N-terminal pro-B-type natriuretic Peptide predicts significant coronary artery lesion in the unstable angina patients with normal electrocardiogram, echocardiogram, and cardiac enzymes

Predictive value of N-terminal-Pro brain natriuretic peptide in the detection of coronary artery disease in patients with positive myocardial perfusion imaging

Background: N-terminal pro-brain natriuretic peptide (NT-ProBNP) increases during myocardial ischemia and has a potential for the diagnosis of patients with coronary artery disease (CAD). We aimed to determine the incremental diagnostic value of NT-ProBNP in the selection of patients with positive myocardial perfusion imaging (MPI) for coronary angiography. We also tested the association between the level of NT-ProBNP and severity of CAD based on the vessel score and Gensini score.

Methods: In this cross-sectional study, stable angina patients with positive MPI who were assessed by coronary angiography in Imam Khomeini Hospitalwere enrolled. After the collection of demographic and clinical data, NT-ProBNP was measured in all patients on the day of coronary angiography, and its association with the presence of CAD, vessel score and Gensini score was tested.

Results: We enrolled 170 patients (mean age61.2±10.1 years, 86 males (50.6%)). Seventy-two (42.3%) patients had at least one stenotic vessel. NT-Pro BNP was significantly higher in the CAD-positive group (OR=1.01, 95% CI: 1.00-1.02; p=0.008) and could independently predict the presence of CAD at a cut-off point of 69.5, with a sensitivity of 55.6%, specificity of 82.5% and diagnostic accuracy of 61.7%. The Gensini score had a modest correlation with NT-Pro BNP (r=0.60, p<0.001). The combination of MPI result and NT-Pro BNP could predict the presence of CAD (OR=14.57, 95% CI: 4.28, 49.56; p<0.001).

Conclusion: Serum level of NT-Pro BNP alone and its combination with the results of MPI can significantly predict the presence of CAD and therefore, highlights the need for performing coronary angiography.

The severity of coronary artery disease and reversible ischemia revealed by N-terminal pro-brain natriuretic peptide in patients with unstable angina and preserved left ventricular function

The association between the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and the severity of coronary artery disease (CAD) diagnosed by coronary angiography and other approaches has been investigated. The clinical application of NT-proBNP is restricted by the drawbacks of these techniques now available in screening out patients who need intensive or conservative treatment. Fractional flow reserve (FFR) is superior to coronary angiography and other functional indicators. Accordingly, we designed to investigate the association between NT-proBNP and myocardial ischemia from the perspective of anatomy and physiology in patients with unstable angina and preserved left ventricular function. Plasma samples were collected from 110 patients and NT-proBNP levels were measured by radioimmunoassay. The severity of coronary artery stenosis in patients was measured by coronary angiography and FFR. Stenosis ≥50% in the left main artery or stenosis of 70%, and fractional flow reserve (FFR) ≤0.80 in one or more coronary branches with diameter ≥2mm were defined as "positive", which require revascularization. NT-proBNP levels increased progressively between patients with negative and positive angiographic results (p<0.05), and between FFR-negative and FFR-positive patients (p<0.05). A significant correlation was observed between logNT-proBNP and logGS (GS=Gensini score, p<0.001). NT-proBNP level serves as a predictor of positive results of angiographic stenosis and FFR, with the area under the receiver operating characteristic curve being 0.697 and 0.787, respectively. NT-proBNP levels are correlated with the severity of anatomic coronary obstruction and inducible myocardial ischemia, but NT-proBNP per se is insufficient to identify clinically significant angiographic and physiological stenoses.

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

There is a substantial need for a diagnostic tool to aid in the early diagnosis of heart failure and in the recognition of those at risk for its development, as well as in guidance of therapy. Testing for amino-terminal pro-brain natriuretic peptide (NT-proBNP) has been recognized to have utility in the diagnosis, prognosis and management of heart failure. In addition, numerous other applications for NT-proBNP testing are now recognized, such as evaluation of patients with heart disease in the absence of heart failure, as well as the diagnostic and prognostic evaluation of patients with acute coronary syndromes or pulmonary thromboembolism.

Relation between N-terminal pro-B-type natriuretic peptide and coronary plaque components in patients with acute coronary syndrome: virtual histology-intravascular ultrasound analysis

BACKGROUND

The N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is a sensitive indicator of hemodynamic stress and its increased level is associated with higher mortality in acute coronary syndrome (ACS) patients. Virtual histology-intravascular ultrasound (VH-IVUS) can provide quantitative information on plaque components.

METHODS

We measured preprocedural serum NT-pro-BNP levels in 156 ACS patients with preserved left ventricular systolic function and normal serum creatinine. VH-IVUS classified the color-coded tissue into four major components: fibrotic, fibro-fatty, dense calcium, and necrotic core (NC). Thin-cap fibroatheroma (TCFA) was defined as focal, NC-rich (>or=10% of the cross-sectional area) plaques being in contact with the lumen in a plaque burden of at least 40%. We divided the patients into two groups according to the NT-pro-BNP levels [group I: >or=200 pg/ml (n = 58) vs. group II: <200 pg/ml (n = 98)].

RESULTS

The percent areas of NC at the minimum lumen site (19.8+/-13.1% vs. 15.2+/-11.1%, P = 0.027) and at the largest NC site (24.7+/-10.3% vs. 19.2+/-11.4%, P = 0.015) were significantly greater in group I than in group II. Percent NC volume was significantly greater in group I than in group II (15.8+/-8.1% vs. 10.1+/-9.1%, P = 0.008). The total number of TCFAs was 38 in group I and 56 in group II. The presence of at least one TCFA (58 vs. 38%, P = 0.009) and multiple TCFAs (25 vs. 10%, P = 0.005) within culprit lesions were observed more frequently in group I than in group II. The TCFAs were located more in proximal in group I than in group II [the length from coronary ostium to TCFA: 10.8+/-7.6 mm in group I vs. 25.7+/-16.3 mm in group II (P<0.001)]: 85% of TCFAs was located within 20 mm from coronary ostium in group I; conversely only 36% of TCFAs was located within 20 mm from coronary ostium in group II (P<0.001).

CONCLUSION

VH-IVUS analysis shows that ACS patients with high NT-pro-BNP levels had more vulnerable plaque component (more NC-containing lesions and higher frequency of culprit lesion TCFAs) and had more proximally located TCFAs.

B-type natriuretic peptide release and left ventricular filling pressure assessed by echocardiographic study after subarachnoid hemorrhage: a prospective study in non-cardiac patients

INTRODUCTION

Serum B-type natriuretic peptide (BNP) is frequently elevated after subarachnoid hemorrhage (SAH), but whether this high BNP level is related to transient elevation of left ventricular filling pressure (LVFP) is unknown. However, in patients with preexistent cardiac pathologies, it is impossible to differentiate between BNP elevation caused by chronic cardiac abnormalities and BNP related to acute neurocardiac injury.

METHODS

All adult patients with SAH admitted to our intensive care unit were eligible. Patients were excluded for the following reasons: admission >48 hours after aneurysm rupture, pre-existing hypertension, or cardiac disease. Levels of BNP and cardiac troponin Ic were measured daily for 7 days. Echocardiography was performed by a blinded cardiologist on days 1, 2, and 7. Doppler signals from the mitral inflow, tissue Doppler, and the color M-mode-derived flow propagation velocity (FPV) were obtained to assess echo-estimated LVFP.

RESULTS

During a 3-year period, sixty-six consecutive patients with SAH were admitted. Thirty one patients were studied. The BNP level was >100 ng/L in 25 patients (80%) during the first 3 days, with a peak on day 2 (median, 126 ng/L) followed by a gradual decrease (median variation days 1 to 7, 70%). All patients had an ejection fraction >50%. Early transmitral velocity/tissue Doppler mitral annular early diastolic velocity was low: 5.4 (+/- 1.5) on day 1, 5.8 (+/- 1.2) on day 2, and 5.1 (+/- 0.9) on day 7. Early transmitral velocity/FPV was also low: 1.27 (+/- 0.4), 1.25 (+/- 0.3), and 1.1 (+/- 0.2) on days 1, 2, and 7, respectively. Cardiac troponin Ic levels ranged from 0 to 3.67 microg/L and were correlated with BNP (r = 0.63, P < 0.01).

CONCLUSIONS

BNP rises gradually over two days and return to normal within a week after SAH. Its release is associated with myocardial necrosis, but is unrelated to elevated LVFP assessed by echocardiography.

Usefulness of preprocedural N-terminal pro-brain natriuretic peptide in predicting angiographic no-reflow phenomenon during stent implantation in patients with ST-segment elevation acute myocardial infarction

The no-reflow phenomenon after primary percutaneous coronary intervention (PCI) is associated with larger infarct size, worse functional recovery, and higher incidence of complication after acute ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the relation between preprocedural N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) and angiographic no-reflow phenomenon. We measured preprocedural serum NT-pro-BNP level in 159 consecutive patients with acute STEMI (aged 63 +/- 12 years; 72% men) before PCI. Angiographic no-reflow after PCI was defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade <3. Baseline characteristics, including time from chest pain onset, between the no-reflow (n = 67) and normal-reflow groups (n = 92) were similar. NT-pro-BNP was significantly higher in the no-reflow group than the normal reflow group (1,982 +/- 3,314 vs 415 +/- 632 pg/ml; p = 0.005). Also, high-sensitivity C-reactive protein, monocytes, and troponin-T were significantly higher in the no-reflow group than the normal-reflow group. In the no-reflow group, NT-pro-BNP was much higher in patients with TIMI flow grade 0 (n = 41; 2,290 +/- 3,495 pg/ml) than those with TIMI grade 1 or 2 (n = 26; 1,575 +/- 2,340 pg/ml), but without significant difference. The area under the receiver-operating characteristic curve for NT-pro-BNP was 0.78, and the optimal cut-off value identified using receiver-operating characteristic curve analysis was 500 pg/ml. At the standard cut-off value of >500 pg/ml, increased NT-pro-BNP showed a high probability of no-reflow phenomenon (odds ratio 4.42, 95% confidence interval 1.15 to 17.00, p = 0.028). In conclusion, preprocedural NT-pro-BNP may be a strong predictor of the development of no-reflow phenomenon after PCI in patients with acute STEMI.

Usefulness of serum N-terminal pro-brain natriuretic peptide to predict in-stent restenosis in patients with preserved left ventricular function and normal troponin I levels

The level of N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is a strong predictor of mortality in patients with acute coronary syndrome and may be a strong prognostic marker in patients with chronic coronary artery disease. We investigated whether NT-pro-BNP could predict in-stent restenosis (ISR) in asymptomatic patients with preserved left ventricular (LV) systolic function who underwent percutaneous coronary intervention. We measured serum NT-pro-BNP levels in 249 patients (61 +/- 9 years of age; 73% men) with preserved LV systolic function (ejection fraction >50%) who underwent follow-up coronary angiography. Initial diagnoses were stable angina in 50 (20%), unstable angina in 133 (53%), and myocardial infarction in 66 (27%). Baseline characteristics between groups with ISR (n = 92) and without ISR (n = 157) were similar. The level of NT-pro-BNP was higher in patients with ISR than in those without ISR (222 +/- 327 vs 94 +/- 136 pg/ml, p = 0.001). In the ISR group, NT-pro-BNP level was higher in patients with left anterior descending coronary artery ISR (n = 53, 312 +/- 479 pg/ml) than in those with left circumflex coronary artery ISR (n = 19, 115 +/- 98 pg/ml, p = 0.018). At the standard cutoff of >200 pg/ml, a high NT-pro-BNP level indicated a high probability of ISR (odds ratio 2.18, 95% confidence interval 1.0 to 4.5, p = 0.038). In multivariate analysis, NT-pro-BNP level was an independent predictor for ISR. In conclusion, NT-pro-BNP could be a predictor of ISR in asymptomatic patients with preserved LV systolic function.

Evaluation of cardiac involvement following major orthopedic surgery

BACKGROUND

Cardiovascular morbidity is frequent after non-cardiac surgery and the early recognition of cardiac involvement is an essential tool for clinical risk stratification and management. The aim of this study was to investigate the behavior of traditional and emerging cardiac markers, including NT-prohormone-brain natriuretic peptide (NT-proBNP) and ischemia-modified albumin (IMA), in the perioperative period in patients undergoing major uncomplicated orthopedic surgery.

METHODS

A total of 37 patients undergoing major orthopedic surgery were longitudinally evaluated for NT-proBNP, IMA, cardiac troponin T (cTnT), creatine kinase isoenzyme MB and myoglobin 3 h before surgery and 4 and 72 h thereafter.

RESULTS

NT-proBNP values were significantly increased at 72 h postoperative compared to both 3 h preoperative and 4 h postoperative (NT-proBNP: 20 vs. 4.5 pmol/L, p<0.001 and 20 vs. 5.9 pmol/L, p<0.001). IMA levels were significantly increased at 4 and 72 h postoperative vs. 3 h preoperative (132 vs. 113 kU/L, p=0.02 and 151 vs. 113 kU/L, p<0.001). In a stepwise regression model, the perioperative liquid amount and degree of modification in postoperative creatinine levels (delta-creatinine) were independently related to the NT-proBNP increase.

CONCLUSIONS

The significant increase observed in NT-proBNP suggests that patients undergoing major uncomplicated orthopedic surgery may develop subclinical cardiac stress, presumably attributable to the considerable infusion of liquids. The clinical significance of this finding deserves further investigation, especially in patients at higher risk of heart failure.

N-Terminal ProBNP Levels Can Predict Cardiac Failure After Cardiac Surgery

BACKGROUND

The aim of this study was to evaluate the relationship between the preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) level and the need for the inotropic support in the early postoperative period of patients undergoing coronary artery bypass graft surgery.

METHODS AND RESULTS

The patients were divided into 2 groups: NT-proBNP level<220 pg/ml (group A, n=26) or >220 pg/ml (group B, n=26). The normal value for NT-proBNP level was accepted as <220 pg/ml. The cardiac output was measured on arrival in intensive care and at the 16th hour. The groups were compared with respect to early postoperative hemodynamic measurements, urinary output, use of inotropic agents and requirement for additional cardiac-assist devices. Left ventricular ejection fraction, cardiac output and cardiac index were lower in group B and inotropic agents were used for a longer period of time and at higher doses in this group (p<0.05).

CONCLUSION

Measurement of the NT-proBNP level in the period before cardiac surgery can indicate the postoperative prognosis of the patient and may be a predictor of the need for postoperative inotropic treatment.

Direct Comparison of Brain Natriuretic Peptide (BNP) and N-Terminal Pro-BNP Secretion and Extent of Coronary Artery Stenosis in Patients With Stable Coronary Artery Disease

BACKGROUND

It is unclear whether coronary artery stenosis affects the secretion of N-terminal pro-brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) from the heart independent of ventricular dysfunction. Therefore, this study evaluated the relationship between BNP and NT-proBNP secretion, plasma levels and the severity of coronary artery stenosis in patients with stable coronary artery disease (CAD).

METHODS AND RESULTS

Plasma levels of BNP and NT-proBNP in the aortic root (AO) and coronary sinus (CS) in 251 consecutive patients with stable CAD were measured. The transcardiac increase of NT-proBNP was significantly increased with the severity of coronary artery stenosis (p=0.012), but that of BNP was not (p=0.116). The molar ratio of the (CS-AO) NT-pro-BNP/(CS-AO) BNP increased with the severity of coronary artery stenosis (p=0.019) and decreased after coronary revascularization (p=0.018, n=36). Step-wise multivariate linear regression analyses were used to detect independent predictors of the (CS-AO) NT-proBNP among 10 variables including hemodynamic parameters and the Gensini score, which is a measure of the extent and severity of CAD. Among these variables, left ventricular ejection fraction (p<0.0001), left ventricular end-diastolic pressure (p=0.003) and log Gensini score (p=0.008) were significant independent predictors.

CONCLUSION

These findings suggest that the transcardiac increase of NT-proBNP from the heart increases with the severity of coronary artery stenosis independent of hemodynamic overload, and plasma NT-proBNP may be superior to BNP to assess disease severity in CAD patients.

Evaluation of cardiac laboratory markers in patients with systemic sclerosis

OBJECTIVES

Myocardial involvement is frequent in systemic sclerosis, but symptoms are usually delayed and non-specific, thus often misrecognized. The aim of this study was the evaluation of the early subclinical cardiac involvement in patients with systemic sclerosis by means of non-invasive laboratory cardiac markers.

DESIGN AND METHODS

Cardiac troponin T (cTnT), ischemia modified albumin (IMA) and NT-prohormone-brain natriuretic peptide (NT-proBNP) were measured in 40 female patients with systemic sclerosis and in 40 matched healthy controls.

RESULTS

Patients with systemic sclerosis displayed significantly increased concentrations of serum IMA (106 versus 93.5 kunits/l, P < 0.0001) and NT-proBNP (89 versus 37 pg/ml, P < 0.0001), whereas no significant differences could be observed in both IMA and NT-proBNP values in limited versus diffuse pattern of disease.

CONCLUSIONS

The increased levels of NT-proBNP and IMA could be considered a sign of early myocardial involvement, warranting further heart examination and a regular follow-up.

Difference in Elevation of N-Terminal Pro-BNP and Conventional Cardiac Markers Between Patients With ST Elevation vs Non-ST Elevation Acute Coronary Syndrome

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in patients with acute coronary syndrome (ACS), and is a powerful predictor of long-term mortality. Differences in the clinical utility and pathophysiological implication of NT-proBNP and conventional cardiac markers in patients with ST elevation (STE) vs non-STE (NSTE) ACS were investigated in the present study.

METHODS AND RESULTS

Ninety consecutive patients admitted with acute chest pain and a diagnosis of unstable angina or acute myocardial infarction were analyzed. Patients with >or=Killip class II were excluded to focus on the effect of myocardial ischemia on the release of cardiac markers. The markers were measured on admission and analyzed according to the time from onset. Conventional cytosolic marker (creatine kinase-MB) and myofibril marker (troponin T: TnT) were both significantly higher in STE-ACS patients compared with NSTE-ACS patients. Conversely, NT-proBNP was significantly higher in NSTE-ACS patients than STE-ACS especially within 3 h of onset, suggesting a larger ischemic insult despite the smaller extent of myocardial necrosis compared with STE-ACS patients. There was no significant correlation between NT-proBNP level and left ventricular ejection fraction (LVEF) obtained at acute-phase echocardiography in either NSTE-ACS patients (LVEF 57.7+/-11.2%) or STE-ACS patients (LVEF 55.1+/-12.7%). Comparison between NT-proBNP and TnT levels revealed a marked difference of elevations, with significantly augmented elevation of NT-proBNP (p<0.001) in NSTE-ACS patients as compared with prominent elevation of TnT in STE-ACS patients.

CONCLUSIONS

NT-proBNP is an early sensitive marker of myocardial ischemia that rises much higher in the earlier phase as compared with conventional markers of myocardial damage, especially in NSTE-ACS patients.