastolic blood pressure (DBP). HRR was significantly associated with pre-exercise BNP (r=-0.36, p=0.004) and post-exercise BNP (r=-0.27, p=0.006), but not BNP changes. Further, pre-exercise BNP levels showed a greater association with HRR than post-exercise BNP levels.

Conclusion

HRR is independently associated with pre-exercise and post-exercise BNP levels, even in patients with normal systolic function.

Cardiac autonomic neuropathy in patients with diabetes and no symptoms of coronary artery disease: comparison of 123I-metaiodobenzylguanidine myocardial scintigraphy and heart rate variability

Purpose

The purpose of this study was to evaluate the prevalence of cardiac autonomic neuropathy (CAN) in a cohort of patients with type 2 diabetes, truly asymptomatic for coronary artery disease (CAD), using heart rate variability (HRV) and ¹²³I-metaiodobenzylguanidine (¹²³I-mIBG) myocardial scintigraphy.

Methods

The study group comprised 88 patients with type 2 diabetes prospectively recruited from an outpatient diabetes clinic. In all patients myocardial perfusion scintigraphy, CAN by HRV and ¹²³I-mIBG myocardial scintigraphy were performed. Two or more abnormal tests were defined as CAN-positive (ECG-based CAN) and one or fewer as CAN-negative. CAN assessed by ¹²³I-mIBG scintigraphy was defined as abnormal if the heart-to-mediastinum ratio was <1.8, the washout rate was >25%, or the total defect score was >13.

Results

The prevalence of CAN in patients asymptomatic for CAD with type 2 diabetes and normal myocardial perfusion assessed by HRV and ¹²³I-mIBG scintigraphy was respectively, 27% and 58%. Furthermore, in almost half of patients with normal HRV, ¹²³I-mIBG scintigraphy showed CAN.

Conclusion

The current study revealed a high prevalence of CAN in patients with type 2 diabetes. Secondly, disagreement between HRV and ¹²³I-mIBG scintigraphy for the assessment of CAN was observed.

Increased plasma concentrations of N-terminal pro-B-type natriuretic peptide in patients with mild primary hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism (PHPT) is associated with heart disease. The aims of the present study were to evaluate how cardiac function and secretion of N-terminal pro-B-type natriuretic peptide (NT-proBNP) correlate in patients with mild PHPT, and how the plasma level of NT-proBNP is influenced by cure of the parathyroid disease.

DESIGN AND PATIENTS

Forty-two patients with PHPT without symptoms of heart disease were examined before and 1 year after curative parathyroidectomy.

MEASUREMENTS

Plasma or serum concentrations of NT-proBNP, calcium, PTH, creatinine, oestradiol, testosterone and SHBG were measured. Cardiac function was evaluated by equilibrium radionuclide angiography (ERNA).

RESULTS

At baseline, NT-proBNP levels correlated negatively with systolic function [left ventricular ejection fraction (LVEF), P < 0.001]. Twelve per cent of the patients had NT-proBNP levels above normal reference values preoperatively. One year postoperatively, the corresponding proportion was 21%. The mean plasma concentration of NT-proBNP increased after parathyroidectomy (P < 0.01) in parallel with a dip in diastolic function (peak filling rate, P < 0.05) and a falling trend in systolic function (LVEF, P = 0.08). The postoperative percentage changes in circulating NT-proBNP and total oestradiol correlated positively (P < 0.05).

CONCLUSIONS

Patients with mild PHPT and normal renal function may have high levels of circulating NT-proBNP despite the absence of symptomatic heart disease. Cure of the parathyroid disease is followed by a further increase in NT-proBNP secretion in parallel with ERNA measures, indicating subclinical changes in heart function. These results are in line with data indicating an association between PHPT and increased risk of premature death.

Oxygen Therapy Prevents Ventricular Arrhythmias in Patients With Congestive Heart Failure and Sleep Apnea

BACKGROUND

Although ventricular arrhythmia is critical for the prognosis of patients with severe congestive heart failure (CHF), it is difficult to control the arrhythmia using conservative therapies. However, many CHF patients also have sleep apnea syndrome (SAS) and oxygen supply improves their prognosis. The beneficial effects of oxygen treatment for ventricular arrhythmia have not yet been clarified, so the present study was designed to evaluate the effects of oxygen treatment for premature ventricular contraction (PVC).

METHODS AND RESULTS

Patients with CHF and SAS were divided into 3 groups: (1) the "PVC declined" group that included patients who had frequent PVCs and oxygen treatment that suppressed the number of PVC; (2) the "PVC not affected" group that included patients who had frequent PVCs and oxygen treatment did not affect the number of PVC; and (3) the "few PVC" group that included patients who had no or few PVCs. The group 1 patients showed higher apnea-hypopnea index, standard deviation of all R-R intervals, left ventricular ejection fraction, and brain natriuretic peptide levels than the patients in group 2. Oxygen treatment in group 3 did not affect the PVC frequency.

CONCLUSIONS

Oxygen treatment may be useful for preventing ventricular arrhythmia in selected patients with CHF and SAS.