N-terminal pro-brain natriuretic peptide on admission has prognostic value across the whole spectrum of acute coronary syndromes

NT-proBNP in the Early Convalescent Phase after High-Risk Myocardial Infarction Is Associated with Adverse Cardiovascular Outcomes: the PARADISE-MI Trial

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is associated with heart failure (HF) hospitalizations and death when measured during a myocardial infarction (MI). However, NT-proBNP concentrations change following the initial ischemic insult and less is known about the prognostic importance of NT-proBNP in the early convalescent phase.

METHODS

PARADISE-MI randomized 5661 patients with MI complicated by LVEF ≤40% and/or pulmonary congestion to sacubitril/valsartan or ramipril. Patients with available week 2 NT-proBNP concentrations and without-incident HF between randomization and week 2 (n = 1062) were analyzed. Associations of week 2 NT-proBNP with subsequent clinical outcomes were evaluated in landmark analyses using Cox models adjusted for clinical characteristics, including LVEF, baseline NT-proBNP and atrial fibrillation.

RESULTS

Median 2-week NT-proBNP concentration was 1391 [676-2507] ng/L. Patients in the highest NT-proBNP quartile (≥2507 ng/L) were older, had lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate (eGFR), higher Killip class, and more atrial fibrillation. Higher NT-proBNP concentrations were independently associated with greater risk of cardiovascular death or incident HF (adjusted hazard ratio [aHR], 1.65 per doubling of NT-proBNP; 95% confidence interval [CI], 1.31-2.09), HF hospitalization (aHR, 1.87; 95% CI, 1.38-2.54), recurrent myocardial infarction (aHR, 1.46; 95% CI, 1.09-1.95) and all-cause death (aHR, 1.85; 95% CI, 1.35-2.53).

CONCLUSIONS

Patients with elevated NT-proBNP concentrations approximately 2 weeks after a high-risk myocardial infarction are at heightened risk of incident HF, recurrent coronary events, and death independent of baseline NT-proBNP concentrations and clinical characteristics. Elevations in NT-proBNP concentrations in the early convalescent phase may assist in risk stratification and the identification of patients in need of more advanced preventive treatment approaches.

Cardiac Magnetic Resonance to Reclassify Diagnosis and Detect Cardiomyopathies in Hospitalized Patients with Acute Presentation

BACKGROUND

Cardiomyopathies are a significant cause of heart failure, arrhythmia, and cardiac morbidity in the general population. Cardiovascular magnetic resonance (CMR) is a valuable tool for the diagnostic work-up of patients with acute cardiac events.

OBJECTIVES

This study evaluated the diagnostic value of CMR and the yield of cardiomyopathies in hospitalized cardiac patients with acute presentation.

METHODS

A retrospective analysis was conducted with 535 consecutive hospitalized patients who underwent CMR at Hippokration Hospital, Athens, Greece, to identify a subset of scans performed on an urgent basis of hospitalized patients. Demographic data, causes of admission, CMR findings, and plasma cardiac biomarkers (hs-Troponin I, NT-proBNP, and CRP) were systematically recorded.

RESULTS

Out of the initial 535 CMR scans evaluated, a further analysis was conducted with 104 patients who were in hospital and underwent CMR on an urgent basis. From the total population of hospitalized patients, 33% had CMR findings indicative of underlying cardiomyopathy, with dilated cardiomyopathy being the most common subtype (36%), followed by arrhythmogenic cardiomyopathy (27%), hypertrophic cardiomyopathy (15%), or other subtypes (e.g., cardiac amyloidosis, sarcoidosis, endomyocardial fibrosis, EGPA, or unclassified). CMR led to the reclassification of the initial diagnosis into that of underlying cardiomyopathy in 32% of cases. The highest reclassification rate was observed within the subgroup with heart failure (71%), followed by that of acute myocardial infarction/ischemic heart disease (24%) and myocarditis (22%).

CONCLUSIONS

CMR imaging effectively contributed to the differential diagnosis of hospitalized patients with acute cardiac events that remained without a definitive diagnosis after their initial work-up and uncovered underlying cardiomyopathy in almost one-third of this cohort.

Predictive value of NT-proBNP for major adverse cardiovascular events within a 6-month period in patients with acute coronary syndrome

BACKGROUND

The role of NT-proBNP as a cardiac biomarker for predicting short-term major adverse cardiovascular events (MACEs) in acute coronary syndrome (ACS) remains unclear.

AIMS

This study investigated the utility of the NT-proBNP level for predicting MACEs within a 6-month period in patients with ACS.

METHODS

This prospective study included 241 consecutively enrolled adults with ACS between September 2023 and February 2024. Demographic data, clinical characteristics, GRACE score, and high-sensitivity cardiac troponin T (hs-cTnT) and NT-proBNP levels were compared between patients who were MACE-positive vs. MACE-negative within a 6-month period.

RESULTS

The overall mortality rate was 8.7%, and the incidence of MACEs was 43.2%. The mean serum levels of hs-cTnT and NT-proBNP were significantly higher in the MACE-positive than in the MACE-negative group. Age, concomitant coronary artery disease, NT-proBNP, and GRACE score were independent predictors of MACEs in patients with ACS. An NT-proBNP level of 250 pg/mL had a sensitivity of 73.1% and a specificity of 88.3% for predicting MACEs, with an area under the curve of 0.847. The estimated risk of MACEs was 70% and 90% for NT-proBNP values of 600 pg/mL and 900 pg/mL, respectively.

CONCLUSION

The NT-proBNP level measured at ED admission was strongly associated with short-term MACEs in patients with all ACS subtypes and was an important prognostic biomarker. Therefore, combining the NT-proBNP level with the GRACE score in ACS patients may provide significant benefits in terms of predicting MACEs and obtaining a more accurate risk stratification.

Brain natriuretic peptide as a predictive marker of mortality in sepsis: an updated systematic review and meta-analysis

INTRODUCTION

Early identification of patients with sepsis at high risk of death remains a challenge, and whether brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) has a prognostic effect on patients with sepsis is controversial. Here, we clarified the prognostic value of BNP and NT-proBNP and sought to establish suitable cutoff values and intervals.

METHODS

We searched five databases to identify studies that met the inclusion criteria. The primary outcomes were the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the curve (AUC), and corresponding 95% credible interval (95% CI) of BNP and NT-proBNP. The secondary outcomes were the sensitivity and specificity of BNP or NT-proBNP in subgroup analyses.

RESULTS

Forty-seven studies were included in our meta-analysis. The pooled sensitivity of NT-proBNP (0.77 [0.68, 0.84]) was weaker than that of BNP (0.82 [0.76, 0.87]), the pooled specificity of NT-proBNP (0.70 [0.60, 0.77]) was less than that of BNP (0.77 [0.71, 0.82]), and the AUC of BNP (0.87 [0.83-0.89]) was greater than that of NT-proBNP (0.80 (0.76-0.83]). The results of the subgroup analysis showed that the cutoff range of 400-800 pg/mL for BNP had high sensitivity (0.86 [0.74-0.98]) and specificity (0.87 [0.81-0.93]) and was probably the most appropriate cutoff range.

CONCLUSIONS

Elevated levels of BNP and NT-proBNP were significantly related to the mortality of patients with sepsis and had a moderate prognostic value in predicting the mortality of patients with sepsis. In addition, our meta-analysis preliminarily established appropriate cutoff values for BNP and NT-proBNP.

Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care

The role of cardiac biomarkers in diagnosing acute myocardial infarction is undoubted. In the 2020 guidelines of the European Society of Cardiology, the measurement of cardiac peptides to gain prognostic information has a class IIa indication in all patients with ACS. In emergency care, ruling out a non-ST elevation myocardial infarction requires documentation of normal levels of cardiac biomarkers, which remain stable or have very small variations within several hours. This review aims to summarize the current knowledge and recent progresses in the field of cardiac biomarker discovery, from their routine use in emergency rooms to their prognostic roles in modern risk assessment tools. Integrated approaches combining cardiac troponin with other biomarkers of ventricular dysfunction or inflammation, or with modern cardiac imaging in emergency care are also presented, as well as the role of modern algorithms for serial troponin measurement in the modern management of emergency departments.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

The Prognostic Value of Natriuretic Peptides in Stable Patients with Suspected Acute Myocarditis: A Retrospective Study

Risk stratification in acute myocarditis is based on the clinical signs of heart failure, the degree of cardiac dysfunction, and the findings in cardiac magnetic resonance (CMR). The aim of the current study is to examine the prognostic yield of the natriuretic peptide N-terminal-pro hormone Brain Natriuretic Peptide (NT-proBNP) and C-reactive protein (CRP) in acute myocarditis among patients with preserved/mildly reduced left ventricular ejection fraction (LVEF). We retrospectively analyzed 59 patients (median age 28 years, 76% males) with ICD-9 discharge diagnosis of acute myocarditis. Basic characteristics, echocardiographic, and laboratory parameters were obtained from computerized files. The median length of stay was 3, (IQR 2−5) days, and the median LVEF was 48% (IQR, 54−62%). High levels of NT-proBNP and CRP were associated with increased length of stay (r = 0.57, p < 0.001; r = 0.4 p = 0.001, respectively), while troponin level was not (r = 0.068, p = 0.61). During the index hospitalization, complications occurred in 14 (23.7%) patients. High NT-proBNP and CRP levels were associated with complications (p < 0.001, and p = 0.001, respectively), while troponin level was not (p = 0.452). In conclusion, routine measurement of NT-proBNP and CRP are preferred over troponin for risk stratification in hemodynamically stable myocarditis.

Complement component 7 is associated with total- and cardiac death in chest-pain patients with suspected acute coronary syndrome

BACKGROUND

Complement activation has been associated with atherosclerosis, atherosclerotic plaque destabilization and increased risk of cardiovascular events. Complement component 7 (CC7) binds to the C5bC6 complex which is part of the terminal complement complex (TCC/C5b-9). High-sensitivity C-reactive protein (hsCRP) is a sensitive marker of systemic inflammation and may reflect the increased inflammatory state associated with cardiovascular disease.

AIM

To evaluate the associations between CC7 and total- and cardiac mortality in patients hospitalized with chest-pain of suspected coronary origin, and whether combining CC7 with hsCRP adds prognostic information.

METHODS

Baseline levels of CC7 were related to 60-months survival in a prospective, observational study of 982 patients hospitalized with a suspected acute coronary syndrome (ACS) at 9 hospitals in Salta, Argentina. A cox regression model, adjusting for conventional cardiovascular risk factors, was fitted with all-cause mortality, cardiac death and sudden cardiac death (SCD) as the dependent variables. A similar Norwegian population of 871 patients was applied to test the reproducibility of results in relation to total death.

RESULTS

At follow-up, 173 patients (17.7%) in the Argentinean cohort had died, of these 92 (9.4%) were classified as cardiac death and 59 (6.0%) as SCD. In the Norwegian population, a total of 254 patients (30%) died. In multivariable analysis, CC7 was significantly associated with 60-months all-cause mortality [hazard ratio (HR) 1.26 (95% confidence interval (CI), 1.07-1.47) and cardiac death [HR 1.28 (95% CI 1.02-1.60)], but not with SCD. CC7 was only weakly correlated with hsCRP (r = 0.10, p = 0.002), and there was no statistically significant interaction between the two biomarkers in relation to outcome. The significant association of CC7 with total death was reproduced in the Norwegian population.

CONCLUSIONS

CC7 was significantly associated with all-cause mortality and cardiac death at 60-months follow-up in chest-pain patients with suspected ACS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01377402, NCT00521976.

Urinary N-terminal pro-brain natriuretic peptide: prognostic value in patients with acute chest pain

AIMS

The objective of this study was to investigate the prognostic value of urinary N-terminal pro-brain natriuretic peptide (NT-proBNP) compared with plasma NT-proBNP in patients presenting with acute chest pain in the emergency department.

METHODS AND RESULTS

We measured simultaneously plasma and urinary NT-proBNP at admission in 301 patients with acute chest pain. In our cohort, 174 patients suffered from acute coronary syndrome (ACS). A follow-up (median of 55 months) was performed regarding the endpoints all-cause mortality and major adverse cardiac events (mortality, congestive heart failure, ACS with the necessity of a coronary intervention, and stroke). Fifty-four patients died during follow-up; 98 suffered from the combined endpoint. A significant and positive correlation of urinary and plasma NT-proBNP was found (r = 0.87, P < 0.05). Patients with troponin positive ACS had significantly elevated levels of plasma and urinary NT-proBNP compared with those with unstable angina pectoris or chest wall syndrome (each P < 0.05). The highest levels of both biomarkers were found in patients with congestive heart failure (each P < 0.05). According to Kaplan-Meier analysis, plasma and urinary NT-proBNP were significant predictors for mortality and the combined endpoint in the whole study cohort and in the subgroup of patients with ACS (each P < 0.05). Regarding Cox regression analysis, plasma and urinary NT-proBNP were independent predictors for mortality and the combined endpoint (each P < 0.05).

CONCLUSIONS

Urinary NT-proBNP seems to provide a significant predictive value regarding the endpoints all-cause mortality and major adverse cardiac events in patients with acute chest pain and those with ACS.

NT-proBNP level before primary PCI and risk of poor myocardial reperfusion: Insight from the On-TIME II trial

BACKGROUND

N-terminal fragment of the brain natriuretic peptide prohormone (NT-proBNP), a marker for neurohumoral activation, has been associated with adverse outcome in patients with myocardial infarction. NT-proBNP levels may reflect extensive ischemia and microvascular damage, therefore we investigated the potential association between baseline NT-proBNP level and ST-resolution (STR), a marker of myocardial reperfusion, after primary percutaneous coronary intervention (pPCI).

METHODS

we performed a post-hoc analysis of the On-TIME II trial (which randomized ST-elevation myocardial infarction (STEMI) patients to pre-hospital tirofiban administration vs placebo). Patients with measured NT-proBNP before angiography were included. Multivariate logistic-regression analyses was performed to investigate the association between baseline NTproBNP level and STR one hour after pPCI.

RESULTS

Out of 984 STEMI patients, 918 (93.3%) had NT-proBNP values at baseline. Patients with STR <70% had higher NT-proBNP values compared to patients with complete STR (>70%) [Mean ±SD 375.2 ±1021.7 vs 1007.4 ±2842.3, Median (IQR) 111.7 (58.4-280.0) vs 168.0 (62.3-601.3), P <.001]. At multivariate logistic regression analysis, independent predictors associated with higher risk of poor myocardial reperfusion (STR <70%) were: NT-proBNP (OR 1.17, 95%CI 1.04-1.31, P = .009), diabetes mellitus (OR 1.87, 95%CI 1.14-3.07, P = .013), anterior infarct location (OR 2.74, 95% CI 2.00-3.77, P <.001), time to intervention (OR 1.06, 95%CI 1.01-1.11, P = .021), randomisation to placebo (OR 1.45, 95%CI 1.05-1.99, P = .022).

CONCLUSIONS

In STEMI patients, higher baseline NT-proBNP level was independently associate with higher risk of poor myocardial reperfusion, supporting the potential use of NT-proBNP as an early marker for risk stratification of myocardial reperfusion after pPCI in STEMI patients.

Role of Computed Tomography in Postoperative Follow-up of Arterial Switch Operation

An arterial switch operation (ASO) is the standard treatment for infants and children born with D-loop transposition of the great arteries. During the ASO, the great vessels are transected from the native roots, switched and anastomosed with the opposite roots. This is accompanied by the relocation of the pulmonary artery anterior to the aorta by using the LeCompte maneuver and the translocation of coronary arteries to the neo-aorta. ASO has led to improved overall survival, and postoperative mortality is rare. Despite the improved outcomes, several postoperative sequelae may occur, and therefore patients require long-term follow-up. Computed tomography (CT) has emerged as a robust imaging modality in pre and postoperative evaluation of a variety of congenital heart disorders including ASO. Unlike echocardiography and cardiovascular magnetic resonance, CT is not hindered by a poor acoustic window, metallic devices or the need for sedation or general anesthesia. CT with advanced three-dimensional postprocessing techniques, high pitch scanning, wider detector system, electrocardiogram-dependent modulation and dose-reduction strategies is invaluable in assessing the postoperative complications after ASO.

CT and MRI for Repaired Complex Adult Congenital Heart Diseases

An increasing number of adult congenital heart disease (ACHD) patients continue to require life-long diagnostic imaging surveillance using cardiac CT and MRI. These patients typically exhibit a large spectrum of unique anatomical and functional changes resulting from either single- or multi-stage palliation and surgical correction. Radiologists involved in the diagnostic task of monitoring treatment effects and detecting potential complications should be familiar with common cardiac CT and MRI findings observed in patients with repaired complex ACHD. This review article highlights the contemporary role of CT and MRI in three commonly encountered repaired ACHD: repaired tetralogy of Fallot, transposition of the great arteries after arterial switch operation, and functional single ventricle after Fontan operation.

Predictors of neo-aortic valve regurgitation in the long term after arterial switch operation

Although arterial switch operations (ASOs) have been performed globally to repair d-transposition of the great arteries (d-TGA) in neonates and infants, few studies have been reported regarding the influence of the hemodynamics of patients with d-TGA who have undergone ASO on the development of neo-aortic valve regurgitation (AR). We aimed to investigate the relationship between the hemodynamics and development of AR after ASO in patients with d-TGA by catheter evaluation. This observational study screened 114 consecutive patients who underwent ASO for d-TGA or Taussig-Bing anomaly and who subsequently underwent catheter evaluations in our institution. We reviewed their records for the past 20 years and collected their first catheterization data post-ASO in early childhood. Thirty-six post-ASO patients who underwent catheter evaluations in both the early surgical and long-term phases were finally analyzed. Patients were divided into the following groups according to the presence of significant AR in the long-term phase: the AR group (n = 9 with AR ≥ grade II by the Sellers classification) and the non-AR group (n = 27 with AR < grade II). In the long-term phase, the diastolic blood pressure was significantly lower and the ascending aortic diameter was significantly larger in the AR group than in the non-AR group (p = 0.004 and p = 0.006, respectively). The systolic blood pressure (SBP) and pulse pressure (PP) were similar in both groups. Meanwhile, in the early surgical phase, SBP and PP were significantly higher in the AR group than in the non-AR group (p = 0.029 and p = 0.002, respectively). The receiver operating characteristic curve for late AR showed that the area under the curve for SBP and PP in the early surgical phase were 0.746 and 0.853, respectively. Even though sensitivity analysis was performed, SBP or PP greater than the cutoff value in the early surgical phase was identified as predictors for late AR. Our results suggested that high SBP or PP in the early surgical phase could influence the development of AR in the long term after ASO.

Growth Pattern of the Neo-Aorta after Arterial Switch Operation during Childhood

Background and Objectives

Neo-aortic root dilatation (ARD) and annular dilatation (AAD) tend to develop after arterial switch operation (ASO). However, the trend of neo-aortic growth has not been well established. This paper aims to identify this trend, its associated factors, and predictors of neo-aortic dilatation after ASO.

Methods

We analyzed the growth trend of the neo-aortic root, annulus, and sinotubular junction (STJ) z-scores using random coefficients model and the risk factors affecting neo-aortic dilatation in 163 patients who underwent ASO from 2006 to 2015.

Results

Among 163 patients, 41 had a ventricular septal defect, and 11 had Taussig-Bing (TB) anomaly. The median follow-up duration was 6.61 years. The increased in the neo-aortic root z-score was different between the trapdoor and non-trapdoor coronary artery transfer techniques (0.149/year, p<0.001 vs. 0.311/year, p<0.001). Moreover, the neo-aortic annulus and STJ z-score significantly increased over time after ASO (0.067/year, p<0.001; 0.309/year, p<0.001). Pulmonary artery banding (PAB) was rather a negative affecting factor. The probabilities of freedom from ARD, AAD, and neo-aortic STJ dilatation at 10 years after ASO were 33.4%, 53.9%, and 65.4%. Neo- aortic regurgitation within 1 year was the predictor of ARD, AAD, and neo-aortic STJ dilatation. TB anomaly, PAB, and native pulmonary sinus z-score were other predictors for ARD.

Conclusion

The growth of neo-aortic root, annulus, and STJ after ASO was greater than somatic growth during childhood. The coronary artery transfer technique affected the growth pattern of the neo-aortic root.

Combined effect of serum N-terminal pro-brain natriuretic peptide and galectin-3 on prognosis 1 year after ischemic stroke

RATIONALE

N-terminal pro-brain natriuretic peptide (NT-proBNP) and galectin-3 are important biomarkers related to ischemic stroke. However, the predictive value of the combination of them has not been examined in previous studies.

OBJECTIVE

The aim of this study was to investigate the combined effect of NT-proBNP and galectin-3 on clinical outcomes in ischemic stroke patients.

METHODS

A total of 2694 patients (63.62% males; mean age = 62.4 in admission) with serum NT-proBNP and galectin-3 measured simultaneously were included in this study. The primary outcome was composite outcome of death or major disability 1 year after stroke onset. Secondary outcomes were separately death, major disability, vascular events and the composite outcome of vascular events or death. The participants were divided into 4 groups according to NT-proBNP and galectin-3. Odd ratios (ORs; for nonevent outcome without time variables: primary outcome, major disability) or hazard ratios (HRs; for event outcome with time variables: death, vascular events, and the composite outcome of vascular events or death) were calculated to assess the association of NT-proBNP and galectin-3 status with adverse outcomes.

RESULTS

At the 1-year follow-up, 589 patients experienced a primary outcome after stroke onset. After adjustment for potential confounders, high NT-proBNP/high galectin-3 group were associated with increased risks of primary outcome (OR: 1.43; 95% confidence interval [CI], 1.02-2.00; P value = 0.039), death (HR: 2.74; 95% CI, 1.42-5.29; P value = 0.003), and the composite outcome of vascular events or death (HR: 1.66; 95% CI, 1.06-2.58; P value = 0.026). Statistical tests for interactions between the 4 groups and primary outcome or death were not significant (all P interaction > 0.05).

CONCLUSION

Simultaneously increased NT-proBNP and galectin-3 significantly increased the risk of poor clinical outcomes 1 year after ischemic stroke. Using NT-proBNP and galectin-3 together can result in an accurate prediction of ischemic stroke prognosis.

N-terminal pro-B-type natriuretic peptide as a prognostic indicator for 30-day mortality following out-of-hospital cardiac arrest: a prospective observational study

BACKGROUND

Early risk stratification applying cardiac biomarkers may prove useful in sudden cardiac arrest patients. We investigated the prognostic utility of early-on levels of high sensitivity cardiac troponin-T (hs-cTnT), copeptin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a prospective observational unicenter study, including patients with OHCA of assumed cardiac origin from the southwestern part of Norway from 2007 until 2010. Blood samples for later measurements were drawn during cardiopulmonary resuscitation or at hospital admission.

RESULTS

A total of 114 patients were included, 37 patients with asystole and 77 patients with VF as first recorded heart rhythm. Forty-four patients (38.6%) survived 30-day follow-up. Neither hs-cTnT (p = 0.49), nor copeptin (p = 0.39) differed between non-survivors and survivors, whereas NT-proBNP was higher in non-survivors (p <  0.001) and significantly associated with 30-days all-cause mortality in univariate analysis, with a hazard ratio (HR) for patients in the highest compared to the lowest quartile of 4.6 (95% confidence interval (CI), 2.1-10.1), p <  0.001. This association was no longer significant in multivariable analysis applying continuous values, [HR 0.96, (95% CI, 0.64-1.43), p = 0.84]. Similar results were obtained by dividing the population by survival at hospital admission, excluding non-return of spontaneous circulation (ROSC) patients on scene [HR 0.93 (95% CI, 0.50-1.73), P = 0.83]. We also noted that NT-proBNP was significantly higher in asystole- as compared to VF-patients, p <  0.001.

CONCLUSIONS

Early-on levels of hs-cTnT, copeptin and NT-proBNP did not provide independent prognostic information following OHCA. Prediction was unaffected by excluding on-scene non-ROSC patients in the multivariable analysis.

TRIAL REGISTRATION

ClinicalTrials. gov, NCT02886273 .

Predictive value of C-reactive protein and NT-pro-BNP levels in sepsis patients older than 75 years: a prospective, observational study

INTRODUCTION

Using biomarkers to predict mortality in patients with sepsis is important because these patients frequently have high mortality rates and unsatisfactory outcomes. The performance of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein (CRP) to predict clinical outcomes in elderly sepsis patients is unimpressive. We aimed to assess the prognostic value of NT-pro-BNP, CRP and the combination of both in selected medical ICU sepsis patients more than 75 years old.

METHODS

In total, 245 consecutive patients were screened for eligibility and followed during their ICU stays. We collected the patients' baseline characteristics, including their Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and NT-pro-BNP and CRP levels. The primary outcome was ICU mortality. Potential predictors were analyzed for their possible associations with the outcome. We also evaluated the ability of NT-pro-BNP and CRP levels combined with the APACHE II score to predict ICU mortality by calculating the C-index and net reclassification improvement (NRI).

RESULTS

Univariate regression revealed that CRP, NT-pro-BNP, APACHE II score, lactic acid level, NEU count(neutrophil count)and HCT level independently predicted ICU mortality (all P < 0.01). The C-index for the prediction of ICU mortality by the APACHE II score (0.847 ± 0.029; P < 0.001) was greater than that for NT-pro-BNP (0.673 ± 0.039; P < 0.01) or CRP (0.626 ± 0.039; P < 0.01) (all P < 0.01). Compared with the APACHE II score (0.847 ± 0.029; P < 0.001), the combination of CRP (0.849 ± 0.029; P < 0.01) or NT-pro-BNP (0.853 ± 0.028; P < 0.01) or both (0.853 ± 0.030; P < 0.01) with the APACHE II score did not significantly increase the C-index for predicting ICU mortality (all P > 0.05). However, the addition of NT-pro-BNP to the APACHE II score gave an NRI of 8.6% (P = 0.000), the addition of CRP to the APACHE II score provided an NRI of 11.34% (P = 0.012), and the addition of both markers to the APACHE II score yielded an NRI of 29.0% (P = 0.000). In the MOF subgroup (N = 118), CRP (OR = 2.62, P < 0.05) but not NT-pro-BNP (OR = 1.73, p > 0.05) independently predicted ICU mortality, and the addition of CRP to the APACHE II score obviously increased its predictive ability (NRI = 13.88%, P = 0.000). In the non-MOF group (N = 127), neither CRP (OR = 5.447, P = 0.078) nor NT-pro-BNP (OR = 2.239, P = 0.016) was an independent predictor of ICU mortality.

CONCLUSIONS

In sepsis patients older than 75 years, NT-pro-BNP and CRP can serve as independent predictors of mortality, and the addition of NT-pro-BNP or CRP or both to the APACHE II score significantly improves the ability to predict ICU mortality. CRP appears to be useful for predicting ICU outcomes in elderly sepsis patients with multiple-organ failure.

The relationship between serum NT-proBNP levels and severity of coronary artery disease assessed by SYNTAX score in patients with acute myocardial infarction

Background/aim

In the present study, we aimed to investigate the relationship between NT-proBNP and SYNTAX score, which is a measure of the complexity of coronary artery disease.

Materials and methods

We enrolled 405 consecutive patients with myocardial infarction who underwent coronary angiographic examination. Patients were divided into 3 groups according to their SYNTAX scores. Those with SYNTAX score ≤22 were included in the low SYNTAX score group (LSTX), those with a score of 23–32 were included in the intermediate SYNTAX score group (ISTX), and those with a score of ≥33 were included in the high SYNTAX score group (HSTX).

Results

NT-proBNP levels were found to be significantly higher in the HSTX group compared to the other groups (P < 0.001) and in the ISTX group compared to the LSTX group (P < 0.001). The NT-proBNP levels demonstrated an increase from low SYNTAX score to high SYNTAX score tertiles.

Conclusions

NT-ProBNP levels in patients with myocardial infarction on admission were independently associated with extent, severity, and complexity of coronary atherosclerosis as assessed by SYNTAX score.

Stronger correlation with myocardial ischemia of high-sensitivity troponin T than other biomarkers

BACKGROUND

Acute myocardial infarction (AMI) is considered a major cause of death and disability. Myocardial perfusion scintigraphy (MPS) as a non-invasive diagnostic imaging procedure and certain biomarkers associated with myocardial ischemia (ISCH), such as ischemia-modified albumin (IMA), neuropeptide Y (NPY), N-terminal pro b-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hsTnT) could probably aid in the detection of myocardial infarction.

METHODS

Between December 2011 and June 2012, we prospectively analyzed patients who underwent a MPS study with the clinical question of myocardial ISCH. An exercise test was performed along with a MPS. Blood was drawn from the patients before exercise and the within 3 minutes from achieving maximum load and was analyzed for the aforementioned biomarkers.

RESULTS

A total of 71 patients (56 men and 15 women) were enrolled with a mean age of 61 ± 12 years. Twenty-six patients (36.6%) showed reduced uptake on stress MPS images that normalized at rest, a finding consistent with ISCH. Between ISCH and non-ISCH groups, only hsTnT levels showed a significant difference with the highest levels pertaining to the former group both before (0.0075 ng/ml vs 0.0050 ng/ml, P = 0.023) and after stress exercise (0.0085 vs 0.0050, P = 0.015). The most prominent differences were seen in higher stages of the Bruce protocol (stress duration > 9.05 minutes - P < 0.017). None of the IMA, NPY, and NP-pro BNP showed significant differences in time between the two groups.

CONCLUSIONS

Although IMA, NPY, and NT-pro BNP may not detect minor ischemic myocardial insults, serum hsTnT holds a greater ability of detecting not only myocardial infarction but also less severe ischemia. Further studies with larger cohorts of patients are warranted in order to better define the role of hsTnT as a screening tool for myocardial ischemia.

Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide

Objective

Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls.

Methods

We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4  hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging.

Results

Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2  hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4  hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009).

Conclusion

Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.

Initial Phase NT-proBNP, but Not Copeptin and High-Sensitivity Cardiac Troponin-T Yielded Diagnostic and Prognostic Information in Addition to Clinical Assessment of Out-of-Hospital Cardiac Arrest Patients With Documented Ventricular Fibrillation

AIM

Sudden cardiac arrest (SCA) secondary to ventricular fibrillation (VF) may be due to different cardiac conditions. We investigated whether copeptin, hs-cTnT and NT-proBNP in addition to clinical assessment may help to identify the etiology of SCA and yield prognostic information.

METHODS AND RESULTS

EDTA-blood was collected prior to or at hospital admission from patients with SCA of assumed cardiac origin. Clinical data were obtained from hospital records. VF was the primary heart rhythm in 77 patients who initially were divided into 2 groups based on whether they had an ischemic or non-ischemic mechanism as the most likely cause of SCA. They were further divided into 4 groups according to whether or not they had a history of previous heart disease. The patients were categorized by baseline clinical information, ECG, echocardiography and coronary angiography; Group 1 (n = 43): SCA with first AMI, Group 2 (n = 10): SCA with AMI and previous MI, Group 3 (n = 3): SCA without AMI and without former heart disease, Group 4 (n = 18): SCA without AMI and with known heart disease. Copeptin and hs-cTNT did not differ between patient groups, whereas NT-proBNP was significantly higher in patients with established heart disease without AMI and differed between non-AMI and AMI. Furthermore, NT-proBNP was significantly elevated in non-survivors as compared to survivors.

CONCLUSION

NT-proBNP provided both diagnostic and prognostic information in blood samples collected close to out-of-hospital resuscitation of VF patients, whereas copeptin and hs-cTnT failed to do so.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02886273.

High-sensitivity cardiac troponin I and risk of heart failure in patients with suspected acute coronary syndrome: a cohort study

Aims

Heart failure may occur following acute myocardial infarction, but with the use of high-sensitivity cardiac troponin assays we increasingly diagnose patients with minor myocardial injury. Whether troponin concentrations remain a useful predictor of heart failure in patients with acute coronary syndrome is uncertain.

Methods and results

We identified all consecutive patients (n = 4748) with suspected acute coronary syndrome (61 ± 16 years, 57% male) presenting to three secondary and tertiary care hospitals. Cox-regression models were used to evaluate the association between high-sensitivity cardiac troponin I concentration and subsequent heart failure hospitalization. C-statistics were estimated to evaluate the predictive value of troponin for heart failure hospitalization. Over 2071 years of follow-up there were 83 heart failure hospitalizations. Patients with troponin concentrations above the upper reference limit (URL) were more likely to be hospitalized with heart failure than patients below the URL (118/1000 vs. 17/1000 person years, adjusted hazard ratio: 7.0). Among patients with troponin concentrations

Conclusion

Cardiac troponin is an excellent predictor of heart failure hospitalization in patients with suspected acute coronary syndrome. The strongest associations were observed in patients with troponin concentrations in the normal reference range, in whom high-sensitivity cardiac troponin assays identify those at increased risk of heart failure who may benefit from further investigation and treatment.

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Key Words

• Acute coronary syndrome
• Heart failure
• High-sensitivity cardiac troponin

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MESH Headings

• Acute Coronary Syndrome/blood
• Acute Coronary Syndrome/complications
• Acute Coronary Syndrome/diagnosis
• Aged
• Biomarkers/blood
• Female
• Heart Failure/blood
• Heart Failure/etiology
• Humans
• Male
• Middle Aged
• Predictive Value of Tests
• Prognosis
• Risk Factors
• Troponin I/blood

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Grants

• 201492/Z/16/Z Wellcome Trust
• FS/16/75/32533 British Heart Foundation
• SP/12/10/29922 British Heart Foundation
• SP/12/10/29922 British Heart Foundation
• HICG/1/40 Chief Scientist Office
• FS/16/14/32023 British Heart Foundation
• PG/15/51/31596 British Heart Foundation

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Affiliation(s)

Dominik Stelzle BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Anoop S V Shah BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Atul Anand BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Fiona E Strachan BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Andrew R Chapman BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Martin A Denvir BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
Nicholas L Mills BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little Fracne Cresc, Edinburgh EH16 4SB, UK
David A McAllister The Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK The Usher Institute of Population Health and Informatics, University of Edinburgh, Edinburgh, UK

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Association between increased N-terminal pro-brain natriuretic peptide level and poor clinical outcomes after acute ischemic stroke

BACKGROUND AND PURPOSE

N-terminal pro-brain natriuretic peptide (NT-proBNP) has been shown to be associated with the prognosis of cardiovascular diseases and NT-proBNP level is elevated in patients with acute ischemic stroke. However, the association between NT-proBNP and poor prognosis after ischemic stroke is still uncertain. The aim of this study was to examine whether serum NT-proBNP is associated with global clinical outcomes in a large cohort of patients with acute ischemic stroke.

METHODS

Baseline serum NT-proBNP level was measured in a subset of 3126 patients with acute ischemic stroke, and the patients were followed up to assess their clinical outcomes within 1year after the stroke. Cox proportional hazard models and logistic regression models were used to assess the effects of NT-proBNP on the primary outcome (composite outcome of death and vascular events) and poor functional outcomes.

RESULTS

During 1year of follow-up, 278 (9.0%) patients with a primary outcome and 685 (22.1%) patients with a poor functional outcome were identified. The cumulative incidence of primary outcomes increased across serum NT-proBNP quartiles (log-rank P<0.001). Hazard ratios (95% confidence interval) of the highest quartile compared with the lowest quartile were 1.47 (1.01-2.13) for the primary outcome, 1.79 (1.07-2.98) for death after multivariable adjustment. In addition, serum NT-proBNP was also associated with poor functional outcomes (odds ratio, 1.47; 95% confidence interval, 1.11-1.94; P_trend=0.008).

CONCLUSIONS

This study showed that high NT-proBNP levels increased the risk of a composite outcome of death and vascular events and poor functional outcomes at 1year after stroke onset among ischemic stroke patients with elevated blood pressure, suggesting that NT-proBNP might be a potential prognostic factor for ischemic stroke.

Prognostic impact of intensive statin therapy on N-terminal pro-BNP level in non-ST-segment elevation acute myocardial infarction patients

OBJECTIVE

This study explored the impact of intensive daily dosing of atorvastatin on in-hospital N-terminal pro-B-type natriuretic peptide level, left ventricular systolic function and incidence of major adverse cardiac events in non-ST-segment elevation myocardial infarction patients.

BACKGROUND

Several studies showed that early initiation of statin therapy in acute coronary syndrome patients has a favorable prognostic impact.

METHODS

Hundred statin naive patients were prospectively enrolled. Once eligible, patients were randomly assigned to receive either a moderate daily dose that is, 20 mg (Group A) or an intensified daily dose that is, 80 mg (Group B) of atorvastatin, in addition to an equally divided loading dose given 24 and 12 h before coronary angiography (80 mg each). N-terminal pro-B-type natriuretic peptide levels were recorded before and after coronary intervention. Collected data after 3 months included; N-terminal pro-B-type natriuretic peptide levels, left ventricle systolic function and major adverse cardiac events.

RESULTS

Mean age of the study cohort was 55 ± 10 years, 68% being males. There was no significant difference between both groups concerning procedural data. Group B patients showed a significantly lower N-terminal pro-B-type natriuretic peptide levels at both sampling occasions, i.e., after coronary intervention and 3 months later (P < 0.001). After 3 months, the same group showed higher left ventricle ejection fraction (P < 0.05), with no significant difference between both groups regarding incidence of major adverse cardiac events.

CONCLUSION

Intensive atorvastatin therapy in non-ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention is associated with; lower in-hospital N-terminal pro BNP level and higher LVEF after 3 months.

Development and Evaluation of Up-Converting Phosphor Technology-Based Lateral Flow Assay for Quantitative Detection of NT-proBNP in Blood

A newly assay, up-converting phosphor technology-based lateral flow (UPT-LF) assay, was developed for rapid and quantitative detection of N-terminal fragment of B-type natriuretic peptide precursor (NT-proBNP), one of the most important serum molecular maker of heat failure, in plasma samples as a point of care testing (POCT) method for diagnosis of acute heart failure. Human plasma from 197 patients with acute heart failure and 200 healthy controls was assessed using the UPT-LF assay, in a comparison with a Roche Elecsys assay. The limit of detection of the UPT-LF assay, with a coefficient of variation (CV) of less than 15%, was 116 ng/L, which is lower than the clinical diagnosis cutoff (150 ng/mL). The linear range was 50-35,000 ng/L. The CVs were less than 10% for both UPT-LF and Roche Elecsys assays for plasma samples under different storages, demonstrating the good stability and reproducibility. There are certain linear correlations between the results of UPT-LF and Roche Elecsys assay for EDTA-K2 and heparin-anticoagulated plasma, as well as for serum samples. For UPT-LF assay, there is a significant correlation between the values derived from analysis of EDTA-K2 and heparin-anticoagulated plasma samples (R = 0.995). No statistically significant difference was found between serum and plasma samples for UPT-LF assay. Our results demonstrate that NT-proBNP levels in healthy adults are elevated with age and had a relationship with sex, and with the age increase the NT-proBNP levels of females are significantly higher than those of males (p<0.01). The UPT-LF assay has a high reproducibility, stability, sensitivity, specificity, and is consistent with Roche Elecsys assay, and therefore it could be used as a POCT method for the quantitative detection of NT-proBNP in blood for clinical diagnosis and research of acute heart failure.

Numerical simulation of closure performance for neo-aortic valve for arterial switch operation

Background

Modeling neo-aortic valve for arterial switch surgical planning to simulate the neo-aortic valve closure performance.

Methods

We created five geometrical models of neo-aortic valve, namely model A, model B, model C, model D and model E with different size of sinotubular junction or sinus. The nodes at the ends of aorta and left ventricle duct fixed all the degrees of freedom. Transvalvular pressure of normal diastolic blood pressure of 54 mmHg was applied on the neo-aortic valve cusps. The neo-aortic valve closure performance was investigated by the parameters, such as stress of neo-aortic root, variation of neo-aortic valve ring as well as aortic valve cusps contact force in the cardiac diastole.

Results

The maximum stress of the five neo-aortic valves were 96.29, 98.34, 96.28, 98.26, and 90.60 kPa, respectively. Compared among five neo-aortic valve, aortic valve cusps contact forces were changed by 43.33, −10.00% enlarging or narrowing the sinotubular junction by 20% respectively based on the reference model A. The cusps contact forces were changed by 6.67, −23.33% with sinus diameter varying 1.2 times and 0.8 times respectively.

Conclusions

Comparing with stress of healthy adult subjects, the neo-aortic valve of infant creates lower stress. It is evident that enlarging or narrowing the sinotubular junction within a range of 20% can increase or decrease the maximum stress and aortic valve cusps contact force of neo-aortic valve.

C-Type Natriuretic Peptides in Coronary Disease

AIMS

C-type natriuretic peptide (CNP) is a paracrine growth factor expressed in the vascular endothelium. Although upregulated in atheromatous arteries, the predictive value of plasma CNP products for outcome in coronary disease is unknown. This study aimed to compare the prognostic value of plasma CNP products with those of other natriuretic peptides in individuals with coronary artery disease, and investigate their associations with cardiac and renal function.

METHODS AND RESULTS

Plasma concentrations of CNP and amino-terminal proCNP (NT-proCNP) were measured at baseline in 2129 individuals after an index acute coronary syndrome admission and related to cardiac and renal function, other natriuretic peptides [atrial NP (ANP) and B-type NP (BNP)] and prognosis (primary end point, mortality; secondary end point, cardiac readmission). Median follow-up was 4 years. At baseline, and in contrast to CNP, ANP, and BNP, plasma NT-proCNP was higher in males and weakly related to cardiac function but strongly correlated to plasma creatinine. All NPs were univariately associated with mortality. Resampling at 4 and 12 months in survivors showed stable concentrations of NT-proCNP whereas all other peptides declined. When studied by diagnosis (myocardial infarction, unstable angina) at index admission using a multivariate model, NT-proBNP predicted mortality and readmission in myocardial infarction. In unstable angina, only NT-proCNP predicted both mortality and cardiac readmission.

CONCLUSIONS

In contrast to the close association of NT-proBNP with cardiac function, and predictive value for outcome after myocardial infarction, plasma NT-proCNP is highly correlated with renal function and is an independent predictor of mortality and cardiac readmission in individuals with unstable angina.

Long-term outcomes of the arterial switch operation for transposition of the great arteries and ventricular septal defect and/or aortic arch obstruction

OBJECTIVES

Long-term outcomes after the arterial switch operation (ASO) for complex transposition of the great arteries (TGA) should be clarified.

METHODS

A retrospective study was conducted in patients operated on between 1982 and 1998. Overall 220 postoperative survivors, 79.1% with a ventricular septal defect, 13.2% with multiple ventricular septal defects, and 29.1% with aortic arch obstruction, were followed for 17 years (0-28 years).

RESULTS

The conditional survival rate was 96.7% [95% confidence interval (CI): 94.4-99.1] at 25 years. Late sudden death occurred in 2 asymptomatic patients. The cumulative incidence rate of death or reinterventions was 3.8% (95% CI: 2.9-4.8) at 25 years, with age at ASO <10 days and aortic regurgitation at discharge identified as independent risk factors. The cumulative incidence rate of neoaortic regurgitation was 41.6% (95% CI: 20.5-62.8) at 25 years with an aorto-pulmonary diameter mismatch at the time of the ASO, age at ASO <10 days and aortic regurgitation at discharge identified as independent risk factors. At the last follow-up, 53 patients (24.1%) had neoaortic root dilatation with an aortic sinus z-score ≥3 and 6 of them had a Bentall operation at a median delay of 14.1 years since the ASO. The only independent factors for neoaortic root dilatation were male sex and an aorto-pulmonary diameter mismatch at the time of the ASO.

CONCLUSIONS

Despite a continual rate of reinterventions, long-term survival and cardiovascular outcome are excellent after ASO for complex TGA. Dilatation of the neoaortic root and neoaortic regurgitation may be observed with time and 2 late sudden deaths occurred, justifying a close follow-up in all patients.

Aortic dilation in pediatric patients

Aortic dilation at the level of the aortic root can be caused by a variety of congenital or acquired conditions that lead to weakening of the aortic wall. In this retrospective study, we sought to determine the frequency of different associated diagnoses from children with aortic dilation seen at a single institution. A total of 377 children (68 % male) met study inclusion criteria. Patients were classified based on the suspected or confirmed associated diagnosis in one of the following categories: congenital heart disease (241/377, 64 %), chromosomal (34/377, 9 %), Marfan syndrome (26/377, 7 %), other genetic and non-genetic (22/377, 6 %), Loeys-Dietz syndrome (6/377, 2 %), and unknown (48/377, 13 %). Bicuspid aortic valve was by far the most prevalent congenital heart defect (206/241, 85 %), while Turner syndrome was the most frequent chromosomal abnormality (12/34, 35 %). Patients with Marfan syndrome were more likely to have severe dilation of the ascending aorta (p = 0.002) and to require aortic root replacement surgery (p < 0.001) compared to those in other diagnosis categories.

CONCLUSION

The differential diagnosis of aortic dilation is broad and requires a careful assessment of cardiac anatomy. Evaluation by a clinical geneticist in this setting should be strongly considered given the high frequency of associated genetic conditions.

WHAT IS KNOWN

• Aortic dilation is frequent in bicuspid aortic valve and other congenital heart defects. • Aortic dilation can be seen in several connective tissue disorders. Limited information is available in regard to the differential diagnosis of aortic dilation in children.

WHAT IS NEW

• In patients with aortic dilation concurrent congenital heart disease is frequently diagnosed. • Almost 18 % of cases in the present study had a defined presumptive or confirmed genetic diagnosis. We suggest considering a genetics evaluation in the setting of aortic dilation.

INTERACTING DISCIPLINES: Cardiac natriuretic peptides and obesity: perspectives from an endocrinologist and a cardiologist

Since their discovery in 1981, the cardiac natriuretic peptides (cNP) atrial natriuretic peptide (also referred to as atrial natriuretic factor) and brain natriuretic peptide have been well characterised in terms of their renal and cardiovascular actions. In addition, it has been shown that cNP plasma levels are strong predictors of cardiovascular events and mortality in populations with no apparent heart disease as well as in patients with established cardiac pathology. cNP secretion from the heart is increased by humoral and mechanical stimuli. The clinical significance of cNP plasma levels has been shown to differ in obese and non-obese subjects. Recent lines of evidence suggest important metabolic effects of the cNP system, which has been shown to activate lipolysis, enhance lipid oxidation and mitochondrial respiration. Clinically, these properties lead to browning of white adipose tissue and to increased muscular oxidative capacity. In human association studies in patients without heart disease higher cNP concentrations were observed in lean, insulin-sensitive subjects. Highly elevated cNP levels are generally observed in patients with systolic heart failure or high blood pressure, while obese and type-2 diabetics display reduced cNP levels. Together, these observations suggest that the cNP system plays a role in the pathophysiology of metabolic vascular disease. Understanding this role should help define novel principles in the treatment of cardiometabolic disease.

Metabolic Syndrome is Associated With Higher Wall Motion Score and Larger Infarct Size After Acute Myocardial Infarction

Background:

Infarct size is an important surrogate end point for early and late mortality after acute myocardial infarction. Despite the high prevalence of metabolic syndrome in patients with atherosclerotic diseases, adequate data are still lacking regarding the extent of myocardial necrosis after acute myocardial infarction in these patients.

Objectives:

In the present study we aimed to compare myocardial infarction size in patients with metabolic syndrome to those without metabolic syndrome using peak CK-MB and cardiac troponin I (cTnI) at 72 hours after the onset of symptoms.

Patients and Methods:

One-hundred patients with metabolic syndrome (group I) and 100 control subjects without metabolic syndrome (group II) who experienced acute myocardial infarction were included in the study. Diagnosis of metabolic syndrome was based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines published in 2001. Myocardial infarction size was compared between the two groups of patients using peak CK-MB and cTnI level in 72 hours after the onset of symptoms.

Results:

Peak CK-MB and cTnI in 72 hours were found to be significantly higher in patients with metabolic syndrome compared with control subjects (both P < 0.001). Patients with metabolic syndrome also had markedly higher wall motion abnormality at 72 hours after the onset of symptoms as assessed by echocardiographically-derived Wall Motion Score Index (WMSI) (P < 0.001). Moreover, statistically significant relationships were found between WMSI and peak CK-MB and also cTnI at 72 hours (Spearman's rho = 0.56, P < 0.001 and Spearman's rho = 0.5, P < 0.001; respectively). However, association between WMSI and left ventricular ejection fraction was insignificant (Spearman's rho = -0.05, P = 0.46).

Conclusions:

We showed that patients with metabolic syndrome have larger infarct size compared to control subjects.

N-terminal pro-brain natriuretic peptide and cardiac troponin I for the prognostic utility in elderly patients with severe sepsis or septic shock in intensive care unit: A retrospective study

BACKGROUNDS

Using biomarkers to predict mortality in patient with severe sepsis or septic shock is of importance, as these patients frequently have high mortality and unsatisfied outcome. N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI) play extremely important roles in prognostic value in the mortality of severe sepsis and septic shock.

AIMS

The present study was retrospectively designed to evaluate the predicting mortality of NT-proBNP and cTnI in elderly patients with severe sepsis or septic shock administered in the intensive care unit (ICU) and also to evaluate whether the predicting ability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score or C-reactive protein (CRP) was increased in combination with the biomarkers.

PATIENTS AND METHODS

A cohort of 430 patients (aged ≥65 years) with severe sepsis or septic shock admitted to our ICU between October 2011 and December 2013 was included in the study. Patient data including clinical, laboratory, and survival and mortality were collected. All patients were examined with NT-proBNP, cTnI, CRP, and APACHE-II score and were categorized as the survived and deceased groups according to the outcome 30 days after ICU treatment.

RESULTS

The levels of NT-proBNP and cTnI (P < .01) or CRP (P < .05) were significantly higher in the deceased group than those in the survived group. The predicting mortality of APACHE-II score alone was low but largely improved, when it was combined with both NT-proBNP and cTnI (P < .05).

CONCLUSION

The alteration of NT-proBNP and cTnI levels strongly predicated the ICU prognosis in elderly patients with severe sepsis or septic shock. N-terminal pro-brain natriuretic peptide and cTnI were superior to CRP in predicting mortality. The predicting ability of APACHE-II score was improved only when combined with NT-proBNP and cTnI.

N-Terminal Pro-Brain Natriuretic Peptide Level is Associated With Severity and Complexity of Coronary Atherosclerosis in Patients With Acute Coronary Syndrome

N-terminal pro-brain natriuretic peptide (NT-proBNP) levels are associated with short- and long-term mortality in acute coronary syndrome (ACS). We investigated whether baseline NT-proBNP levels are associated with burden of coronary atherosclerosis assessed by SYNTAX score (SXScore). We enrolled 509 patients with ACS who underwent coronary angiography. The patients were divided into tertiles according to the SXScore: low SXScore (≤ 22), intermediate SXScore (23-32), and high SXScore (≥ 33). The NT-proBNP levels demonstrated an increase from low SXScore tertile to high SXScore tertile. The NT-proBNP levels according to the SXScore tertiles are as follows: low and intermediate (median 635 vs 1635, P = .014), low and high (median 635 vs 4568, P < .001), and intermediate and high (median 1635 vs 4568, P < .001). In multivariate analysis, NT-proBNP remained an independent predictor of high SXScore (odds ratio: 2.688, 95% confidence interval: 1.315-5.494, P = .007) together with age (P = .002), neutrophil-lymphocyte ratio (P = .017), and presence of non-ST-segment elevation ACS (P = .002). The NT-proBNP was independently associated with burden of coronary atherosclerosis in patients with ACS.

Serum corin is reduced and predicts adverse outcome in non-ST-elevation acute coronary syndrome

BACKGROUND AND OBJECTIVES

The aim of the current study was to describe the role of corin, an enzyme that cleaves pro-atrial natriuretic peptide and pro-brain natriuretic peptide into their active peptides, in patients with acute coronary syndrome (ACS).

METHODS

Serum corin level was studied in patients with non-ST-elevation ACS who underwent percutaneous coronary intervention (n=152) and in control volunteers (n=103).

RESULTS

The corin level was lower in acute coronary syndrome patients (798±288 pg/ml) than in the controls (1165±613 pg/ml, p<0.0001). Those acute coronary syndrome patients who developed major adverse cardiovascular events (MACE; 60.9%) within 3 years of discharge had lower corin levels than the patients who did not experience major adverse cardiovascular events (698.16±233.67 vs. 952.1±297.81 pg/ml, p<0.0001). Using a multiple logistic regression model, corin level was a significant predictor of post-ACS MACE: p=0.0004 for 50 pg/ml steps, AUC 0.791, while p<0.0001, and AUC 0.804 using corin and brain natriuretic peptide as predictors.

CONCLUSIONS

Patients with non-ST-elevation ACS have lower serum corin levels than controls. Corin levels are lower in ACS patients who later experience MACE and thus might be predictor for MACE. This new putative biomarker may be useful, either alone or in combination with other biomarkers, for cardiovascular risk stratification assessment and outcome prediction in ACS patients.

Interleukin-6 as a predictor of cardiovascular events in troponin-negative non-ST elevation acute coronary syndrome patients

AIM

Risk stratification in acute coronary syndrome without ST-segment elevation (NSTE-ACS) and troponin-negative remains a challenge. We evaluated the value of interleukin-6 (IL-6) and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognosis assessment of low-moderate risk NSTE-ACS and troponin-negative, and whether these biomarkers could improve the predictive performance of the established thrombolysis in myocardial infarction (TIMI) risk score.

METHODS

A total of 212 low-moderate risk patients with NSTE-ACS and troponin-negative were prospectively studied. Clinical follow up at 6 months was performed for adverse endpoints.

RESULTS

A total of 28 patients (13.5%) presented adverse clinical events. Those with adverse clinical events were associated with higher levels of IL-6 [8.58 (5.13-20.95) ng/l vs. 6.12 (4.16-9.14) ng/l, p = 0.043] and NT-proBNP [275.3 (108.6-548.2) ng/l vs. 126.8 (55.97-430.20) ng/l, p = 0.046]. In moderate risk group, we observed a higher event rate in patients with troponin-negative but elevated levels of IL-6 (p = 0.024). Only elevated IL-6 (> 12.40 ng/l) was an independent predictor of adverse outcomes [hazard ratios: 3.62, 95% confidence interval (CI) 1.69-7.75, p = 0.001]. The addition of IL-6 and history of ischaemic heart disease (IHD) to TIMI risk score significantly improved both the discrimination (integrated discrimination improvement, p = 0.003) and reclassification (Clinical Net reclassification improvement, p = 0.010) of the model for adverse events.

CONCLUSIONS

Interleukin-6 is an independent predictor of adverse events in low-moderate risk patients with NSTE-ACS and troponin-negative. Its use identifies a higher risk population in moderate-risk patients. This provides together with history of IHD a better discrimination and reclassification beyond that achieved with clinical risk variables from TIMI risk score in these patients.

B-type natriuretic peptide levels predict extent and severity of coronary artery disease in non-ST elevation acute coronary syndrome and normal left ventricular function

BACKGROUND

B-type natriuretic peptide has been used as a biological marker for prognosis in patients with acute coronary syndrome (ACS). However, a relation between the quantity of BNP levels and the severity of coronary artery disease has not been systematically evaluated.

METHODS

197 patients with ACS without ST elevation with normal LV systolic function were enrolled. BNP was measured in all recruited patients within 12 h of hospitalization. All patients underwent coronary angiography. We correlated BNP levels in patients with unstable angina (USAP) and non ST-elevation myocardial infarction (NSTEMI) with angiographic disease severity including Gensini Score.

RESULTS

BNP levels were significantly higher in the NSTEMI group in comparison to the USAP Group (161 ± 149.3 vs 79.6 ± 94.2 pg/mL; p < 0.001). BNP levels rose significantly with increasing number of vessels involved (1-vessel = 51.4 ± 31.6; 2-vessels = 114.0 ± 67.8; 3 vessels = 265.4 ± 188.8 pg/mL, p < 0.001). Most importantly, BNP> 80 pg/ml was found to strongly predict the presence of Triple vessel disease (odds ratio 18.87; 95% confidence intervals 5.36-66.36), and Double vessel disease (odds ratio 3.62; 95% confidence intervals 1.75-7.47). In single vessel group, BNP was significantly higher when LAD was involved vessel (64.78 vs 49.76 pg/mL, p < 0.05). Gensini Score showed a strong correlation with BNP levels (r = 0.675, p < 0.01), and Gensini Score was significantly higher in those with BNP> 80 pg/ml (40.9 ± 29.7 vs 13.4 ± 16.5 p < 0.001).

CONCLUSION

Circulating BNP levels appear elevated in Non ST Elevation ACS, even in the absence of LV systolic dysfunction. High BNP levels are associated with multi-vessel disease and diffuse coronary atherosclerosis.

ACHTUNG-Rule: a new and improved model for prognostic assessment in myocardial infarction

BACKGROUND

THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI), PLATELET GLYCOPROTEIN IIB/IIIA IN UNSTABLE ANGINA: Receptor Suppression Using Integrilin (PURSUIT) and Global Registry of Acute Coronary Events (GRACE) scores have been developed for risk stratification in myocardial infarction (MI). The latter is the most validated score, yet active research is ongoing for improving prognostication in MI.

AIM

Derivation and validation of a new model for intrahospital, post-discharge and combined/total all-cause mortality prediction - ACHTUNG-Rule - and comparison with the GRACE algorithm.

METHODS

1091 patients admitted for MI (age 68.4 ± 13.5, 63.2% males, 41.8% acute MI with ST-segment elevation (STEMI)) and followed for 19.7 ± 6.4 months were assigned to a derivation sample. 400 patients admitted at a later date at our institution (age 68.3 ± 13.4, 62.7% males, 38.8% STEMI) and followed for a period of 7.2 ± 4.0 months were assigned to a validation sample. Three versions of the ACHTUNG-Rule were developed for the prediction of intrahospital, post-discharge and combined (intrahospital plus post-discharge) all-cause mortality prediction. All models were evaluated for their predictive performance using the area under the receiver operating characteristic (ROC) curve, calibration through the Hosmer-Lemeshow test and predictive utility within each individual patient through the Brier score. Comparison through ROC curve analysis and measures of risk reclassification - net reclassification improvement index (NRI) or Integrated Discrimination Improvement (IDI) - was performed between the ACHTUNG versions for intrahospital, post-discharge and combined mortality prediction and the equivalent GRACE score versions for intrahospital (GRACE-IH), post-discharge (GRACE-6PD) and post-admission 6-month mortality (GRACE-6).

RESULTS

Assessment of calibration and overall performance of the ACHTUNG-Rule demonstrated a good fit (p value for the Hosmer-Lemeshow goodness-of-fit test of 0.258, 0.101 and 0.550 for ACHTUNG-IH, ACHTUNG-T and ACHTUNG-R, respectively) and high discriminatory power in the validation cohort for all the primary endpoints (intrahospital mortality: AUC ACHTUNG-IH 0.886 ± 0.035 vs. AUC GRACE-IH 0.906 ± 0.026; post-discharge mortality: AUC ACHTUNG-R 0.827 ± 0.036 vs. AUC GRACE-6PD 0.811 ± 0.034; combined/total mortality: AUC ACHTUNG-T 0.831 ± 0.028 vs. AUC GRACE-6 0.815 ± 0.033). Furthermore, all versions of the ACHTUNG-Rule accurately reclassified a significant number of patients in different, more appropriate, risk categories (NRI ACHTUNG-IH 17.1%, p (2-sided) = 0.0021; NRI ACHTUNG-R 22.0%, p = 0.0002; NRI ACHTUNG-T 18.6%, p = 0.0012). The prognostic performance of the ACHTUNG-Rule was similar in both derivation and validation samples.

CONCLUSIONS

All versions of the ACHTUNG-Rule have shown excellent discriminative power and good calibration for predicting intrahospital, post-discharge and combined in-hospital plus post-discharge mortality. The ACHTUNG version for intrahospital mortality prediction was not inferior to its equivalent GRACE model, and ACHTUNG versions for post-discharge and combined/total mortality demonstrated apparent superiority. External validation in wider, independent, preferably multicentre, registries is warranted before its potential clinical implementation.