Sex Differences in the Prognostic Power of Brain Natriuretic Peptide and N-Terminal Pro-Brain Natriuretic Peptide for Cardiovascular Events - The Japan Morning Surge-Home Blood Pressure Study

Sizing and mending of appendicular muscle mass for hydration during the 12-lead electrocardiogram: True incidence of sarcopenia in heart failure

BACKGROUND

Our aim was to develop and evaluate a method for the measurement of muscle mass during the 12-channel electrocardiogram (ECG), to determine the incidence of sarcopenia in patients with overhydration and to correct it for congestion.

METHODS

A 12-channel ECG that simultaneously provided multifrequency segmental impedance data was used to measure total body water (TBW), extracellular water (ECW), ECW/TBW ratio and appendicular muscle mass (AppMM), validated by whole-body dual-energy X-ray absorptiometry. The mean ECW/TBW ratio was 0.24 ± 0.018 (SD) and 0.25 ± 0.016 for young (age range 20-25 years) healthy males (n = 77) and females (n = 88), respectively. The deviation of the ECW/TBW ratio from this mean was used to correct AppMM for excess ECW ('dry AppMM') in 869 healthy controls and in 765 patients with chronic heart failure (CHF) New York Heart Association classes II-IV. The association of AppMM and dry AppMM with grip strength was also examined in 443 controls and patients.

RESULTS

With increasing N-terminal pro-brain natriuretic peptide (NT-proBNP), a continuous decline of AppMM indices is observed, which is more pronounced for dry AppMM indices (for males with NT-proBNP < 125 pg/mL: AppMM index mean = 8.4 ± 1.05, AppMM index dry mean = 8.0 ± 1.46 [n = 201, P < 0.001]; for females with NT-proBNP < 150 pg/mL: AppMM index mean = 6.4 ± 1.0, AppMM index dry mean = 5.8 ± 1.18 [n = 198, P < 0.001]; for males with NT-proBNP > 1000 pg/mL: AppMM index mean = 7.6 ± 0.98, AppMM index dry mean = 6.2 ± 1.11 [n = 137, P < 0.001]; and for females with NT-proBNP > 1000 pg/mL: AppMM index mean = 5.9 ± 0.96, AppMM index dry mean = 4.8 ± 0.94 [n = 109, P < 0.001]). The correlation between AppMM and upper-body AppMM and grip strength (r-value) increased from 0.79 to 0.83 (P < 0.001) and from 0.80 to 0.84 (P < 0.001), respectively, after correction (n = 443). The decline of AppMM with age after correction for ECW is much steeper than appreciated, especially in males: In patients with CHF and sarcopenia, the incidence of sarcopenia may be up to 30% higher after correction for ECW excess according to the European (62% vs. 57%, for males, and 43% vs. 31%, for females) and Foundation for the National Institutes of Health (FNIH) (56% vs. 46%, for males, and 54% vs. 38%, for females) consensus guidelines.

CONCLUSIONS

The incidence of sarcopenia in CHF as defined by the European Working Group on Sarcopenia and FNIH consensus may be up to 30% higher after correction for ECW excess. This correction improves the correlation between muscle mass and strength. The presented technology will facilitate, on a large scale, screening for sarcopenia, help identify mechanisms and improve understanding of clinical outcomes.

Prognostic significance of serial N-terminal pro-B-type natriuretic peptide levels in patients with acute myocardial infarction: A prospective study

OBJECTS

This study aimed to investigate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at different sampling times and prognosis in patients with acute myocardial infarction (AMI) undergoing emergency percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Between March 2017 and January 2020, 1,105 patients with AMI who underwent emergency PCI were included. NT-proBNP levels were measured on days 0, 1, 2, 3, and 7. A composite of all-cause death, MI recurrence (reMI), and rehospitalization due to heart failure, known as major adverse cardiovascular events (MACE), was recorded. During the 36.8-month follow-up, 175 patients (15.8%) experienced MACEs. When patients were grouped based on quartiles of NT-proBNP levels on days 0 and 7, the results demonstrated that patients in quartile 4 showed a substantially increased MACE risk compared to those in quartile 1 (hazard ratio [HR] 2.27, 95% confidence interval [CI]:1.27-4.08, P = .006; HR 2.20, 95%CI:1.23-3.94, P = .008). There were U-shaped relationships between the HR for MACE and NT-proBNP levels on days 2, 3, and 7, as well as peak NT-proBNP (P _{for nonlinearity} = .007, .006, .004, and .009, respectively). A similar relationship was observed in the HR for reMI and NT-proBNP levels on days 2 and 3. For MACE at 3 years, serial NT-proBNP levels improved the predictive accuracy of the Global Registry of Acute Coronary Events (GRACE) risk score (concordance index [C-index]: 0.711; continuous net reclassification improvement [NRI]: 0.192, 95% CI: 0.022-0.445; integrated discrimination improvement [IDI]: 0.034, 95% CI: 0.016-0.064). For all-cause death at 3 years, the combination of NT-proBNP and GRACE score showed excellent performance, with C-index, continuous NRI, and IDI values of 0.801, 0.373 (95%CI: 0.072-0.853), and 0.051 (95%CI: 0.025-0.091), respectively.

CONCLUSIONS

Early and sequential measurement of NT-proBNP levels could assist in predicting MACE risk. Moreover, the relationship between MACE risk and NT-proBNP levels was U-shaped.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov NCT: 03593928.

The joint association of diabetes status and NT-ProBNP with adverse cardiac outcomes in patients with non-ST-segment elevation acute coronary syndrome: a prospective cohort study

AIMS

To examine the joint association of diabetes status and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with subsequent risk of major adverse cardio-cerebral events (MACCEs) and all-cause mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

METHODS

A total of 7956 NSTE-ACS patients recruited from the Cardiovascular Center Beijing Friendship Hospital Database Bank were included in this cohort study. Patients were divided into nine groups according to diabetes status (normoglycemia, prediabetes, diabetes) and NT-proBNP tertiles (< 92 pg/ml, 92-335 pg/ml, ≥ 336 pg/ml). Multivariable Cox proportional hazards models were used to estimate the individual and joint association of diabetes status and NT-proBNP with the risk of MACCEs and all-cause mortality.

RESULTS

During 20,257.9 person-years of follow-up, 1070 MACCEs were documented. In the fully adjusted model, diabetes and a higher level of NT-proBNP were independently associated with MACCEs risk (HR 1.42, 95% CI: 1.20-1.68; HR 1.72, 95% CI: 1.40-2.11) and all-cause mortality (HR 1.37, 95% CI: 1.05-1.78; HR 2.80, 95% CI: 1.89-4.17). Compared with patients with normoglycemia and NT-proBNP < 92 pg/ml, the strongest numerical adjusted hazards for MACCEs and all-cause mortality were observed in patients with diabetes and NT-proBNP ≥ 336 pg/ml (HR 2.67, 95% CI: 1.83-3.89; HR 2.98, 95% CI: 1.48-6.00). The association between MACCEs and all-cause mortality with various combinations of NT-proBNP level, HbA1c, and fasting plasma glucose was studied.

CONCLUSIONS

Diabetes status and elevated NT-proBNP were independently and jointly associated with MACCEs and all-cause mortality in patients with NSTE-ACS.

Sex and N-terminal pro B-type natriuretic peptide: The potential mediating role of iron biomarkers

BACKGROUND

Levels of N-terminal pro B-type natriuretic peptide (NT-proBNP), a marker of heart failure and cardiovascular risk, are generally higher in women than men. We explored whether iron biomarkers mediate sex differences in NT-proBNP levels.

METHODS

We included 5,343 community-dwelling individuals from the Prevention of Renal and Vascular Endstage Disease study. With linear regression analyses, we investigated the association of sex and iron biomarkers with NT-proBNP levels, independent of adjustment for potential confounders. The assessed iron biomarkers included ferritin, transferrin saturation (TSAT), hepcidin, and soluble transferrin receptor (sTfR). Next, we performed mediation analyses to investigate to which extent iron biomarkers influence the association between sex and NT-proBNP.

RESULTS

Of the included 5,343 participants, the mean standard deviation age was 52.2 ± 11.6 years and 52% were females. After adjustment for potential confounders, women compared to men, had higher NT-proBNP (β = 0.31; 95%CI = 0.29, 0.34), but lower ferritin (β = -0.37; 95%CI = -0.39, -0.35), hepcidin (β = -0.22, 95%CI = -0.24, -0.20), and TSAT (β = -0.07, 95% CI = -0.08, -0.06). Lower ferritin (β = -0.05, 95%CI = -0.08, -0.02), lower hepcidin (β = -0.04, 95%CI = -0.07, -0.006), and higher TSAT (β = 0.07; 95%CI = 0.01, 0.13) were associated with higher NT-proBNP. In mediation analyses, ferritin and hepcidin explained 6.5 and 3.1% of the association between sex and NT-proBNP, respectively, while TSAT minimally suppressed (1.9%) this association.

CONCLUSION

Our findings suggest that iron biomarkers marginally explain sex differences in levels of NT-proBNP. Future studies are needed to explore causality and potential mechanisms underlying these pathways.

Circulating cardiovascular biomarkers during and after preeclampsia: Crosstalk with placental function?

Cardiovascular disease (CVD) is the leading cause of death in women, yet sex-specific risk factors remain understudied. Preeclampsia and other adverse pregnancy outcomes imply an increased maternal cardiovascular risk. We hypothesized that cardiac troponin T (cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) are increased in such pregnancies and correlate with markers of placental dysfunction. We also investigated these cardiovascular biomarkers 1 or 3 years postpartum. Prior to delivery, we included serum from 417 pregnant women: 55 early-onset preeclampsia (EO-PE), 63 late-onset preeclampsia (LO-PE), 30 gestational hypertension (GH) and 269 healthy controls. Postpartum, we included 341 women 1 or 3 years after delivery: 26 EO-PE, 107 LO-PE, 61 GH, and 147 healthy pregnancies. Prior to delivery, median cTnT and NT-proBNP concentrations were higher in women with EO-PE, LO-PE, or GH than in controls. Median GDF-15 was higher in EO-PE and LO-PE compared to controls. Postpartum, GDF-15 was elevated in women with previous EO-PE. Markers of placental dysfunction correlated with CVD biomarkers in pregnancy, but not postpartum. Our findings underscore the cardiovascular burden of hypertensive disorders of pregnancy and the crosstalk with placental function. The upregulation of circulating GDF-15 following early-onset preeclampsia is in line with the epidemiological excessive risk of premature CVD in this group of women. GDF-15 may be explored for targeting postpartum women with most to gain from intensified preventive follow-up for CVD.

Cardiovascular biomarkers in pregnancy with diabetes and associations to glucose control

AIM

Cardiovascular disease (CVD) is a leading cause of death in both men and women. Type 1 and 2 diabetes mellitus (DM1 and DM2) are well-known risk factors for CVD. In addition, gestational diabetes mellitus (GDM) is a female sex-specific risk factor for CVD. Here, we measure circulating concentrations of cardiac troponin T (cTNT), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) during pregnancy-a window of time often referred to as a cardiovascular stress test for women.

METHODS

This study utilized data from 384 pregnant women: 64 with DM1, 16 with DM2, 35 with GDM and 269 euglycemic controls. Blood was predominantly sampled within a week before delivery. Cardiovascular biomarker concentrations were measured in serum using electrochemiluminescence immunoassay.

RESULT

Circulating cTnT levels were higher in women with DM1, DM2 and GDM as compared to controls, whereas NT-proBNP and GDF-15 levels were only increased in women with DM1. Glucose dysregulation, assessed by third trimester HbA1c levels, positively correlated with all three CVD biomarker levels, whereas pregestational body mass index correlated negatively with GDF-15.

CONCLUSIONS

Our results support the presence of myocardial affection in women with diabetic disorders during pregnancy. Although pregestational DM1 in this study was associated with the most adverse CVD biomarker profile, women with GDM displayed an adverse cTnT profile similar to what we found in women with pregestational DM2. This supports that women with GDM should be offered long-term intensified cardiovascular follow-up and lifestyle advice following delivery, similarly to the well-established CV follow-up of women with pregestational DM.

New Conversion Formula Between B-Type Natriuretic Peptide and N-Terminal-Pro-B-Type Natriuretic Peptide - Analysis From a Multicenter Study

BACKGROUND

Although B-type natriuretic peptide (BNP) and N-terminal (NT)-proBNP are commonly used markers of heart failure, a simple conversion formula between these peptides has not yet been developed for clinical use.Methods and Results: A total of 9,394 samples were obtained from Nara Medical University, Jichi Medical University, and Osaka University. We randomly selected 70% for a derivation set to investigate a conversion formula from BNP to NT-proBNP using estimated glomerular filtration rate (eGFR) and body mass index (BMI); the remaining 30% was used as the internal validation set and we used a cohort study from Nara Medical University as an external validation set. Multivariate linear regression analysis revealed a new conversion formula: log NT-proBNP = 1.21 + 1.03 × log BNP - 0.009 × BMI - 0.007 × eGFR (r²=0.900, P<0.0001). The correlation coefficients between the actual and converted values of log NT-proBNP in the internal and external validation sets were 0.942 (P<0.0001) and 0.891 (P<0.0001), respectively. We applied this formula to samples obtained from patients administered with sacubitril/valsartan. After treatment initiation, NT-proBNP levels decreased and actual BNP levels increased. However, the calculated BNP levels decreased roughly parallel to the NT-proBNP levels.

CONCLUSIONS

This new and simple conversion formula of BNP and NT-proBNP with eGFR and BMI is potentially useful in clinical practice.

Differences in NT-proBNP Response and Prognosis in Men and Women With Heart Failure With Reduced Ejection Fraction

Background

NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) is a prognostic biomarker in heart failure (HF) with reduced ejection fraction. However, it is unclear whether there is a sex difference in NT‐proBNP response and whether the therapeutic goal of NT‐proBNP ≤1000 pg/mL has equivalent prognostic value in men and women with HF with reduced ejection fraction.

Methods and Results

In a secondary analysis of the GUIDE‐IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment) trial we analyzed trends in NT‐proBNP and goal attainment by sex. Differences in clinical characteristics, HF treatment, and time to all‐cause death or HF hospitalization were compared. Landmark analysis at 3 months determined the prognostic value of early NT‐proBNP goal achievement in men and women. Of the 286 (32%) women and 608 (68%) men in the GUIDE‐IT trial, women were more likely to have a nonischemic cause and shorter duration of HF. Guideline‐directed medical therapy was less intense over time in women. The absolute NT‐proBNP values were consistently lower in women; however, the change in NT‐proBNP and clinical outcomes were similar. After adjustment, women achieving the NT‐proBNP goal had an 82% reduction in death or HF hospitalization compared with a 59% reduction in men.

Conclusions

Men and women with HF with reduced ejection fraction had a similar NT‐proBNP response despite less intensive HF treatment among women. However, compared with men, the early NT‐proBNP goal of ≤1000 pg/mL had greater prognostic value in women. Future efforts should be aimed at intensifying guideline‐directed medical therapy in women, which may result in greater NT‐proBNP reductions and improved outcomes in women with HF with reduced ejection fraction.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01685840.

Cardiac natriuretic peptides

Investigations into the mixed muscle-secretory phenotype of cardiomyocytes from the atrial appendages of the heart led to the discovery that these cells produce, in a regulated manner, two polypeptide hormones - the natriuretic peptides - referred to as atrial natriuretic factor or atrial natriuretic peptide (ANP) and brain or B-type natriuretic peptide (BNP), thereby demonstrating an endocrine function for the heart. Studies on the gene encoding ANP (NPPA) initiated the field of modern research into gene regulation in the cardiovascular system. Additionally, ANP and BNP were found to be the natural ligands for cell membrane-bound guanylyl cyclase receptors that mediate the effects of natriuretic peptides through the generation of intracellular cGMP, which interacts with specific enzymes and ion channels. Natriuretic peptides have many physiological actions and participate in numerous pathophysiological processes. Important clinical entities associated with natriuretic peptide research include heart failure, obesity and systemic hypertension. Plasma levels of natriuretic peptides have proven to be powerful diagnostic and prognostic biomarkers of heart disease. Development of pharmacological agents that are based on natriuretic peptides is an area of active research, with vast potential benefits for the treatment of cardiovascular disease.