Philosophy of the New York Heart Association regarding assessment of cardiovascular function

Prognostic value of NT-proBNP added to clinical parameters to predict two-year prognosis of chronic heart failure patients with mid-range and reduced ejection fraction - A report from FAR NHL prospective registry

BACKGROUND

According to guidelines, the prognosis of patients with chronic heart failure can be predicted by determining the levels of natriuretic peptides, the NYHA classification and comorbidities. The aim our work was to develop a prognostic score in chronic heart failure patients that would take account of patients' comorbidities, NYHA and NT-proBNP levels.

METHODS AND RESULTS

A total of 1,088 patients with chronic heart failure with reduced ejection fraction (HFrEF) (LVEF<40%) and mid-range EF (HFmrEF) (LVEF 40-49%) were enrolled consecutively. Two-year all-cause mortality, heart transplantation and/or LVAD implantation were defined as the primary endpoint (EP). The occurrence of EP was 14.9% and grew with higher NYHA, namely 4.9% (NYHA I), 11.4% (NYHA II) and 27.8% (NYHA III-IV) (p<0.001). The occurrence of EP was 3%, 10% and 15-37% in patients with NT-proBNP levels ≤125 ng/L, 126-1000 ng/L and >1000 ng/L respectively. Discrimination abilities of NYHA and NT-proBNP were AUC 0.670 (p<0.001) and AUC 0.722 (p<0.001) respectively. The predictive value of the developed clinical model, which took account of older age, advanced heart failure (NYHA III+IV), anaemia, hyponatraemia, hyperuricaemia and being on a higher dose of furosemide (>40 mg daily) (AUC 0.773; p<0.001) was increased by adding the NT-proBNP level (AUC 0.790).

CONCLUSION

The use of prediction models in patients with chronic heart failure, namely those taking account of natriuretic peptides, should become a standard in routine clinical practice. It might contribute to a better identification of a high-risk group of patients in which more intense treatment needs to be considered, such as heart transplantation or LVAD implantation.

Vagal afferents inhibit the antidiuresis and antinatriuresis secondary to bilateral carotid occlusion in the chloralose-anesthetized dog

It has been reported that bilateral carotid occlusion (BCO) does not alter renal excretory function in conscious dogs on a high-salt diet with intact vagi provided renal perfusion pressure (RPP) is held constant. In contrast, low carotid sinus pressures in chloralose-anesthetized dogs with severed vagi elicit significant reductions in renal excretory function which were mediated by renal sympathetic nerves. The purpose of the present study was to investigate the influence of BCO on renal function in chloralose-anesthetized, volume expanded dogs with and without intact cervical vagi and with RPP held constant. A total of 10 dogs, volume expanded with hypotonic saline, were prepared to measure systemic arterial pressure (SAP), carotid sinus pressure (CSP), RPP, and urine flow. With the cervical vagi intact, BCO elicited an increase in SAP from 132 +/- 4 mm Hg to 172 +/- 5 mm Hg (p less than 0.01). This was associated with significant and paradoxical increases in urine flow (+35%), sodium excretion (+63%), osmolar clearance (+32%), and free water clearance (+33%). These changes were also accompanied by small but significant increases in ERBF (+11%) and GFR (+12%). Bilateral cervical vagotomy alone (Vx) increased SAP (129 +/- 6 mm Hg to 146 +/- 5 mm Hg, p less than 0.05). Urine flow and free water clearance were decreased but sodium excretion and osmolar clearance were increased. No change in ERBF or GFR was measured. BCO after Vx elicited a greater increase in SAP as compared to BCO alone (194.5 +/- 6.2 mm Hg) which was accompanied by significant decreases in urine flow (-60%), sodium excretion (-55%), osmolar clearance (-43%), ERBF (-13%), and GFR (-19%). Therefore, the results of this study demonstrate that the contrasting influences of BCO on renal function reported previously in conscious and anesthetized animal models may be due to the presence or absence of the inhibitory influences of afferent fibers contained in the cervical vagi, probably cardiac in origin.