Serial analyses of N-terminal pro-B-type natriuretic peptide in patients with non–ST-segment elevation acute coronary syndromes

Assessing Stroke Recurrence Risk by Using a Lipoprotein-Associated Phospholipase A2 and Platelet Count-Based Nomogram

Stroke recurrence remains a critical challenge in clinical neurology, necessitating the identification of reliable predictive markers for better management and treatment strategies. This study investigates the interaction between lipoprotein-associated phospholipase A2 (Lp-PLA2) and platelets as a potential predictor for stroke recurrence, aiming to refine risk assessment and therapeutic approaches. In a retrospective cohort of 580 ischemic stroke patients, we analyzed clinical data with a focus on Lp-PLA2 and platelet levels. By using multivariable logistic regression, we identified independent predictors of stroke recurrence. These predictors were then used to develop a comprehensive nomogram. The study established diabetes mellitus, hypertension, low-density lipoprotein (LDL), Lp-PLA2 levels, and platelet counts as independent predictors of stroke recurrence. Crucially, the interaction parameter Lp-PLA2 * platelet (multiplication of Lp-PLA2 and platelet count) exhibited superior predictive power over each factor considered separately. Our nomogram incorporated diabetes mellitus, cerebral infarction causes, hypertension, LDL, and the Lp-PLA2 * platelet count interaction and demonstrated enhanced accuracy in predicting stroke recurrence compared to traditional risk models. The interaction between Lp-PLA2 and platelets emerged as a significant predictor for stroke recurrence when integrated with traditional risk factors. The developed nomogram offers a novel and practical tool in molecular neurobiology for assessing individual risks, facilitating personalized treatment strategies. This approach underscores the importance of multifactorial assessment in stroke management and opens avenues for targeted interventions to mitigate recurrence risks.

Temporal biomarker concentration patterns during the early course of acute coronary syndrome

OBJECTIVES

Biomarker concentrations and their changes during acute coronary syndrome (ACS) provide clinically useful information on pathophysiological processes, e.g. myocardial necrosis, hemodynamic stress and inflammation. However, current evidence on temporal biomarker patterns early during ACS is limited, and studies investigating multiple biomarkers are lacking.

METHODS

We measured concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), NT-terminal pro-B-type natriuretic peptide, C-reactive protein, and growth-differentiation factor-15 (GDF-15) in plasma samples obtained at randomization in ACS patients from the PLATelet inhibition and patient Outcomes (PLATO) trial. Linear regressions with interaction analyses were used to investigate the associations of biomarker concentrations with the time from symptom onset and to model temporal biomarker concentration patterns.

RESULTS

The study population consisted of 16,944 patients (median age 62 years; 71.3 % males) with 6,853 (40.3 %) having ST-elevation myocardial infarction (STEMI) and 10,141 (59.7 %) having non-ST-elevation ACS (NSTE-ACS). Concentrations of all biomarkers were associated with time from symptom onset (pinteraction<0.001), apart for GDF-15 (pinteraction=0.092). Concentration increases were more pronounced in STEMI compared to NSTE-ACS. Temporal biomarker patterns for hs-cTnT and hs-cTnI were different depending on sex whereas biomarker patterns for the other biomarkers were similar in cohorts defined by age and sex.

CONCLUSIONS

Temporal concentration patterns differ for various biomarkers early during ACS, reflecting the variability in the activation and duration of different pathophysiological processes, and the amount of injured myocardium. Our data emphasize that the time elapsed from symptom onset should be considered for the interpretation of biomarker results in ACS.

Difference of cardiac rehabilitation in the morning or evening on indexes of left ventricular and N-terminal pro-brain natriuretic peptide: a randomized controlled trial

The present study aimed to evaluate the effects a cardiac rehabilitation program (CRP) performed in the morning or evening on left ventricular (LV) filling indices and the level of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in patients undergoing percutaneous coronary angioplasty during the COVID-19 pandemic.

Methods

This was a randomized controlled single-blinded clinical trial. Ninety-six patients (mean age: 50.2 ± 8.1 years, 36 women and 44 men) with percutaneous coronary angioplasty were divided into two groups of intervention and control. In each group, the CRP was performed in either morning or evening. The CRP included walking and performing push-ups and sit-ups for 8 weeks. The participants of the control groups received routine care. The functional indices of LV, including LV ejection fraction, systolic function, and diastolic function (i.e. the transmitral flow), the E/e' to left atrium peak strain ratio (as an estimation for LA stiffness), and NT-proBNP level were measured in all participants before starting and at the end of the CRP.

Results

In the intervention group, the individuals performing the CRP in the evening had significantly higher E-wave (0.76±0.02 vs. 0.75±0.03; P=0.008), ejection fraction (52.5±5.64 vs. 55.5±3.59; P=0.011), and diastolic function velocity (E/A ratio, 1.03±0.06 vs. 1.05±0.03; P=0.014) and significantly lower A-wave (0.72±0.02 vs. 0.71±0.01; P=0.041), E/e' ratio (6.74±0.29 vs. 6.51±0.38; P=0.038), and NT-proBNP level (2007.9±214.24 vs. 1933.9±253.13; P=0.045) compared with those performing the program in the morning.

Conclusions

A supervised CRP performed in the evening compared with morning was more effective in improving LV functional indices. Therefore, such home-based interventions are recommended to be performed in the evening during the COVID-19 pandemic.

Impact of dapagliflozin on cardiac function following anterior myocardial infarction in non-diabetic patients - DACAMI (a randomized controlled clinical trial)

BACKGROUND

The role of Sodium-glucose co-transporter 2 inhibitors (SGLT2i) in heart failure is established. Early data also suggests their favorable role in patients with acute coronary syndromes, but more evidence is still needed.

METHODS

In this dual center, double-blinded randomized controlled trial, non-diabetic patients (N = 100) who presented with anterior ST- elevation myocardial infarction (STEMI) & had undergone successful primary percutaneous coronary intervention, but their left ventricular ejection fraction was below 50%, were randomized to dapagliflozin 10 mg or a placebo once daily. The primary endpoint was a change in cardiac function assessed by N-terminal pro-Brain Natriuretic Peptide - NT-proBNP measured at baseline & 12 weeks post the cardiac event &/or echocardiographic parameters (left ventricular ejection fraction, left ventricular diastolic dimension & left ventricular mass index) assessed at baseline, 4-weeks & 12-weeks post the cardiac event.

RESULTS

From October 2021 to April 2022, 100 patients were randomized. The mean drop of NT- proBNP in the study group was more significant compared to the control group by 10.17% (95% CI: -3.28-19.67, p-value 0.034). In addition, the decrease in the left ventricular mass index (LV mass index) was also significant in the study group compared to the control group by 11.46% (95% CI: -19.37 to -3.56, p-value 0.029).

CONCLUSIONS

Dapagliflozin seems to have a role in preventing left ventricular dysfunction & maintaining cardiac function following anterior ST-elevation myocardial infarction. More Large-scale trials need to be done to confirm these findings further. This trial is locally registered at the National Heart Institute, Cairo - Egypt, and Faculty of Medicine, Ain Shams University, with reference numbers CTN1012021 & MS-07/2022, respectively. It is also registered retrospectively at the US National Institutes of Health (ClinicalTrial.gov) with identifier number: NCT05424315 - June 16th,2022.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand

OBJECTIVE

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported.

METHODS

First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity.

RESULTS

Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log₂(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084.

CONCLUSIONS

In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score.

TRIAL REGISTRATION NUMBER

ACTRN12615000676516.

B-Type Natriuretic Peptide and Long-Term Cardiovascular Mortality in Patients With Coronary Heart Disease

Background

The plasma concentration of B‐type natriuretic peptide (BNP) is a strong predictor of adverse cardiovascular events. The aim of this study was to determine whether the association between plasma BNP concentration and cardiovascular mortality is sustained or diminishes with increasing time after BNP is measured.

Methods and Results

Six thousand seven hundred forty patients with a history of myocardial infarction or unstable angina who participated in the LIPID (Long‐Term Intervention with Pravastatin in Ischemic Disease) trial had plasma BNP concentration measured at baseline and after 1 year. Associations with cardiovascular mortality were evaluated in landmark analyses 1 to <5, 5 to <10, and 10 to 16 years after randomization. There were 1640 cardiovascular deaths. The cardiovascular mortality rate increased progressively from 10.2 to 19.1 to 26.3/1000 patient‐years from 1 to <5, 5 to <10, and 10 to 16 years after baseline, respectively. The average of baseline and 1‐year BNP concentration was more strongly associated with cardiovascular mortality compared with baseline or 1‐year BNP only. The hazard ratio (HR) for cardiovascular death associated with each doubling of average BNP concentration was similar during years 1 to <5 (HR, 1.53 [95% CI, 1.44–1.63]), years 5 to <10 (HR, 1.52 [95% CI, 1.44–1.60]), and years 10–16 (HR, 1.43 [95% CI, 1.36–1.50]), P<0.0001 for all.

Conclusions

BNP concentration remains an independent predictor of cardiovascular mortality more than a decade after it is measured. Because of random variation in plasma concentrations, the average of >1 BNP measurement improves long‐term risk prediction.

Risk Estimates of Imminent Cardiovascular Death and Heart Failure Hospitalization Are Improved Using Serial Natriuretic Peptide Measurements in Patients With Coronary Artery Disease and Type 2 Diabetes

Background

Baseline and temporal changes in natriuretic peptide (NP) concentrations have strong prognostic value with regard to long‐term cardiovascular risk stratification. To increase the clinical utility of NP sampling for patient management, we wanted to assess the incremental predictive value of 2 serial NP measurements compared with a single measurement and provide absolute risk estimates for cardiovascular death or heart failure hospitalization (HFH) within 6 months based on 2 serial NP measurements.

Methods and Results

Consecutive NP samples obtained from 5393 patients with a recent coronary event and type 2 diabetes enrolled in the ELIXA (Evaluation of Cardiovascular Outcomes in Patients With Type 2 Diabetes After Acute Coronary Syndrome During Treatment With Lixisenatide) trial were used to construct best logistic regression models with outcome of cardiovascular death or HFH (136 events). Absolute risk estimates of cardiovascular death or HFH within 6 months using either BNP (B‐type natriuretic peptide) or NT‐proBNP (N‐terminal pro‐BNP) serial measurements were depicted based on the concentrations of 2 serial NP measurements. During the 6‐month follow‐up periods, the incidence rate (±95% CIs) of cardiovascular death or HFH for patients was 14.0 (11.8‒16.6) per 1000 patient‐years. Risk prediction depended on NP concentrations from both prior and current sampling. NP sampling 6 months apart improved the predictive value and reclassification of patients compared with a single sample (AUROC [Area Under the Receiver Operating Characteristic curve]: BNP, P=0.003. NT‐proBNP, P<0.0001), with a majority of moderate‐risk patients (6‐month risk between 1% and 10%) being reclassified on the basis of the second NP sample.

Conclusions

Serial NP measurements improved prediction of imminent cardiovascular death or HFH in patients with coronary artery disease and type 2 diabetes. The absolute risk estimates provided may aid clinicians in decision‐making and help patients understand their short‐term risk profile.

Serial Changes in Exercise Capacity, NT-proBNP, and Adiponectin in Patients with Acute Coronary Syndrome before and after Phase II Rehabilitation as well as at the 12-Month Follow-Up

Background. Acute coronary syndrome (ACS) causes pathophysiological changes in exercise capacity, N-terminal part of pro-brain natriuretic peptide (NT-proBNP), and adiponectin that impact the course of coronary artery disease and clinical outcomes after cardiac rehabilitation (CR). However, the serial changes and the relationship between the changes in these parameters for a prolonged term remain uninvestigated. Methods. Eighty-one patients with ACS underwent a three- or four-week CR program after acute care and were followed up for 12 months. Exercise capacity on a cycle ergometer and blood levels of NT-proBNP and adiponectin were determined before and after CR as well as at the 12-month follow-up. Results. Exercise capacity increased from 100 watts (in median) before CR to 138 watts after CR and 150 watts at 12 months. The NT-proBNP level (526 pg/ml before CR) remained almost unchanged after CR (557 pg/ml) and then decreased at 12 months (173 pg/ml). The adiponectin level (14.5 µg/ml before CR) increased after CR (16.0 µg/ml) and at 12 months (17.2 µg/ml). There was no significant correlation among the changes in these parameters at each observation time point. Conclusion. During the observation period from before CR to the 12-month follow-up, exercise capacity, NT-proBNP, and adiponectin underwent significant changes; however, these changes were independent from each other and not correlated linearly, and they provide complementary information in clinical practice. Thus, all these parameters should be included and determined at different time points for a prolonged period of time.

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

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

Value of Follow-Up N-Terminal Probrain Natriuretic Peptide (NT-proBNP) after a Modified Fontan Procedure

Objective

To assess the value of N-terminal probrain natriuretic peptide (NT-proBNP) in short-term and long-term follow-up after a modified Fontan procedure.

Methods

We retrospectively enrolled children who had undergone a modified Fontan procedure in the Heart Center of Guangzhou Women and Children's Medical Center from January 2014 to September 2020 and collected data on NT-proBNP values before bidirectional Glenn procedure, before Fontan procedure, and on 1, 3, 7, 30, 90, and 180 days and 1, 2, 3, 4, 5, and 6 year after Fontan procedure. The relationship between changes in NT-proBNP levels and the outcomes in children was analyzed.

Results

A total of 108 children (78 boys and 30 girls, mean age: 54.62 ± 29.38 weeks) were included in the analysis. According to one-way analysis of variance, the left ventricular type and biventricular type of single ventricle physiology showed shorter duration on cardiopulmonary bypass during the operation and lower levels of NT-proBNP after the operation than the right ventricular type and univentricular type physiology.

Conclusion

NT-proBNP is a good indicator for mid and long-term follow-up after a modified Fontan procedure. The left ventricular type and biventricular type of single ventricle physiology show better mid and long-term benefits from the modified Fontan procedure than the right ventricular type and univentricular type physiology.

Stabilization patterns and variability of hs-CRP, NT-proBNP and ST2 during 1 year after acute coronary syndrome admission: results of the BIOMArCS study

Objectives Details of the biological variability of high-sensitivity C-reactive protein (hs-CRP), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and ST2 are currently lacking in patients with acute coronary syndrome (ACS) but are crucial knowledge when aiming to use these biomarkers for personalized risk prediction. In the current study, we report post-ACS kinetics and the variability of the hs-CRP, NT-proBNP and ST2. Methods BIOMArCS is a prospective, observational study with high frequency blood sampling during 1 year post-ACS. Using 1507 blood samples from 191 patients that remained free from adverse cardiac events, we investigated post-ACS kinetics of hs-CRP, NT-proBNP and ST2. Biological variability was studied using the samples collected between 6 and 12 months after the index ACS, when patients were considered to have stable coronary artery disease. Results On average, hs-CRP rose peaked at day 2 and rose well above the reference value. ST2 peaked immediately after the ACS but never rose above the reference value. NT-proBNP level rose on average during the first 2 days post-ACS and slowly declined afterwards. The within-subject variation and relative change value (RCV) of ST2 were relatively small (13.8%, RCV 39.7%), while hs-CRP (41.9%, lognormal RCV 206.1/-67.3%) and NT-proBNP (39.0%, lognormal RCV 185.2/-64.9%) showed a considerable variation. Conclusions Variability of hs-CRP and NT-proBNP within asymptomatic and clinically stable post-ACS patients is considerable. In contrast, within-patient variability of ST2 is low. Given the low within-subject variation, ST2 might be the most useful biomarker for personalizing risk prediction in stable post-ACS patients.

The association of baseline N-terminal pro-B-type natriuretic peptide with short and long-term prognosis following percutaneous coronary intervention in non-ST segment elevation acute coronary syndrome with multivessel coronary artery disease: a retrospective cohort study

BACKGROUND

Several studies have shown that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is strongly correlated with the complexity of coronary artery disease and the prognosis of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS), However, it remains unclear about the prognostic value of NT-proBNP in patients with NSTE-ACS and multivessel coronary artery disease (MCAD) undergoing percutaneous coronary intervention (PCI). Therefore, this study aimed to reveal the relationship between NT-proBNP levels and the prognosis for NSTE-ACS patients with MCAD undergoing successful PCI.

METHODS

This study enrolled 1022 consecutive NSTE-ACS patients with MCAD from January 2010 to December 2014. The information of NT-proBNP levels was available from these patients. The primary outcome was in-hospital all-cause death. In addition, the 3-year follow-up all-cause death was also ascertained.

RESULTS

A total of 12 (1.2%) deaths were reported during hospitalization. The 4th quartile group of NT-proBNP (> 1287 pg/ml) showed the highest in-hospital all-cause death rate (4.3%) (P < 0.001). Besides, logistic analyses revealed that the increasing NT-proBNP level was robustly associated with an increased risk of in-hospital all-cause death (adjusted odds ratio (OR): 2.86, 95% confidence interval (CI) = 1.16-7.03, P = 0.022). NT-proBNP was able to predict the in-hospital all-cause death (area under the curve (AUC) = 0.888, 95% CI = 0.834-0.941, P < 0.001; cutoff: 1568 pg/ml). Moreover, as revealed by cumulative event analyses, a higher NT-proBNP level was significantly related to a higher long-term all-cause death rate compared with a lower NT-proBNP level (P < 0.0001).

CONCLUSIONS

The increasing NT-proBNP level is significantly associated with the increased risks of in-hospital and long-term all-cause deaths among NSTE-ACS patients with MCAD undergoing PCI. Typically, NT-proBN P > 1568 pg/ml is related to the all-cause and in-hospital deaths.

Clinical Applications of Natriuretic Peptides in Heart Failure and Atrial Fibrillation

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

Growth-differentiation factor-15 predicts adverse cardiac events in patients with acute coronary syndrome: A meta-analysis

BACKGROUND

We aimed to analyse the association between high-level growth-differentiation factor-15 (GDF-15) and mortality, recurrent MI and heart failure compared to low-level GDF-15 in patients with acute coronary syndrome (ACS).

METHODS

PubMed and EMBASE were searched from their commencement to December 2017 for qualified studies that evaluated the associations between GDF-15 and ACS. Risk ratios were synthesized with random effect meta-analysis. Publication bias and sensitivity analyses were also conducted.

RESULTS

A total of thirteen studies and 43,547 participants were analyzed systematically in our meta-analysis. Our study showed a significant association between GDF-15 values and mortality (p = 0.000, RR = 6.75, 95% CI = 5.81-7.84) and recurrent MI (p = 0.000, RR = 1.95, 95% CI = 1.72-2.21) in the overall analyses. Subgroup analyses revealed similar results. However, there was evidence of heterogeneity in the study of heart failure, whose overall RR was 6.66, with an I² of 87.3%.

CONCLUSION

There was a significant association between high-level GDF-15 and mortality, recurrent MI in patients with ACS. We need more data to research the risk stratification of heart failure in ACS patients in the future.

Sleep study-guided multidisciplinary therapy (SGMT) for patients with acute coronary syndrome: Trial rationale and design

Obstructive sleep apnea (OSA) is an emerging risk marker for acute coronary syndrome (ACS). This randomized trial aims to determine the effects of sleep study-guided multidisciplinary therapy (SGMT) comprising overnight sleep study, continuous positive airway pressure, and behavioral therapy for OSA during the subacute phase of ACS. We hypothesize that SGMT will reduce (1) the plasma levels of N-terminal pro brain natriuretic peptide and suppression of tumorigenicity 2; (2) the estimated 10-year risk of cardiovascular mortality as measured by the European Systematic Coronary Risk Evaluation (SCORE) algorithm; and (3) the cardiovascular event rate during a 3-year follow-up, compared with standard therapy. In the SGMT trial, 180 patients presenting with ACS will be randomly assigned to SGMT (n = 90) and standard therapy (n = 90) groups. Both groups will receive guideline-mandated treatment for ACS. Those assigned to SGMT will additionally undergo a sleep study and, if OSA is diagnosed, attend a multidisciplinary OSA clinic where they will receive personalized treatment including continuous positive airway pressure and behavioral/lifestyle counseling. The primary endpoint is the plasma N-terminal pro brain natriuretic peptide concentration at 7-month follow-up. This report presents the baseline characteristics of 117 patients (SGMT group: n =54; standard therapy group: n =63) who had been enrolled into the study as of August 31, 2017. The results of this trial will help us to understand whether active OSA diagnosis and treatment will improve the physiologic and clinical cardiovascular outcomes of this group of patients.

Natriuretic peptides in acute coronary syndromes: A new role to predict recurrent ischemic event-related mortality?

Risk stratification in acute coronary syndromes (ACS) has been previously based on the severity of acute clinical presentation, presence of cardiovascular comorbidities, and abnormalities of ischemia-specific biomarkers, most importantly troponins. Natriuretic peptides (NPs), which become elevated upon increased myocardial wall stress, are established diagnostic and prognostic biomarkers in patients with heart failure. Recently, their prognostic potential in ACS has been reported, specifically as predictors of future new-onset heart failure or left ventricular (LV) systolic dysfunction. In the current issue of the Hellenic Journal of Cardiology, a new role of NPs is suggested in ACS as predictors of long-term mortality associated with recurrent cardiac ischemic events, specifically in patients with preserved or mid-range LV ejection fraction upon index ACS. Potential pathophysiological mechanisms that explain the association between augmented NP levels with recurrent myocardial ischemia are hypothesized including the potential of NPs to reflect augmented local and/or systemic inflammation, prothrombotic state, and vascular dysregulation.

Prognostic Biomarkers in Acute Coronary Syndromes: Risk Stratification Beyond Cardiac Troponins

PURPOSE OF REVIEW

Cardiac troponin (cTn) plays an essential role for assessment of outcome in acute coronary syndrome (ACS). However, the prognostic value of cTn is not absolute. In this mini-review, we summarize the evidence on the utility of established biomarkers of left-ventricular dysfunction, hemodynamic stress, inflammation, and renal dysfunction for risk prediction beyond cTn in ACS.

RECENT FINDINGS

Only few biomarkers consistently demonstrate additive prognostic value to cTn levels. The B-type natriuretic peptides (NPs) and growth-differentiation factor-15 (GDF-15) are most promising in this regard. However, there are uncertainties regarding the role of these biomarkers for guidance of treatment decisions, and their prognostic increment to cTn levels measured with high-sensitivity assays is largely unknown. The NPs and GDF-15 provide the strongest prognostic increment to cTn levels in ACS. However, the role of these biomarkers for clinical decision-making in contemporary settings has still to be defined.

Prognostic Value of Serial N-Terminal Pro-Brain Natriuretic Peptide Testing in Patients With Acute Myocardial Infarction

Natriuretic peptides (NPs) are important predictors of outcomes in patients with acute myocardial infarction (AMI) but can change over time. The association of patterns of NP changes after AMI on outcomes is less clear. We measured N-terminal pro-brain natriuretic peptide (NT-proBNP) during the AMI admission and at 1 month in a prospective AMI registry. Outcomes included 1-year readmission and 2-year mortality. An elevated NT-proBNP was defined using age-specific criteria. Patients were classified into 3 groups (low/low [referent group], high/low, high/high) based on NT-proBNP value at enrollment and 1 month. The incremental predictive value of NT-proBNP was determined after adjusting for 6-month GRACE risk score, diabetes, and ejection fraction <40%. Among 773 patients, 303 (38%) were low/low, 240 (30%), and were high/high, 230 (29%) were high/low. Two-year mortality was highest in high/high patients but similar in the high/low and low/low patients (13.1% vs 2.7% and 2.3%, respectively). Similarly, readmission was significantly more likely in the high/high versus the high/low and low/low groups. After adjustment, mortality was significantly higher in the high/high group (hazard ratio 4.02, 95% CI 1.67 to 9.66) compared with the low/low group, although readmission was no longer statistically different (hazard ratio 1.37, 95% CI 0.93 to 2.03). In conclusion, a persistently elevated NT-proBNP assessed 1 month after discharge was associated with a higher risk of mortality in patient with AMI. Postdischarge risk stratification using NT-proBNP has the potential to identify higher risk patients after AMI.

Temporal Biomarker Profiling Reveals Longitudinal Changes in Risk of Death or Myocardial Infarction in Non–ST-Segment Elevation Acute Coronary Syndrome

BACKGROUND

There are conflicting data on whether changes in N-terminal pro–B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) concentrations between time points (delta NT-proBNP and hs-CRP) are associated with a change in prognosis.

METHODS

We measured NT-proBNP and hs-CRP at 3 time points in 1665 patients with non–ST-segment elevation acute coronary syndrome (NSTEACS). Cox proportional hazards was applied to the delta between temporal measurements to determine the continuous association with cardiovascular events. Effect estimates for delta NT-proBNP and hs-CRP are presented per 40% increase as the basic unit of temporal change.

RESULTS

Median NT-proBNP was 370.0 (25th, 75th percentiles, 130.0, 996.0), 340.0 (135.0, 875.0), and 267.0 (111.0, 684.0) ng/L; and median hs-CRP was 4.6 (1.7, 13.1), 1.9 (0.8, 4.5), and 1.8 (0.8, 4.4) mg/L at baseline, 30 days, and 6 months, respectively. The deltas between baseline and 6 months were the most prognostically informative. Every +40% increase of delta NT-proBNP (baseline to 6 months) was associated with a 14% greater risk of cardiovascular death (adjusted hazard ratio (HR) 1.14, 95% CI, 1.03–1.27) and with a 14% greater risk of all-cause death (adjusted HR 1.14, 95% CI, 1.04–1.26), while every +40% increase of delta hs-CRP (baseline to 6 months) was associated with a 9% greater risk of the composite end point (adjusted HR 1.09, 95% CI, 1.02–1.17) and a 10% greater risk of myocardial infarction (adjusted HR 1.10, 95%, CI 1.00–1.20).

CONCLUSIONS

Temporal changes in NT-proBNP and hs-CRP are quantitatively associated with future cardiovascular events, supporting their role in dynamic risk stratification of NSTEACS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00699998

Role of B-Type Natriuretic Peptide and N-Terminal Prohormone BNP as Predictors of Cardiovascular Morbidity and Mortality in Patients With a Recent Coronary Event and Type 2 Diabetes Mellitus

BACKGROUND

Natriuretic peptides are recognized as important predictors of cardiovascular events in patients with heart failure, but less is known about their prognostic importance in patients with acute coronary syndrome. We sought to determine whether B-type natriuretic peptide (BNP) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) could enhance risk prediction of a broad range of cardiovascular outcomes in patients with acute coronary syndrome and type 2 diabetes mellitus.

METHODS AND RESULTS

Patients with a recent acute coronary syndrome and type 2 diabetes mellitus were prospectively enrolled in the ELIXA trial (n=5525, follow-up time 26 months). Best risk models were constructed from relevant baseline variables with and without BNP/NT-proBNP. C statistics, Net Reclassification Index, and Integrated Discrimination Index were analyzed to estimate the value of adding BNP or NT-proBNP to best risk models. Overall, BNP and NT-proBNP were the most important predictors of all outcomes examined, irrespective of history of heart failure or any prior cardiovascular disease. BNP significantly improved C statistics when added to risk models for each outcome examined, the strongest increments being in death (0.77-0.82, P<0.001), cardiovascular death (0.77-0.83, P<0.001), and heart failure (0.84-0.87, P<0.001). BNP or NT-proBNP alone predicted death as well as all other variables combined (0.77 versus 0.77).

CONCLUSIONS

In patients with a recent acute coronary syndrome and type 2 diabetes mellitus, BNP and NT-proBNP were powerful predictors of cardiovascular outcomes beyond heart failure and death, ie, were also predictive of MI and stroke. Natriuretic peptides added as much predictive information about death as all other conventional variables combined.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01147250.

Analyzing Dynamic Changes of Laboratory Indexes in Patients with Acute Heart Failure Based on Retrospective Study

Background. Changes of N-terminal probrain natriuretic peptide (NT-proBNP) have been studied whether in the long term or the short term in patients of acute heart failure (AHF); however, changes of NT-proBNP in the first five days and their association with other factors have not been investigated. Aims. To describe the dynamic changes of relevant laboratory indexes in the first five days between different outcomes of AHF patients and their associations. Methods and Results. 284 AHF with dynamic values recorded were analyzed. Changes of NT-proBNP, troponin T, and C-reactive protein were different between patients with different outcomes, with higher values in adverse group than in control group at the same time points (p < 0.05). Then, prognostic use and risk stratification of NT-proBNP were assessed by receiver-operating characteristic curve and logistic regression. NT-proBNP levels at day 3 showed the best prognostic power (area under the curve = 0.730, 95% confidence interval (CI): 0.657 to 0.794) and was an independent risk factor for adverse outcome (odds ratio, OR: 2.185, 95% CI: 1.584–3.015). Classified changes of NT-proBNP may be predictive for adverse outcomes in AHF patients. Conclusions. Sequential monitoring of laboratory indexes within the first 5 days may be helpful for management of AHF patients.

B-type natriuretic peptides in chronic obstructive pulmonary disease: a systematic review

Background

Patients with chronic obstructive pulmonary disease (COPD) have increased cardiovascular risk. Natriuretic peptides (NP) in other populations are useful in identifying cardiovascular disease, stratifying risk, and guiding therapy.

Methods

We performed a systematic literature review to examine NP in COPD, utilising Medline, EMBASE, and the Cochrane Library.

Results

Fifty one studies were identified. NP levels were lower in stable compared to exacerbation of COPD, and significantly increased with concomitant left ventricular systolic dysfunction or cor pulmonale. Elevation occurred in 16 to 60% of exacerbations and persisted in approximately one half of patients at discharge. Cardiovascular comorbidities were associated with increased levels. Levels consistently correlated with pulmonary artery pressure and left ventricular ejection fraction, but not pulmonary function or oxygen saturation. NP demonstrated high negative predictive values (0.80 to 0.98) to exclude left ventricular dysfunction in both stable and exacerbation of COPD, but relatively low positive predictive values. NP elevation predicted early adverse outcomes, but the association with long term mortality was inconsistent.

Conclusion

NP reflect diverse aspects of the cardiopulmonary continuum which limits utility when applied in isolation. Strategies integrating NP with additional variables, biomarkers and imaging require further investigation.

B-type natriuretic peptide-guided treatment for heart failure

BACKGROUND

Heart failure is a condition in which the heart does not pump enough blood to meet all the needs of the body. Symptoms of heart failure include breathlessness, fatigue and fluid retention. Outcomes for patients with heart failure are highly variable; however on average, these patients have a poor prognosis. Prognosis can be improved with early diagnosis and appropriate use of medical treatment, use of devices and transplantation. Patients with heart failure are high users of healthcare resources, not only due to drug and device treatments, but due to high costs of hospitalisation care. B-type natriuretic peptide levels are already used as biomarkers for diagnosis and prognosis of heart failure, but could offer to clinicians a possible tool to guide drug treatment. This could optimise drug management in heart failure patients whilst allaying concerns over potential side effects due to drug intolerance.

OBJECTIVES

To assess whether treatment guided by serial BNP or NT-proBNP (collectively referred to as NP) monitoring improves outcomes compared with treatment guided by clinical assessment alone.

SEARCH METHODS

Searches were conducted up to 15 March 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (OVID), Embase (OVID), the Database of Abstracts of Reviews of Effects (DARE) and the NHS Economic Evaluation Database in the Cochrane Library. Searches were also conducted in the Science Citation Index Expanded, the Conference Proceedings Citation Index on Web of Science (Thomson Reuters), World Health Organization International Clinical Trials Registry and ClinicalTrials.gov. We applied no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials of NP-guided treatment of heart failure versus treatment guided by clinical assessment alone with no restriction on follow-up. Adults treated for heart failure, in both in-hospital and out-of-hospital settings, and trials reporting a clinical outcome were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and evaluated risk of bias. Risk ratios (RR) were calculated for dichotomous data, and pooled mean differences (MD) (with 95% confidence intervals (CI)) were calculated for continuous data. We contacted trial authors to obtain missing data. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table.

MAIN RESULTS

We included 18 randomised controlled trials with 3660 participants (range of mean age: 57 to 80 years) comparing NP-guided treatment with clinical assessment alone. The evidence for all-cause mortality using NP-guided treatment showed uncertainty (RR 0.87, 95% CI 0.76 to 1.01; patients = 3169; studies = 15; low quality of the evidence), and for heart failure mortality (RR 0.84, 95% CI 0.54 to 1.30; patients = 853; studies = 6; low quality of evidence).The evidence suggested heart failure admission was reduced by NP-guided treatment (38% versus 26%, RR 0.70, 95% CI 0.61 to 0.80; patients = 1928; studies = 10; low quality of evidence), but the evidence showed uncertainty for all-cause admission (57% versus 53%, RR 0.93, 95% CI 0.84 to 1.03; patients = 1142; studies = 6; low quality of evidence).Six studies reported on adverse events, however the results could not be pooled (patients = 1144; low quality of evidence). Only four studies provided cost of treatment results, three of these studies reported a lower cost for NP-guided treatment, whilst one reported a higher cost (results were not pooled; patients = 931, low quality of evidence). The evidence showed uncertainty for quality of life data (MD -0.03, 95% CI -1.18 to 1.13; patients = 1812; studies = 8; very low quality of evidence).We completed a 'Risk of bias' assessment for all studies. The impact of risk of bias from lack of blinding of outcome assessment and high attrition levels was examined by restricting analyses to only low 'Risk of bias' studies.

AUTHORS' CONCLUSIONS

In patients with heart failure low-quality evidence showed a reduction in heart failure admission with NP-guided treatment while low-quality evidence showed uncertainty in the effect of NP-guided treatment for all-cause mortality, heart failure mortality, and all-cause admission. Uncertainty in the effect was further shown by very low-quality evidence for patient's quality of life. The evidence for adverse events and cost of treatment was low quality and we were unable to pool results.

Usefulness of NT-proBNP in the Follow-Up of Patients after Myocardial Infarction

Background

Since serial analyses of NT-proBNP in patients with acute coronary syndromes have shown that levels measured during a chronic, later phase are a better predictor of prognosis and indicator of left ventricular function than the levels measured during an acute phase, we sought to assess the association of NT-proBNP, measured 6 months after acute myocardial infarction (AMI), with traditional risk factors, characteristics of in-hospital and early postinfarction course, as well as its prognostic value and optimal cut-points in the ensuing 1-year follow-up.

Methods

Fasting venous blood samples were drawn from 100 ambulatory patients and NT-proBNP concentrations in lithium-heparin plasma were determined using a one-step enzyme immunoassay based on the »sandwich« principle on a Dimension RxL clinical chemistry system (DADE Behring-Siemens). Patients were followed-up for the next 1 year, for the occurrence of new cardiac events.

Results

Median (IQR) level of NT-proBNP was 521 (335–1095) pg/mL. Highest values were mostly associated with cardiac events during the first 6 months after AMI. Negative association with reperfusion therapy for index infarction confirmed its long-term beneficial effect. In the next one-year follow-up of stable patients, multivariate Cox regression analysis revealed the independent prognostic value of NT-proBNP for new-onset heart failure prediction (p=0.014), as well as for new coronary events prediction (p=0.035). Calculation of the AUCs revealed the optimal NT-proBNP cut-points of 800 pg/mL and 516 pg/mL, respectively.

Conclusions

NT-proBNP values 6 months after AMI are mainly associated with the characteristics of early infarction and postinfarction course and can predict new cardiac events in the next one-year follow-up.

CV. Prognostic Value of Serial Brain Natriuretic Peptide Measurements in Patients with Acute Myocardial Infarction

Objectives: Elevated B-type natriuretic peptide (BNP) levels following acute myocardial infarction (AMI) are associated with adverse outcomes. The role of serial BNP monitoring after AMI has been poorly investigated. We aimed to evaluate the prognostic value of in-hospital serial BNP measurements in AMI patients. Methods: Patients with AMI (n = 1,924) were retrospectively evaluated. We selected patients with at least 2 in-hospital BNP measurements. The association between in-hospital mortality and BNP measurements (earliest, highest follow-up and the variation between measurements) were tested in multivariate models. Results: Serial BNP levels were determined in 176 patients. Compared to the rest of the population, these patients were older and had higher mortality rates. In the adjusted models, only the highest follow-up BNP remained associated with in-hospital death (odds ratio 1.06; 95% confidence interval, CI, 1.01-1.15; p = 0.014). Receiver-operating characteristic curve analysis demonstrated that the highest follow-up BNP was the best predictor of in-hospital death (area under the curve = 0.75; 95% CI 0.64-0.86). Conclusions: Serial BNP monitoring was performed in a high-risk subgroup of AMI patients. The highest follow-up BNP was a better predictor of short-term death than the baseline and in-hospital variation values. In AMI patients, a later in-hospital BNP assessment may be more useful than an early measurement.

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: anemia, biomarkers, and recent therapeutic trial implications

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.

Acute coronary syndrome - the present and future role of biomarkers

Over the past two decades there have been dramatic changes in the diagnosis, treatment and prognosis of acute coronary syndrome (ACS). Several new treatment modalities have been added and the prognosis has improved dramatically. Biomarkers play a crucial role in the management of ACS. At present, cardiac troponin is the biomarker of choice for diagnosis of acute myocardial infarction (AMI). Currently, there are no other biomarkers, which can compete, neither regarding specificity nor regarding early sensitivity. However, there is still a clinical need of a biomarker able to reliably rule-in or rule-out AMI immediately on admission. MicroRNAs seem to be promising new candidates for diagnostic purposes. The optimal combination of biomarkers and new imaging techniques is another important area for research. The list of biomarkers associated with an adverse prognosis in ACS is long. However, for most of them it has been very difficult to prove an added clinical value. Only cardiac troponin, and to some degree also B-type natriuretic peptides, is widely used in clinical practice for risk assessment. Among new markers, growth differentiation factor 15 and the mid-regional part of the prohormone of adrenomedullin, have shown some promising results. Since the renal function is assessed in clinical routine, also markers of the renal function have gained increasing interest. Cardiac troponin has been proven useful for selection of antithrombotic, antiplatelet and invasive treatment. Besides cardiac troponin, no other markers have consistently been shown to be useful for selection of specific treatments.

Importance of persistent elevation of cardiac biomarkers in atrial fibrillation: a RE-LY substudy

OBJECTIVES

To evaluate the prognostic importance of transient or persistent elevations of cardiac troponin-I (cTnI) and N-terminal-B-type natriuretic peptide (NT-proBNP) in atrial fibrillation (AF).

METHODS

Plasma samples were obtained at randomisation and after 3 months in 2514 patients with AF in the RE-LY trial; median follow-up was 2.0 years. Patients were grouped based on levels at the two time points according to detectable cTnI levels (≥0.01 µg/L) or NT-proBNP levels above median (≥778 ng/L). These groups were related to occurrence of stroke or cardiovascular events evaluated with Cox models adjusting for established risk factors.

RESULTS

The proportion of patients with detectable cTnI levels at both time points was 48.5%, at one time point 28.5% and at neither time point 21.0%. Patients with detectable cTnI at both time points had substantially higher rates of stroke compared with those with transient elevations and those with no elevation at either time point (p<0.005, effect of cTnI). Persistent elevation of either or both cardiac biomarkers at baseline and 3 months was associated with a higher risk for cardiovascular events and mortality (p<0.0001). Prognostic prediction improved most with the use of repeated measurements of both cardiac biomarkers simultaneously (p<0.05) and achieved C-statistic 0.644 for stroke compared with 0.611 for CHADS2-score.

CONCLUSIONS

Persistent elevation of troponin and NT-proBNP indicates a worse prognosis than transient elevations or no elevations of either marker. Prognostication of stroke, death and thromboembolic events is improved by the use of repeated determinations of cardiac biomarkers.

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov, NCT00262600.

Dynamic use of B-type natriuretic peptide-guided acute coronary syndrome therapy

BACKGROUND

Very few studies have evaluated the potential of using B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) as surrogate markers to guide clinical interventional or conservative therapy decisions.

AIM

: The aim of the current study was to evaluate the potential of using BNP and NT-proBNP as surrogate markers to guide clinical interventional or conservative therapy decisions.

METHODS

We identified randomized controlled trials that randomized patients with acute coronary syndrome (ACS) of unstable angina and myocardial infarction without ST-segment elevation ACS to early invasive therapy versus a more conservative approach by systematic search of articles and databases.

RESULTS

Five randomized controlled trials with a total of 8125 patients and with a mean duration of 11.2 months were included in the meta-analysis. At a mean follow-up of 11.2 months, the incidence of all-cause mortality was 5.9% in the early invasive group, compared with 6.8% in the conservative group (risk ratio = 0.74; 95% confidence interval, 0.59-0.86; P = 0.001).

CONCLUSIONS

In summary, BNP/NT-proBNP-guided management of ACS is significantly improved by early invasive therapy by improving long-term survival and reducing nonfatal myocardial infarction for unstable angina. However, there does not seem to be a clear benefit of using such a strategy over existing clinical recommendations.

Amino-terminal pro-brain natriuretic peptide: a biomarker for diagnosis, prognosis and management of heart failure

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.

Review on natriuretic peptides: where we are, where we are going

BACKGROUND

Tremendous advances have been made in our understanding of the pathophysiology and treatment of congestive heart failure. However, diagnosis of the disease still remains difficult, even with a comprehensive physical examination. Symptoms such as dyspnea are nonspecific and insensitive indicators for heart failure, which can go largely undetected. Several studies have suggested the need for new diagnostic capabilities, especially with the increasing prevalence of heart failure in the US. The discovery of natriuretic peptides as diagnostic biomarkers has been one of the most critical advances for the management of heart failure. Both B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide have the potential to diagnose heart failure, assess prognostic risk of rehospitalization and mortality, and even help guide treatment. Their relative cost-effectiveness and availability have also facilitated their acceptance into many emergency departments, clinics and in-patient units as standard care when evaluating patients with suspected heart failure. Our understanding of the natriuretic peptide system is still in its infancy, but natriuretic peptides have emerged as important diagnostic and prognostic tools that have generated interest in finding broader applications for their use.

OBJECTIVE

The purpose of this review is to discuss the clinical approaches and future applications of natriuretic peptides in diagnosing and managing treatment of congestive heart failure.

METHOD

A comprehensive review of studies to assess the utility of natriuretic peptides for diagnosis and prognosis of heart failure and other conditions.

CONCLUSION

Natriuretic peptides are powerful tools to aid the physician in the diagnosis, prognosis and management of heart failure in both in-patient and out-patient settings. However, natriuretic peptides should be used as an adjunct test as many circumstances can also influence changes in natriuretic peptide levels.

N-terminal pro-brain natriuretic peptide could be a marker of subclinical atherosclerosis in patients with type 2 diabetes

N-terminal pro-brain natriuretic peptide (NT-proBNP), which is a useful biomarker of chronic heart failure, has been shown to be a strong predictor of cardiovascular mortality. The aim of this study was to evaluate the relationships between NT-proBNP and markers of subclinical atherosclerosis in patients with type 2 diabetes. Relationships of NT-proBNP to pulse wave velocity (PWV) or ankle-brachial index (ABI) as well as to various parameters, including body mass index, blood pressure, serum lipid concentration, serum uric acid concentration, and glycemic control (hemoglobin A1c), age, hemoglobin, serum creatinine concentration, severity of diabetic nephropathy or retinopathy, current treatment of diabetes, cardiothoracic ratio on chest radiograph, presence of left ventricular hypertrophy and/or ST-T changes evaluated by electrocardiograph, smoking status and presence of cardiovascular disease were investigated in 323 consecutive patients with type 2 diabetes. Log (NT-proBNP) correlated positively with PWV (r = 0.283, p < 0.0001) and correlated negatively with ABI (r = -0.144, p = 0.0094). Multiple regression analysis demonstrated that age (β = 0.200, p = 0.0033), systolic blood pressure (β = 0.246, p < 0.0001), total cholesterol (β = -0.135, p = 0.0326), uric acid (β = 0.133, p = 0.0462), creatinine (β = -0.184, p = 0.0122), smoking status (β = -0.129, p = 0.0499) and log (NT-proBNP) (β = 0.177, p = 0.0149) were independently correlated with PWV and that systolic blood pressure (β = -0.145, p = 0.0310), log triglyceride (β = -0.151, p = 0.0397) and log (NT-proBNP) (β = -0.207, p = 0.0094) were independently correlated with ABI. In conclusion, NT-proBNP could be a marker of subclinical atherosclerosis in patients with type 2 diabetes.

N-terminal pro-B-type natriuretic peptide is associated with severity of the coronary lesions in unstable angina patients with preserved left ventricular function

OBJECTIVES

To evaluate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) values and the severity of coronary lesions at angiography in unstable angina patients with preserved left ventricular function.

METHODS

A total of 133 patients with primary diagnosis of unstable angina were enrolled into this study. NT-proBNP level was determined before the angiography and Gensini score, a measurement of extent of myocardial ischemia, was calculated after the angiography by experienced cardiologists. Patients with >50% stenosis of the left main or 75% stenosis of one or more coronary branches with diameter >2 mm were defined as "angiography positive" and turned to percutaneous coronary intervention.

RESULTS

There was a significant difference of circulating NT-proBNP level between the angiography positive and negative groups and the median NT-proBNP values were 367.5 pg/mL and 112 pg/mL, respectively (P < 0.001). A significant correlation was observed between log NT-proBNP and log Gensini score (P < 0.001). NT-proBNP level was a predictor of angiography positive result and the area under the receiver operating characteristic curve was 0.776 (95% CI 0.693-0.858).

CONCLUSIONS

NT-proBNP level was found to be higher with the severity of myocardial ischemia. However, the ability of NT-proBNP to identify clinically significant angiographic lesions was moderate.

B-type natriuretic peptide in outpatients after myocardial infarction: optimized cut-off value for incident heart failure prediction

Higher levels of natriuretic peptides were identified in outpatients after myocardial infarction (MI) compared to the healthy population, even in the absence of heart failure (HF). Therefore, we assessed the optimal cut-off value of B-type natriuretic peptide (BNP) in relation to new-onset HF prediction in 79 post-MI patients with preserved left ventricular systolic function (ejection fraction >40%). Plasma BNP was measured by enzyme immunoassay, 6 months after MI and patients were followed-up for the next one year. Cox proportional regression model analysis revealed the independent prognostic value of BNP for HF prediction (p=0.005). As assessed by ROC analysis the optimal cut-off value of BNP was 175 pg/mL (sensitivity 82%; specificity 77%, AUC 0.77), associated with significantly different rates of incident HF by Kaplan-Meier analysis (p=0.001). In this population of outpatients with preserved left ventricular systolic function after MI, BNP strongly correlated with new-onset HF development at the optimal cut-off value of 175 pg/mL.

Growth-Differentiation Factor-15 for Long-Term Risk Prediction in Patients Stabilized After an Episode of Non–ST-Segment–Elevation Acute Coronary Syndrome

Background— Growth-differentiation factor-15 (GDF-15) has emerged as a prognostic biomarker in patients with non–ST-segment–elevation acute coronary syndrome. This study assessed the time course and the long-term prognostic relevance of GDF-15 levels measured repetitively in patients with non–ST-segment–elevation acute coronary syndrome during 6 months after the acute event.

Methods and Results— GDF-15 and other biomarkers were measured at randomization, after 6 weeks, and after 3 and 6 months in 950 patients with non–ST-segment–elevation acute coronary syndrome included in the FRagmin and Fast Revascularization during InStability in Coronary artery disease II study. Study end points were death, recurrent myocardial infarction, and their composite during 5-year follow-up. Median GDF-15 levels decreased slightly from 1357 ng/L at randomization to 1302 ng/L at 6 months ( P <0.001). GDF-15 was consistently related to cardiovascular risk factors and biochemical markers of hemodynamic stress, renal dysfunction, and inflammation. Moreover, GDF-15 was independently related to the 5-year risk of the composite end point when measured at both 3 months (adjusted hazard ratio, 1.8 [1.0 to 3.0]) and 6 months (adjusted hazard ratio, 2.3 [1.3 to 4.1]). Serial measurements of GDF-15 at randomization and 6 months helped to identify patient cohorts at different levels of risk, with patients with persistently elevated GDF-15 levels >1800 ng/L having the highest rate of the composite end point.

Conclusions— GDF-15 is independently related to adverse events in non–ST-segment–elevation acute coronary syndrome both in the acute setting and for at least 6 months after clinical stabilization. Therefore, continued research on GDF-15 should be focused on the usefulness of GDF-15 for support of clinical management in acute and chronic ischemic heart disease.

B-Type Natriuretic Peptides and Cardiovascular Risk

Background— Measurement of B-type natriuretic peptide (BNP) concentration or its precursor (N-terminal fragment [NT-proBNP]) is recommended in patients with symptoms of left ventricular dysfunction and in other settings, but the relevance of these peptides to cardiovascular disease (CVD) in general populations or in patients with stable vascular disease is uncertain.

Methods and Results— Data were collated from 40 long-term prospective studies involving a total of 87 474 participants and 10 625 incident CVD outcomes. In a comparison of individuals in the top third with those in the bottom third of baseline values of natriuretic peptides, the combined risk ratio (RR), adjusted for several conventional risk factors, was 2.82 (95% confidence interval [CI], 2.40 to 3.33) for CVD. Analysis of the 6 studies with at least 250 CVD outcomes (which should be less prone to selective reporting than are smaller studies) yielded an adjusted RR of 1.94 (95% CI, 1.57 to 2.39). RRs were broadly similar with BNP or NT-proBNP (RR, 2.89 [95% CI, 1.91 to 4.38] and 2.82 [95% CI, 2.35 to 3.38], respectively) and by different baseline vascular risk (RR, 2.68 [95% CI, 2.07 to 3.47] in approximately general populations; RR, 3.35 [95% CI, 2.38 to 4.72] in people with elevated vascular risk factors; RR, 2.60 [95% CI, 1.99 to 3.38] in patients with stable CVD). Assay of BNP or NT-proBNP in addition to measurement of conventional CVD risk factors yielded generally modest improvements in risk discrimination.

Conclusions— Available prospective studies indicate strong associations between circulating concentration of natriuretic peptides and CVD risk under a range of different circumstances. Further investigation is warranted, particularly in large general population studies, to clarify any predictive utility of these markers and to better control for publication bias.

Obesity paradox in Korean patients undergoing primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

The effect of body mass index (BMI) on outcomes after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is not well known. In patients registered in the Korean Acute Myocardial Infarction Registry (KAMIR) between November 2005 and November 2007, 3824 STEMI patients who arrived at hospital within 12h after onset of chest pain and underwent primary PCI were analyzed, and divided into four groups according to their BMI: underweight (BMI<18.5 kg/m(2), n=129); normal weight (18.5 < or =BMI <23.0 kg/m(2), n=1253); overweight (23.0 < or =BMI <27.5 kg/m(2), n=1959); and obese (BMI > or =27.5 kg/m(2), n=483). In-hospital mortality, revascularization in 1 year, mortality in 1 year, and overall mortality were compared between groups. Overweight and obese group were significantly younger, had normal left ventricular ejection fraction, and were more likely to be men with a higher incidence of hypertension, diabetes, and hyperlipidemia. There were no significant differences in symptom-to-door time and door-to-balloon time between groups. Obese patients had significantly lower in-hospital and overall mortalities. Major adverse cardiac events showed a bimodal pattern. Obese STEMI patients treated with primary PCI were associated with lower mortality, which may be explained by better use of medical treatment, hemodynamic stability, and younger age.

Pentraxin 3 in unstable angina and non-ST-segment elevation myocardial infarction

PURPOSE

We prospectively investigated the prognostic value of pentraxin 3 (PTX3) in patients with unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI).

BACKGROUND

PTX3 may be a useful marker for localized vascular inflammation and damage to the cardiovascular system. Recent studies have shown that plasma PTX3 is elevated in patients with UA/NSTEMI; however, its prognostic value in UA/NSTEMI remains unclear.

METHODS

PTX3, high-sensitivity C-reactive protein (hsCRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and cardiac troponin I were measured on admission in 204 consecutive patients (mean age of 69 years; 144 males) hospitalized for UA/NSTEMI within 24h (mean of 7.5h) after the onset of chest symptoms. A cardiac event, which was defined as cardiac death, rehospitalization for acute coronary syndrome (ACS), or rehospitalization for worsening heart failure, was monitored for 6 months after admission.

RESULTS

A total of 26 (13%) cardiac events occurred during the 6-month follow-up period. In a stepwise Cox regression analysis including 18 well-known clinical and biochemical predictors of ACS outcome, both PTX3 (relative risk 3.86 per 10-fold increment, P=0.01) and NT-proBNP (relative risk 2.16 per 10-fold increment, P=0.02), but not hsCRP, were independently associated with the 6-month cardiac event. The cardiac event rate was higher in patients with increased PTX3 (> or = 3.1ng/mL of median value) than those without (20% vs. 5.8%, P=0.003). A Kaplan-Meier analysis revealed that patients with increased PTX3 had a higher risk for cardiac events than those without (P=0.002).

CONCLUSION

PTX3 and NT-proBNP may be potent and independent predictors for 6-month cardiac events in patients hospitalized for UA/NSTEMI within 24h after the onset. Measurement of plasma PTX3 may substantially improve the early risk stratification of patients with UA/NSTEMI.

Prognostic value of B-type natriuretic peptide for cardiovascular events independent of left ventricular end-diastolic pressure

BACKGROUND

B-type natriuretic peptide (BNP) correlates with left ventricular (LV) end-diastolic pressure (LVEDP) and predicts cardiovascular events. We sought to determine whether BNP has prognostic value independent of LVEDP.

METHODS

Eligible patients were referred for coronary angiography between March 15, 2002, and April 30, 2008, at a single institution. Inclusion criteria were having BNP, LV ejection fraction (EF), and LVEDP measured within 24 hours of the angiogram. The predictive value of BNP for events independent of LVEDP, EF, and other confounders was determined.

RESULTS

The study population (n = 1,059) was followed for a mean of 1.8 +/- 1.7 years. The mean age was 63 +/- 13 years. The median BNP value was 182 pg/mL; 59% of patients had LVEDP > or =16 mm Hg. B-type natriuretic peptide and LVEDP had a modest but statistically significant correlation (r = 0.24, P < .0001). After adjustment for LVEDP and EF, the hazard ratio for the composite outcome of heart failure admissions and death was 1.37 (1.21-1.55, P < .0001) per unit increase in log BNP. After adjustment for BNP and EF, LVEDP did not predict heart failure admissions and death (hazard ratio 1.05 [0.95-1.10], per 5-mm Hg increase, P = .30). Those with BNP value below the median had longer event-free survival as compared to those with BNP value above the median, regardless of the LVEDP strata (log-rank P < .0001 for LVEDP > or =16 and <16 mm Hg).

CONCLUSION

B-type natriuretic peptide has prognostic value independent of LVEDP in this cohort with suspected coronary artery disease, suggesting this biomarker is not just a prognostic surrogate for elevated LV filling pressure.

Prognostic value of ventricular-arterial coupling and B-type natriuretic peptide in patients after myocardial infarction: a five-year follow-up study

BACKGROUND

The aim of this study was to determine the prognostic role of ventricular-arterial coupling compared with B-type natriuretic peptide (BNP) in patients after myocardial infarctions.

METHODS

Forty-one consecutive patients with history of myocardial infarctions were enrolled. Ventricular-arterial coupling was assessed as the ratio between arterial elastance (E(a)) and end-systolic ventricular elastance (E(es)). E(a) and E(es) were calculated using systolic and diastolic blood pressure, echocardiographically derived stroke volume, left ventricular ejection fraction, and the ratio between aortic preejection time and total systolic time. Cardiovascular mortality was the prespecified endpoint, with 5-year follow-up.

RESULTS

BNP was significantly correlated with New York Heart Association class and known echocardiographic parameters of systolic and diastolic left ventricular function and also with the E(a)/E(es) ratio (P = .001), which emerged as an independent correlate of BNP in multivariate analysis. The E(a)/E(es) ratio demonstrated good accuracy in predicting long-term cardiovascular mortality (area under the receiver operating characteristic curve, 0.73; P = .019), comparable with that of BNP in patients after myocardial infarctions.

CONCLUSION

Ventricular-arterial coupling assessed using the E(a)/E(es) ratio is an independent echocardiographic correlate of BNP levels in patients with previous myocardial infarctions and has a significant role in predicting long-term cardiovascular mortality in this setting.

Predictors of six-month major adverse cardiac events in 30-day survivors after acute myocardial infarction (from the Korea Acute Myocardial Infarction Registry)

Little is known about risk factors for 6-month major adverse cardiac events (MACEs) in 30-day survivors after acute myocardial infarction (AMI). We investigated predictors of 6-month MACE in 30-day survivors after MI from the Korea Acute Myocardial Infarction Registry (KAMIR). From November 2005 to January 2008, 9,706 patients (6,983 men, mean age 64.0 +/- 12.4 years) who survived >30 days after AMI were analyzed. The primary end point was 6-month MACEs including death, MI, and revascularization. During 6-month follow-up, 317 patients (3.2%) had MACEs including 66 (0.6%) deaths, 23 (0.2%) recurrent MIs, and 218 (2.2%) revascularizations. In multivariate logistic regression analysis, factors reflecting demographics (body mass index), severity of left ventricular systolic dysfunction (Killip class >I, in-hospital cardiogenic shock, use of intra-aortic balloon pump), residual myocardial ischemia (previous coronary heart disease, multivessel disease), and electrical instability (ventricular tachycardia/ventricular fibrillation on admission) were independent predictors of 6-month MACEs after adjustment for clinical, angiographic, and procedural data. Plasma level of N-terminal pro-B-type natriuretic peptide provided an additional prognostic value predicting 6-month MACEs. In conclusion, this study provides useful prognostic information for clinicians to advise patients who have survived the acute phase of MI. More intensive management is needed in survivors after MI with these high-risk features.