Tissue Doppler velocities of mitral annulus and NT-proBNP in patients with heart failure

Clinical significance of early-diastolic tissue velocity imaging of lateral mitral annulus for prognosis of nonischemic left ventricular dysfunction

PURPOSE

We explored the potential of tissue velocity imaging (TVI) for prognosis of nonischemic left ventricular (LV) dysfunction (LVD).

METHODS

We reviewed 138 nonischemic LVD patients (58 ± 14 years) who underwent both cardiac magnetic resonance (CMR) and echocardiography. Septal and lateral mitral annular TVI data were compared with late gadolinium enhancement (LGE) on CMR. During a mean follow-up of 24 months, recovery (>15%) of LV ejection fraction and clinical outcomes (cardiovascular death and heart failure hospitalization) were assessed.

RESULTS

LGE was commonly observed in the basal anteroseptal, inferoseptal, and inferior segments, but infrequently observed in the anterolateral segment. LGE was associated with lower early diastolic, septal (Sep-e' = 5.2 ± 2.0 vs 6.9 ± 2.0 cm/s, P = .031) and lateral (Lat-e' = 7.3 ± 3.0 vs 9.5 ± 2.0 cm/s, P < .001) TVI. The relationship between Lat-e' and anterolateral LGE (area under the curve, AUC 0.834) was much better than that between Sep-e' and inferoseptal LGE (AUC 0.699). The 60 patients with LVD reversibility revealed higher Lat-e' (9.8 ± 2.0 vs 6.7 ± 2.2 cm/s, P < .001) and lower LGE burden (7.3 ± 9.0 vs 22 ± 10%, P < .001), while Lat-e' ≤ 7.8 cm/s appeared unfavorable for 31 events patients. On multivariate analyses, Lat-e' (HR 0.79, 95% CI 0.63-0.99, P = .044) and LVD reversibility (HR 0.53, 95% CI 0.16-0.90, P = .018) were still meaningful together with LGE segments and burden.

CONCLUSION

Lat-e' was related with LVD reversibility and a significant predictor of clinical outcomes.

Diagnostic value of NT-proBNP in identifying impaired coronary flow reserve in asymptomatic moderate or severe aortic stenosis

AIM

NT-proBNP has been shown to be a reliable biochemical marker for left ventricular wall stress. The relationship between NT-proBNP and coronary flow reserve (CFR) was evaluated in patients with significant asymptomatic aortic stenosis (AS).

METHODS

A total of 74 patients with moderate or severe AS, mean age 66.68 ± 10.02 years (56.75% males), were enrolled in this prospective study. All patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis >50% in diameter). They had all undergone standard transthoracic Doppler-echo study and adenosine stress transthoracic-echo for CFR measurement and laboratory analysis for NT-proBNP measurement.

RESULTS

The median NT-proBNP value was significantly increased (417.0 pg/ml; interquartile range [IQR]: 176.8-962.2 pg/ml). NT-proBNP was significantly higher in the group with CFR ≤2.5 (median: 549.0 pg/ml; IQR: 311.5-1131.0 pg/ml; as opposed to median: 291.5 pg/ml; IQR: 123.0-636.2 pg/ml; W = 452; p = 0.012). NT-proBNP showed significant negative correlation with CFR (ρ = -0.377, p = 0.001). There was also significant correlation between NT-proBNP and E/E´, S´ and aortic valve resistance. The NT-proBNP value of 334.00 pg/ml was determined as the best cut-off value for the diagnosis of CFR ≤2.5 (area under the curve: 0.67; 95%CI: 0.54-0.79; p < 0.01) and the sensitivity and specificity were 74 and 64%, respectively.

CONCLUSION

Elevated NT-proBNP can indicate patients with impaired CFR in asymptomatic moderate or severe AS patients with preserved ejection fraction and nonobstructive coronary arteries.

N-terminal pro-Brain natriuretic peptide as a useful biomarker for monitoring prognosis in patients with cardiac valve replacement

BACKGROUND

N-terminal pro-Brain natriuretic peptide (NT-proBNP) is an important biomarker to indicate cardiac function, but its significance in cardiac surgery is still unclear.

OBJECTIVE

To explore clinical significance of serum NT-proBNP and their dynamic characteristics in patients with cardiac valve replacement (CVR).

METHODS

Dynamically detecting pre-operative and postoperative serum NT-proBNP on Elecsys 2010 in 60 CVR patients.

RESULTS

(1) There was a good relationship between pre-operative NT-proBNP and pre-operative NYHA classification, ejection fraction, fractional shortening, or between postoperative 1 day log [NT-proBNP] and postoperative ICU time, correlation coefficients were respectively 0.426 (P=0.001), -0.465 (P=0.001), -0.463 (P=0.002), and 0.453 (P=0.006). (2) Pre-operative NT-proBNP would be higher in multivalves damage or mitral lesions patients than that in single valve damage or aortic lesions. It indicated NT-proBNP>1,352 pg/ml could discriminate multivalves damage in Rheumatic Heart Diseases (RHD) patients (sensitivity: 0.742; specificity: 0.64); and NT-proBNP>549.12 pg/ml could differentiate mitral lesions and aortic lesions (sensitivity: 0.92; specificity: 0.75). However, pre-operative serum NT-proBNP for differentiating atrial fibrillation and sinus arrhythmia was not most efficient (AUC=0.655; P=0.044). (3) Perioperative NT-proBNP in CVR patients was characterized by early postoperative NT-proBNP increasing and late postoperative NT-proBNP decreasing. The peak of postoperation NT-proBNP was at postoperative 7 days.

CONCLUSIONS

Serum NT-proBNP was not only a good biomarker to effectively evaluate heart function but also to evaluate the cardiac valve damage in RHD patients, and postoperative NT-proBNP dynamic determination, especially detecting postoperative 1 day, 7 days and 14 days NT-proBNP would be more useful to evaluate prognosis of CVR patients.

Correlation between N-Terminal Pro-Brain Natriuretic Peptide and Doppler Echocardiographic Parameters of Left Ventricular Filling Pressure in Atrial Fibrillation

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia with a population prevalence of about 1%. Natriuretic peptide level is elevated in patients with AF with diastolic dysfunction even with a normal left ventricular (LV) ejection fraction. The N-terminal pro-brain natriuretic peptide (NT-proBNP) level and Doppler echocardiographic parameters for diastolic function have shown correlation with LV filling pressures. We aimed to evaluate the relationship between echocardiographic parameters and serum NT-proBNP in patients with AF with preserved LV ejection fraction.

Methods

We examined transthoracic echocardiography and NT-proBNP levels in the patients with AF and patients with sinus rhythm. Blood samples were taken for serum NT-proBNP measurements within 24 hours of echocardiographic examination. The group 1 was the patients with sinus rhythm (n = 30, mean age 68 ± 13 years) and the group 2 was the patients with AF (n = 33, mean age 70 ± 14 years).

Results

The group 2 patients had significantly higher mitral E, E' (lateral annulus), E/E' (septal annulus), left atrial (LA) volume index, LA size, pulmonary vein diastolic velocity, and NT-proBNP level than those of group 1 patients (p < 0.05). The area under the receiver-operating characteristic curve showed a NT-proBNP had good diagnostic power for E/E' (septal annulus) > 15 in patients with AF at cutoff value of 433 pg/mL.

Conclusion

NT-proBNP level is well correlated with Doppler echocardiographic parameters of diastolic function in patients with AF and preserved LV ejection fraction. NT-proBNP level more than 433 pg/mL may suggest elevated LV filling pressure in patients with AF.

Predictive value of B-type natriuretic peptides in detecting latent left ventricular diastolic dysfunction in beta-thalassemia major

BACKGROUND

Beta-thalassemia major is a unique disease characterized by early diastolic dysfunction, related exclusively to iron myocardial deposition. N-terminal-proBNP(amino-terminal) (NT-proBNP) and B-type natriuretic peptide (BNP) are sensitive biomarkers for the detection of asymptomatic left ventricular (LV) dysfunction, and they have important diagnostic and prognostic implications. Using beta-thalassemia as a model disease with isolated diastolic dysfunction, we sought to investigate the predictive value of NT-proBNP and BNP levels in comparison with the conventional and new Doppler echocardiography indexes in detecting this disorder.

METHODS

Seventy beta-thalassemia major patients (mean age 27.2 +/- 12.5 years) with normal LV systolic function (mean LV ejection fraction = 59% +/- 6.8%), and 50 healthy age-matched adults (control group: mean age 25.5 +/- 10.1 years, mean LV ejection fraction = 60% +/- 4.5%) were included. All subjects were studied thoroughly by tissue Doppler echocardiography and blood samples were taken for plasma NT-proBNP and BNP measurements at the same time. To examine LV diastolic function, patients were divided in 3 groups according to the E mitral/E mitral annulus ratio (E/E'): group A, patients without diastolic dysfunction: E/E' ratio <8; group B, patients with suspected diastolic dysfunction: E/E' ratio 8 to 15; group C, patients with documented diastolic dysfunction: E/E' ratio, >15.

RESULTS

NT-proBNP and BNP levels were higher in thalassemic patients compared with the control group (NT-proBNP levels: 80 +/- 19 vs 21 +/- 4 pg/mL, P < .001; BNP levels: 34 +/- 6 vs 9 +/- 3 pg/mL, P < .001). NT-proBNP levels showed a statistically significant increase in group C in comparison to groups A and B, which was also detected between groups A and B (A vs B: P < .05). BNP levels were also significantly increased in group C in comparison to the other 2 groups, but there was no statistically significant difference between groups A and B. Using receiver operating characteristic analysis, NT-proBNP at a cut point of 49.2 pg/mL was highly accurate (area under curve: 0.97, P < .001) in ruling out diastolic dysfunction (E/E' <8) with a sensitivity of 93.7% and a specificity of 89.6%.

CONCLUSIONS

BNP and NT-proBNP levels are significantly increased in documented left ventricular diastolic dysfunction, while NT-proBNP seems to have better predictive value in detecting latent left ventricular diastolic dysfunction in beta-thalassemia major.

Predischarge QRS score and risk for heart failure after first ST-elevation myocardial infarction

BACKGROUND

The prognostic value of the QRS score, a simple index of infarct size after a first ST-elevation myocardial infarction, has not been adequately explored in the reperfusion era.

METHODS AND RESULTS

We prospectively followed up 100 consecutive survivors of a first ST-elevation myocardial infarction (aged 64 +/- 13 years, 77% were male) without bundle branch block or paced rhythm at hospital discharge for 3 months. The modified 32-point QRS score was calculated as part of the predischarge evaluation. The predefined primary endpoint was the composite of death or hospitalization for heart failure. By 3 months, 6 patients died and 16 patients were readmitted for heart failure, resulting in a 22% primary endpoint rate. Patients with a QRS score >/= 3 at hospital discharge (n = 38) had significantly more events compared with those with a QRS score < 3 (44.7% vs. 8.2%, P < .001), and all six deaths occurred among patients with a QRS score >/= 3 (P = .002). A QRS score < 3 reliably predicted heart-failure free survival during the follow-up period (negative predictive value 91.9%). In multivariate models, the QRS score was an independent predictor of the primary endpoint (hazard ratio = 1.4 per point, 95% confidence interval 1.1-1.8, P = .003).

CONCLUSION

For patients surviving a first ST-elevation myocardial infarction, the predischarge QRS score provides powerful prognostic information on short-term outcomes, including mortality and readmission for heart failure.

The relationship between tissue Doppler imaging and seric NTproBNP levels in sinus rhythm patients: a prospective study

N-terminal pro-brain natriuretic peptide (NTproBNP) correlates with left ventricular (LV) filling pressure. The ratio between early diastolic transmitral velocity and early mitral annular diastolic velocity (E/Ea) reflects LV filling pressure in a variety of cardiac diseases. However this relationship was not validated in some categories of patients. Our aim was to evaluate the correlation between tissue Doppler velocities of the mitral annulus and NTproBNP levels in sinus rhythm patients.

METHODS

Echocardiography was performed in 111 consecutive patients simultaneously with NTproBNP measurement. E/Ea and E/(Ea x Sa) were calculated (Sa is the maximal systolic velocity of mitral annulus); the average of the velocities of septal and lateral mitral annulus was used.

RESULTS

Simple regression analysis demonstrated a significant linear correlation between E/(Ea x Sa) and NTproBNP (r = 0.71, P < 0.0001), superior to E/Ea correlation (r = 0.58, P < 0.0001). Significant but weaker correlations were found between NTproBNP and Sa, pulmonary artery systolic pressure, Ea, mitral E/A (early/late diastolic transmitral velocity), E wave, mitral E deceleration time and LV ejection fraction (LVEF). The optimal E/(Ea x Sa) cut-off for prediction of NTproBNP levels > 900 pg/ml was 1.5 (sensitivity = 81%, specificity = 70%). Among analyzed parameters, E/(Ea x Sa) was best correlated with NTproBNP levels in patients with LVEF >or= 50% (r = 0.80, P < 0.0001), with depressed LVEF (<50%) (r = 0.66, P < 0.0001), with regional wall motion abnormalities (r = 0.75, P < 0.0001), and with E/Ea 8 to 15 (r = 0.58, P < 0.0001).

CONCLUSIONS

E/(Ea x Sa) strongly correlates with NTproBNP, regardless of LVEF, and can be a simple and accurate echocardiographic index in patients in sinus rhythm, particularly in those with regional wall motion abnormalities or intermediate E/Ea.