Systolic and diastolic heart failure are associated with different plasma levels of B-type natriuretic peptide

Diagnosis of heart failure with preserved ejection fraction: a systematic narrative review of the evidence

Heart failure (HF) with preserved ejection fraction (HFpEF) is a common condition in clinical practice, affecting more than half of patients with HF. HFpEF is associated with morbidity and mortality and with considerable healthcare resource utilization and costs. Therefore, early diagnosis is crucial to facilitate prompt management, particularly initiation of sodium-glucose co-transporter 2 inhibitors. Although European guidelines define HFpEF as the presence of symptoms with or without signs of HF, left ventricular EF ≥ 50%, and objective evidence of cardiac structural and/or functional abnormalities, together with elevated natriuretic peptide levels, the diagnosis of HFpEF remains challenging. First, there is no clear consensus on how HFpEF should be defined. Furthermore, diagnostic tools, such as natriuretic peptide levels and resting echocardiogram findings, are significantly limited in the diagnosis of HFpEF. As a result, some patients are overdiagnosed (i.e., elderly people with comorbidities that mimic HF), although in other cases, HFpEF is overlooked. In this manuscript, we perform a systematic narrative review of the diagnostic approach to patients with HFpEF. We also propose a comprehensible algorithm that can be easily applied in daily clinical practice and could prove useful for confirming or ruling out a diagnosis of HFpEF.

Cardiovascular Biomarkers and Diastolic Dysfunction in Patients With Chronic Chagas Cardiomyopathy

Background: Chronic Chagas Cardiomyopathy is a unique form of cardiomyopathy, with a significantly higher mortality risk than other heart failure etiologies. Diastolic dysfunction (DD) plays an important role in the prognosis of CCM; however, the value of serum biomarkers in identifying and stratifying DD has been poorly studied in this context. We aimed to analyze the correlation of six biochemical markers with diastolic function echocardiographic markers and DD diagnosis in patients with CCM.

Methods: Cross-sectional study of 100 adults with different stages of CCM. Serum concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP), galectin-3 (Gal-3), neutrophil gelatinase-associated lipocalin (NGAL), high-sensitivity troponin T (hs-cTnT), soluble (sST2), and cystatin-C (Cys-c) were measured. Tissue Doppler imaging was used to measure echocardiographic parameters indicating DD. Multivariate logistic regression models adjusted by age, sex, BMI, and NYHA classification were used to evaluate the association between the biomarkers and DD.

Results: From the total patients included (55% male with a median age of 62 years), 38% had a preserved LVEF, but only 14% had a normal global longitudinal strain. Moreover, 64% had a diagnosis of diastolic dysfunction, with most of the patients showing a restrictive pattern (n = 28). The median levels of all biomarkers (except for sST2) were significantly higher in the group of patients with DD. Higher levels of natural log-transformed NTproBNP (per 1-unit increase, OR = 3.41, p < 0.001), Hs-cTnT (per 1-unit increase, OR = 3.24, p = 0.001), NGAL (per 1-unit increase, OR = 5.24, p =0.003), and Cys-C (per 1-unit increase, OR = 22.26, p = 0.008) were associated with increased odds of having diastolic dysfunction in the multivariate analyses. Finally, NT-proBNP had the highest AUC value (88.54) for discriminating DD presence.

Conclusion: Cardiovascular biomarkers represent valuable tools for diastolic dysfunction assessment in the context of CCM. Additional studies focusing mainly on patients with HFpEF are required to validate the performance of these cardiovascular biomarkers in CCM, allowing for an optimal assessment of this unique population.

Clinical Outcomes of Autologous Stem Cell-Patch Implantation for Patients With Heart Failure With Nonischemic Dilated Cardiomyopathy

Background

Clinical effectiveness of autologous skeletal cell‐patch implantation for nonischemic dilated cardiomyopathy has not been clearly elucidated in clinical settings. This clinical study aimed to determine the feasibility, safety, therapeutic efficacy, and the predictor of responders of this treatment in patients with nonischemic dilated cardiomyopathy.

Methods and Results

Twenty‐four nonischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% on optimal medical therapy were enrolled. Autologous cell patches were implanted over the surface of the left ventricle through left minithoracotomy without procedure‐related complications and lethal arrhythmia. We identified 13 responders and 11 nonresponders using the combined indicator of a major cardiac adverse event and incidence of heart failure event. In the responders, symptoms, exercise capacity, and cardiac performance were improved postoperatively (New York Heart Association class II 7 [54%] and III 6 [46%] to New York Heart Association class II 12 [92%] and I 1 [8%], P<0.05, 6‐minute walk test; 471 m [370–541 m] to 525 m [425–555 m], P<0.05, left ventricular stroke work index; 31.1 g·m²·beat [22.7–35.5 g·m²·beat] to 32.8 g·m²·beat [28–38.5 g·m²·beat], P=0.21). However, such improvement was not observed in the nonresponders. In responders, the actuarial survival rate was 90.9±8.7% at 5 years, which was superior to the estimated survival rate of 70.9±5.4% using the Seattle Heart Failure Model. However, they were similar in nonresponders (47.7±21.6% and 56.3±8.1%, respectively). Multivariate regression model with B‐type natriuretic peptide, pulmonary capillary wedge pressure, and expression of histone H3K4me3 (H3 lysine 4 trimethylation) strongly predicted the responder of this treatment (B‐type natriuretic peptide: odds ratio [OR], 0.96; pulmonary capillary wedge pressure: ​OR, 0.58; H3K4me3: OR, 1.35, receiver operating characteristic–area under the curve, 0.96, P<0.001).

Conclusions

This clinical trial demonstrated that autologous skeletal stem cell–patch implantation might promise functional recovery and good clinical outcome in selected patients with nonischemic dilated cardiomyopathy, in addition to safety and feasibility.

Registration

URL: http://www.umin.ac.jp/english/. Unique identifiers: UMIN000003273, UMIN0000012906 and UMIN000015892.

Low and elevated B-type natriuretic peptide levels are associated with increased mortality in patients with preserved ejection fraction undergoing transcatheter aortic valve replacement: an analysis of the PARTNER II trial and registry

Aims

B-type natriuretic peptide (BNP) is a cardiac neurohormone that is secreted in response to ventricular volume expansion and pressure overload. There are conflicting data regarding the association between BNP levels and outcomes after transcatheter aortic valve replacement (TAVR). We therefore sought to assess the association between baseline BNP and adverse outcomes in patients with symptomatic, severe aortic stenosis (AS), and left ventricular ejection fraction (LVEF) ≥50%, undergoing TAVR in the PARTNER 2 Trial and Registry.

Methods and results

A total of 1782 patients were included in the analysis, and BNP was evaluated both as a continuous log-transformed value and by a priori categories: low (&lt;50 pg/mL), normal (≥50 and &lt;100 pg/mL), moderately elevated (≥100 and &lt;400 pg/mL), or markedly elevated (≥400 pg/mL). Clinical outcomes from discharge to 2 years were compared between patients according to their baseline BNP level, using Kaplan–Meier event rates and multivariable Cox proportional hazards regression models. After adjustment, spline curves revealed a non-linear association between log-transformed BNP and all-cause and cardiovascular mortality in which both the lowest and highest values were associated with increased mortality. Two-year all-cause mortality rates for those with low (n = 86), normal (n = 202), moderately elevated (n = 885), and markedly elevated (n = 609) baseline BNP were 20.0%, 9.8%, 17.7%, and 26.1%, respectively. In adjusted models, compared to a normal baseline BNP, low [adjusted hazard ratio (HR) 2.6, 95% confidence interval (CI) 1.3–5.0, P-value 0.005], moderately elevated (adjusted HR 1.6, 95% CI 1.0–2.6, P-value 0.06), and markedly elevated (adjusted HR 2.1, 95% CI 1.3–3.5, P-value 0.003) BNP were associated with increased all-cause mortality, driven by cardiovascular mortality.

Conclusions

In a large cohort of patients with severe symptomatic AS and preserved LVEF undergoing TAVR, all-cause and cardiovascular mortality rates at 2 years were higher in patients with low and markedly elevated BNP levels.

Clinical Trial Registration

https://clinicaltrials.gov/ unique identifier #NCT01314313, #NCT02184442, #NCT03222128, and #NCT03222141.

Prognostic Value of a Tissue Doppler Index of Systodiastolic Function in Patients with Asymptomatic Heart Failure

Introduction

Doppler echocardiography with early diastolic transmitral velocity (E)/early mitral annular diastolic velocity (E') ratio has been proposed as the best predictor for evaluating left ventricle (LV) filling pressure. A dimensionless index E/(E' × S') ratio (S' = systolic mitral annulus velocity) resulted in readily, reproducible, and reliable predictor of LV filling pressure. We assessed the prognostic impact of E/E' × S') in patients with asymptomatic heart failure (HF).

Materials and Methods

We calculated E/(E' × S') in 337 patients (179 male, 53%; age 54.7 ± 13.7 years) using the average of septal and lateral mitral annular velocities. We considered a composite endpoint as follows: all-cause death, acute myocardial infarction, stroke, and HF exacerbation.

Results

Baseline ejection fraction resulted 60.2 ± 11.8%; E/E' × S') was 1.45 ± 0.8, with S' 7.4 ± 2.4 cm/s and E/E' 9.5 ± 5.4. After a 22-month median follow-up, there were 42 events: 5 deaths (12%), 3 acute myocardial infarctions (7%), 1 stroke (2%), and 33 HF hospitalizations (79%). In patients reaching the composite endpoint, E/(E' × S') resulted 2.07 ± 1.1 versus 1.3 ± 0.7 in event-free population (P < 0.001). In a Cox-regression analysis, adjusted for confounding clinical factors and conventional echo parameters, E/(E' × S') (P < 0.001), age (P < 0.001), and male gender (P = 0.03) resulted independent predictors of the composite endpoint.

Conclusions

E/(E' × S') was an independent predictor for the future cardiac events in asymptomatic HF.

Natriuretic Peptide System Activation in Acute Heart Failure Patients with Diabetes

BACKGROUND

Elevated B-type natriuretic peptide (BNP) is a hallmark in heart failure (HF). Diabetic patients with chronic HF seem to have higher BNP than nondiabetics. We studied, in acute HF, if BNP levels are different between diabetics and nondiabetics.

METHODS

From a prospectively recruited population of acute HF patients, we selected a convenience sample. In pair-matched analysis, each diabetic patient was matched with a nondiabetic of the same age (±1 year), gender, and according to left ventricular systolic dysfunction. Diabetics and nondiabetics were compared. Cox-regression analysis was used to analyse the prognostic impact of diabetes.

RESULTS

We studied 328 patients, mean age: 78 years, 44.5% male. Diabetics were more often hypertensive and had ischemic HF; they had higher body mass index, lower haemoglobin, and worse renal function. Diabetics were more often discharged on ACE inhibitors/ARB, antiplatelet therapy, and statins. Neither admission nor discharge BNP values differed between diabetics and pair-matched nondiabetics. One-year mortality was also nondifferent between pairs of diabetics and nondiabetics: 44 (26.8%) and 46 (28.0%), respectively. HR for 1-year mortality in diabetics was 1.00 (95% CI: 0.82-1.24) compared with nondiabetics.

CONCLUSIONS

HF patients with diabetes have similar neurohumoral activation when compared with nondiabetics. One-year mortality is also nondifferent after matching for age, gender, and systolic function.

[Diastolic heart failure: heart failure with preserved ejection fraction]

The prognosis for patients with diastolic heart failure--heart failure with preserved ejection fraction--has not improved in the last few decades despite improvement of prognosis for all patients with heart failure. Diastolic dysfunction is a typical finding in elderly patients with heart failure. The diagnostic process is a challenge for clinicians who are often faced with comorbidities like COPD, osteoarthritis, sarcopenia, and diabetes. Classical treatment options fail to improve patients with diastolic heart failure; thus, a comprehensive and specific treatment plan is necessary.

Relationship between B-type natriuretic peptide serum level, echocardiographic TEI index and the degree of diastolic dysfunction in patients with heart failure with preserved systolic function

INTRODUCTION

The growing number of heart failure (HF) patients is becoming an important issue in cardiology. B-type natriuretic peptide (BNP) is a recognized marker of HF, including in patients with preserved systolic function. The TEI index is an indicator of left ventricular function. The aim of the study was to evaluate the relationship between BNP serum level, TEI index and the degree of diastolic dysfunction in patients with HF symptoms and preserved systolic function.

MATERIAL AND METHODS

Hundred patients with arterial hypertension and preserved systolic function were enrolled in the study. The study group consisted of 51 individuals with impaired diastolic function and HF symptoms. Fourty-nine hypertensive individuals without HF symptoms were assigned to the control group. B-type natriuretic peptide and echocardiographic examination were performed. Patients were divided into 4 subgroups - with normal diastolic function, impaired relaxation, pseudonormalization and restriction.

RESULTS

Median value of BNP in patients with normal diastolic function was 28.36 pg/ml, 87.10 pg/ml in patients with impaired relaxation, 212.75 pg/ml and 461.56 pg/ml in the pseudonormalization and restriction group respectively (p < 0.0001). The median value of the TEI index was: 0.386 in patients with normal diastolic function, 0.507 in individuals with impaired relaxation, 0.639 and 0.725 in the pseudonormalization and restriction group respectively. All the differences were statistically significant (p < 0.0001). A significant positive correlation (r = 0.80, p < 0.001) between BNP and the TEI index was found.

CONCLUSIONS

In hypertensive patients with HF symptoms and preserved left ventricular systolic function a highly significant increase in BNP serum level and in the TEI index values related to the deterioration of diastolic dysfunction was found.

Profiling B-type natriuretic peptide in a stable heart failure population: a valuable adjunct to care

AIM

To examine the prognostic importance of absolute values and change in values of BNP in patients with stable heart failure (HF).

METHODS

Five-hundred and fifty-nine patients attending a disease management programme were categorized into tertiles of BNP (group 1; ≤ 95 pg/ml, group 2; 96-249 pg/ml and group 3; ≥ 250 pg/ml). A change in BNP between two stable visits was recorded. Patients were followed up for 1 year for death and a composite morbidity measure of HF hospitalization, all-cause hospitalization, unscheduled visits for clinical deterioration(UC) of HF using survival analysis.

RESULTS

The risk of the combined morbidity outcome increased with increasing tertiles of BNP (Log rank = 17.8 (2), p < 0.001). Furthermore, a 50 and 25% increase in BNP predicted morbidity in stable HF patients with an initial BNP > 200 pg/ml (p = 0.02) and > 450 pg/ml (p = 0.03), respectively.

CONCLUSION

In a stable community HF population, an elevated BNP or an increase in BNP predicts an adverse prognosis thereby potentially identifying a population in need of closer clinical follow-up.

High N-terminal pro-B-type natriuretic peptide: a biomarker of lung cancer?

BACKGROUND

The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is affected by many known factors. Our study aimed to evaluate whether other factors, in particular lung cancer, could be responsible for an increase in NT-proBNP levels in a population with no known risk factors for elevated NT-proBNP.

PATIENTS AND METHODS

This study was based on the RIABO (Recueil de l'Ischémie au Bloc Opératoire) database, a single-center registry that prospectively records in elective noncardiac surgery. Patients aged > 75 years and those presenting with 1 or more known risk factors for high NT-proBNP were excluded. Patients were divided into 2 groups according to preoperative NT-proBNP levels: (≥ 125 pg/mL or < 125 pg/mL).

RESULTS

Between October 2005 and February 2007, 439 patients were eligible for inclusion. Among 35 patients with lung cancer, 26 (74%) had elevated NT-proBNP (≥ 125 pg/mL), versus 9 (26%) with NT-proBNP < 125 pg/mL (P < .0001). By multivariate analysis, the presence of lung cancer was an independent risk factor for a level of NT-proBNP ≥ 125 pg/mL (odds ratio, 7; 95% CI, 2.9-17; P < .0001). We also observed an independent relationship between NT-proBNP ≥ 125 pg/mL and age, female sex, smoking status, and C-reactive protein levels.

CONCLUSION

In our study, patients with lung cancer were 7 times more likely to have elevated NT-proBNP (≥ 125 pg/mL). The presence of lung cancer should therefore be taken into account when interpreting NT-proBNP levels. Further studies are warranted to explore the diagnostic value of this marker in lung cancer and to identify the cause of the elevation.

Assessment of B-type natriuretic peptide in patients with pneumonia

The mammalian heart synthesises and secretes B-type natriuretic peptide (BNP), which has potent diuretic, natriuretic and vascular smooth muscle-relaxing effects as well as complex interactions with the hormonal and nervous systems. Recent studies described that BNP was acute phase reactant. In this study, we aimed to evaluate BNP levels in patients with pneumonia. Twenty-one patients with pneumonia and 21 healthy control subjects were enrolled in this study. Their serum levels of BNP were measured in addition to the standard evaluations. Leucocyte count [19.3 (13.2-25.7) 10(6)/ml vs. 9.55 (3.7-13.9) 10(6)/ml, p < 0.001], erythrocyte sedimentation rate [73 (57-81) mm/h vs. 35 (4-55) mm/h, p < 0.001], C-reactive protein (CRP) [127.72 (27-290) mg/l vs. 13.19 (3-41) mg/l, p < 0.001] and BNP [53.1 (17-91) pg/ml vs. 16.24 (1-38) pg/ml, p < 0.001] levels significantly decreased after treatment period. Initial BNP levels were significantly higher than control groups (53.10 +/- 15.07 pg/ml vs. 18.62 +/- 14.05 pg/ml, p < 0.001) and decreased after treatment to the levels comparable with control subjects. BNP levels correlated with CRP levels at admission (r = 0.716, p < 0.001). We have shown that BNP levels show a transient increase in patients with pneumonia and correlate well with CRP.

Heart failure with preserved systolic function: giving well-deserved attention to the "other" heart failure

Heart failure with preserved systolic function is common in patients hospitalized with decompensated heart failure and is associated with postdischarge morbidity and costs similar to patients with heart failure and systolic dysfunction. It is common in the older people, and hypertension and cardiac ischemia are often etiological factors. Nurses must be able to recognize left ventricular diastolic abnormalities and understand treatment priorities and treatment options on the basis of structural cardiovascular disease; etiology and risk factors; and signs, symptoms, and hemodynamic parameters. Currently, clinical treatments are on the basis of individual randomized clinical trials; however, there are general principles that should be followed during hospitalization and as part of general practice. As in the treatment of systolic heart failure, nurses have active roles in ensuring accurate assessment; optimal care planning; implementation of clinical, psychosocial; and education interventions; and timely and accurate evaluation so that patients have the best chance for successful hospital and postdischarge outcomes.

Relationship between Pericardial Fluid B-type Natriuretic Peptide and Ventricular Structure and Function

BACKGROUND

We undertook this study to investigate the levels of pericardial B-type natriuretic peptide (BNP) and its relationship with ventricular structure and function.

METHODS

Pericardial and plasma BNP concentrations were measured in 18 patients with congenital ventricular septal defect.

RESULTS

The mean level of BNP in the pericardial fluid (324.8+/-137.3 pg/mL) was higher than the plasma (20.8+/-6.1 pg/mL) (p=0.03). Pericardial BNP was correlated with the plasma BNP (r=0.85, p<0.01). A good correlation was also found between the pericardial BNP and left atrial diameter, left ventricular end-diastolic and end-systolic diameter, left ventricular ejection fraction, right ventricular diameter and pulmonary artery systolic pressure (p<0.05).

CONCLUSIONS

The levels of BNP in pericardial fluid were higher than in the plasma. Similar to plasma BNP, pericardial BNP is also related to the ventricular structure and function.

Prognostic value of B-type natriuretic peptide in patients with chronic and advanced heart failure

BACKGROUND

An increase in circulating B-type natriuretic peptide (BNP) is associated with a poor outcome in patients with acute heart failure. The primary aim of this study was to investigate the prognostic value of BNP levels in patients with chronic and advanced heart failure.

METHODS

Fifty patients with New York Heart Association functional classes III and IV were enrolled in the study. Their blood BNP levels at admission were measured and patients were on follow up for 12 +/- 2 months.

RESULTS

There was no significant correlation between BNP levels on admission and left ventricular ejection fraction (r = 0.12, P > 0.05). Twelve patients (24%) died during the follow up. BNP levels were lower in patients who died (501 +/- 72 vs 877 +/- 89 ng/L, P < 0.01). The logistic stepwise regression analysis showed that lower BNP level (<520 ng/L) on admission was an independent predictor of cardiovascular mortality in these patients (odds ratio 1.21, 95% confidence interval 1.06-2.32, P < 0.01).

CONCLUSION

We conclude that patients with chronic and advanced heart failure have a lower circulating BNP level than those who survive. The paradoxically low BNP level is an adverse prognostic marker in advanced heart failure.

Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure

Among the general heart failure (HF) population, over half have diastolic HF (DHF). The proportion of DHF increases with age, from 46% in patients younger than 45 years to 59% in patients older than 85 years. The diagnosis of DHF is made by the combination of signs and symptoms of HF with preserved systolic function (left ventricular ejection fraction >50%), and evidence of diastolic dysfunction obtained by echocardiographic Doppler examination, invasive hemodynamic evaluation, or an elevation of serum B-type natriuretic peptide. The most common risk factors for the development of diastolic dysfunction and DHF include long-standing hypertension, older age, female sex, obesity, diabetes, chronic kidney disease, and coronary artery disease. Acute decompensation occurs in the setting of pressure overload, volume overload, or superimposed cardiac ischemia. The cornerstones of in-hospital management include blood pressure and volume control, heart rate control, and correction of precipitating factors. Priorities in the outpatient clinic include optimal blood pressure control, maintenance of euvolemia with minimal or no diuretics, and, potentially, use of disease-modifying drugs including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor blockers, beta-blockers, and digoxin. Long-term regression of left ventricular hypertrophy, improvement in diastolic filling parameters, and sustained reductions in B-type natriuretic peptide may be future treatment targets for this condition.

Natriuretic peptides: diagnostic tools and predictors of heart failure outcome

Congestive heart failure (CHF) is a progressive disease whose outcome largely depends on early, accurate and prompt diagnosis, accompanied by evidence-based treatment. The explosion of uptake of natriuretic peptides (NPs) in clinical practice belies an understanding of how peptides are used. The signal for NP release is the same signal that causes symptoms of CHF, such as increased wall stress. Thus, NPs can reliably add to the information a physician brings to the table as they attempt to diagnose the acutely dyspneic patient with CHF. Additionally, NPs have strong prognostic utility in the emergency room and the hospital. Monitoring of NPs during treatment for acute CHF may help manage the patient. In the future, it is possible that NPs will play a more prominent role in early detection of left ventricular dysfunction as well as guiding chronic CHF treatment.

Low levels of B-type natriuretic peptide predict poor clinical outcomes in patients with chronic and advanced heart failure

B-type natriuretic peptide (BNP) is a neurohormone produced mainly by ventricular myocytes in response to increased left ventricular end-diastolic pressure. Patients with acute decompensated heart failure often have elevated plasma BNP. However, recent clinical observations have demonstrated that in patients with advanced heart failure, the plasma level of BNP is lower than those with acute heart failure. We hypothesized that a lower circulating BNP level in patients with chronic and advanced heart failure is due to the exhaustion of the biosynthesis mechanisms and is associated with a poor outcome in these patients.

B-type natriuretic peptide is an independent predictor for cardiovascular death in patients with no clinical signs of ventricular dysfunction after acute myocardial infarction

B-type natriuretic peptide (BNP) is released from cardiac ventricles in response to increased wall tension in patients with heart failure. It has been used as a biochemical marker for the diagnosis of congestive heart failure. BNP is also increased in patients with acute myocardial infarction, and is associated with an increased risk of cardiovascular mortality in those with impaired left ventricular function after myocardial infarction. We hypothesized that an increase in BNP soon after acute myocardial infarction is an independent predictor for long-term prognosis in patients with no clinical signs of left ventricular function.