Relationship between N-terminal pro-brain natriuretic peptide, obesity and the risk of heart failure in middle-aged German adults

Effect of body mass index on N-terminal pro-brain natriuretic peptide values in patients with heart failure

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker used for the diagnosis of heart failure. There is a relationship between NT-proBNP levels and body mass index (BMI). The study aimed to explore the impact of BMI on NT-proBNP concentrations and to examine whether other factors independent of or combined with BMI affect NT-proBNP values in patients with heart failure.

RESULTS

A total of 293 participants were recruited. The mean age was 68.9 ± 13.2 years, males accounted for 46.4% of the total cohort, the mean BMI was 23.1 ± 4.0 kg/m2, and the median NT-proBNP level was 3776 (1672-8806) pg/ml. There was an inverse relationship between BMI and log NT-proBNP (r = - 0.29; p < 0.001, Spearman correlation). Each standard deviation increase in BMI (4 kg/m2) was associated with a 7% decrease in NT-proBNP values in the total cohort. The independent inverse determinants of NT-proBNP other than BMI were male gender and eGFR, while the variables directly correlated to NT-proBNP were LVEF ≤ 40% and NYHA class III-IV heart failure.

CONCLUSIONS

There is an inverse association between BMI and NT-proBNP levels. However, the correlation is weak, and there are other variables that have a significant impact on the NT-proBNP values as well. The NT-proBNP levels are still valuable in the diagnosis of heart failure regardless of BMI status.

Impact of socioeconomic and cardiovascular risk factors on the effect of genetic variants associated with NT-proBNP

N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is an established biomarker for diagnosis of heart failure. The study aims to explore whether known cardiovascular risk factors, including education and income as indicators of socioeconomic position (SEP), may interact with the genetic effect of NT-proBNP-related single nucleotide polymorphisms (SNP) to influence plasma levels of NT-proBNP in a population-based study sample. Information on effect alleles of three SNPs previously reported to be related to NT-proBNP was combined individually for 4,520 participants of the Heinz Nixdorf Recall Study to calculate a genetic risk allele sum score (GRS_NT-proBNP). Linear Regression models were used to examine the association of cardiovascular risk factors and GRS_NT-proBNP with log-transformed NT-proBNP levels, as well as cardiovascular risk factor by GRS_NT-proBNP interactions. The GRS_NT-proBNP was associated with NT-proBNP showing 1.13-fold (95% CI 1.10–1.16) higher plasma levels per additional effect allele. Interaction terms included in the regression models gave some indication for interaction of the GRS_NT-proBNP with the SEP indicator income as well as with C-reactive protein. In regression models stratified by income quartiles the strongest genetic effect was observed in the third income quartile showing 1.18-fold (95% CI 1.12–1.25) higher average NT-proBNP levels per additional allele compared to the lowest income quartile with 1.08-fold (95% CI 1.01–1.15) higher NT-proBNP levels. The results of the present study indicate that genetic effects of NT-proBNP increasing alleles are stronger in higher SEP groups. This may be due to a stronger influence of non-genetic cardiovascular risk on NT-proBNP in low SEP groups.

Opposing Associations of NT-proBNP With Risks of Diabetes and Diabetes-Related Complications

OBJECTIVE

Circulating N-terminal pro B-type natriuretic peptide (NT-proBNP) is a classic diagnostic and prognostic marker for heart failure. However, it is inversely associated with diabetes risk. We aimed to investigate relationships of NT-proBNP with risk of diabetes-related complications in initially healthy individuals.

RESEARCH DESIGN AND METHODS

We performed a case-cohort study within the European Prospective Investigation Into Cancer and Nutrition (EPIC)-Potsdam cohort including a random subcohort (n = 1,294) and incident cases of type 2 diabetes (n = 649) and cardiovascular diseases (n = 478). Incident cases of type 2 diabetes (n = 545) were followed up for microvascular (n = 133) and macrovascular (n = 50) complications. Plasma NT-proBNP was measured at baseline in initially healthy participants.

RESULTS

In multivariable models, NT-proBNP was linearly inversely associated with incident type 2 diabetes with a hazard ratio (HR) (95% CI) per doubling in NT-proBNP of 0.91 (0.86, 0.98). The association was only observable in women (0.80 [0.72, 0.90]) compared with men (0.98 [0.91, 1.07]). Among people with incident diabetes, NT-proBNP was positively associated with diabetes complications: overall, 1.31 (1.13, 1.53); microvascular complications, 1.20 (1.01, 1.43); and macrovascular complications, 1.37 (1.03, 1.83).

CONCLUSIONS

Although higher NT-proBNP levels are associated with lower diabetes risk, NT-proBNP is a biomarker for vascular complications in people who develop diabetes independent of potential confounders. Thus, NT-proBNP might be informative to monitor risk for diabetes-related microvascular and macrovascular complications, which should be further explored in future prospective studies.

Relationship of preoperative NT-pro BNP with clinical, perioperative and prognostic markers in cardiac surgery: Preliminary study results

Objective: We aimed to define the relationship of preoperative N-terminal-pro-brain type natriuretic peptide (NT-pro-BNP) testing in routine practice of cardiac surgery with clinical, perioperative variables, surgical outcomes and complications in pediatric and adult cardiac surgery patients. In addition, we assessed relationship of NT-pro-BNP with EuroSCORE II in adult patients undergoing cardiac surgery.   Methods: A total of 48 patients who underwent cardiac surgery in our institution were enrolled into this retrospective  observational cohort study. According to age aspects pediatric (PG, n=20) and adult (AG, n=28) group of patients were separately evaluated. Each group further was categorized into two subgroups (group 1 and 2) on the basis of cut-off points of NT-pro-BNP level (430 and 250pg/ml in adults and children, respectively). Preoperative NT-pro- BNP was obtained from patients. Statistical tests were conducted to reveal differences in clinical and perioperative variables among NT-pro-BNP groups and relationship of the assay with baseline clinical and operative parameters, as well as postoperative outcomes. Results: In adults undergoing cardiac surgery, statistically significant differences  were found between groups with low and high levels of NT-pro-BNP by NYHA classes (I to III, p˂0.001), body mass index (BMI) values (mean (SD) -31.7(3.15) vs 25.9 (3.8) kg/cm2, p=0.017), estimated glomerular filtration rate (eGFR) (111.4 (26.4) vs 77.9 (22.4) ml/min/1.73m2, p=0.036), moderately impaired renal function (20% vs 72.7%, p=0.049), need for inotropes (28.6% vs 86.7%, p=0.006), and mean EuroSCORE II (0.81 (0.19) vs 1.7 (0.5), p=0.008).  There was the positive significant correlation of NT-pro-BNP levels with EuroSCORE II, NYHA class, need for inotropes, renal function and left ventricular (LV) function categories, while its negative correlation was found with BMI, LV ejection fraction and eGFR parameters. In PG – NT-pro-BNP was negatively correlated with age, body surface area, LV end-diastolic and end-systolic dimensions.   Conclusion: In adult patients undergoing cardiac surgery, preoperative NT-pro-BNP level correlated well with several baseline and clinical-operative parameters, including BMI, renal and LV function, NYHA class, need for inotropes support, and EuroSCORE II.   Further studies are needed to define its exact diagnostic and prognostic significance in pediatric patients.

The conundrum of patients with obesity, exercise intolerance, elevated ventricular filling pressures and a measured ejection fraction in the normal range

Patients with obesity, a reduced exercise capacity, increased cardiac filling pressures and a measured left ventricular ejection fraction in the normal range do not have a homogeneous disorder, but instead, exhibit one of three phenotypes. First, many obese people exhibit sodium retention, plasma volume expansion and cardiac enlargement, and some are likely to have heart failure that is related to hypervolaemia, even though cardiac index and circulating levels of natriuretic peptides are not meaningfully increased. Second, in some middle-aged men and women (particularly those with minimal co-morbidities), levels of natriuretic peptides increase markedly and can lower systemic vascular resistance, thus leading to high-output heart failure (HOHF) and glomerular hyperfiltration. Third, older obese people, particularly women with multiple co-morbidities, exhibit the syndrome of heart failure with a preserved ejection fraction (HFpEF). Despite degrees of plasma volume expansion similar to HOHF, these patients exhibit only modestly increased ventricular dimensions and circulating levels of natriuretic peptides (despite a high prevalence of atrial fibrillation), and glomerular function is characteristically impaired. A conceptual framework is proposed to distinguish among the three phenotypes seen in obese patients with exercise intolerance, increased ventricular filling pressures and a measured left ventricular ejection fraction in the normal range, since they may respond differently to therapeutic interventions. Efforts are needed to enhance the recognition of heart failure in obese people and to ensure that clinical trials that are designed to study patients with HFpEF actually enrol those who have the disease.

Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery

Objective

The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality.

Methods

A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures.

Results

Preoperative NT-proBNP was 1.67 times (p<0.0001) and 1.41 times (p<0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders.

NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95%CI 0.73–0.85, p<0.0001), MR (AUC = 0.80, 95%CI 0.72–0.87, p<0.0001) and AS (AUC = 0.66, 95%CI 0.51–0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95%CI 0.71–0.85, p<0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD.

Conclusions

Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.

Association between chemerin, omentin-1 and risk of heart failure in the population-based EPIC-Potsdam study

The adipokines chemerin and omentin-1 have been suggested to influence cardiovascular function. The study aimed to investigate the longitudinal association between chemerin, omentin-1 concentrations and risk of incident heart failure (HF), respectively. We conducted a case-cohort study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort (n = 27548) including a randomly drawn subsample and all incident HF cases during a mean follow-up of 8.2 ± 1.5 years. A total of 212 incident HF cases and 2168 individuals free of HF cases were included in the study. After multivariable adjustment for established cardiovascular risk factors chemerin was strongly associated with risk of HF (HR per doubling chemerin: 4.91; 95%-CI: 2.57-9.39; p < 0.0001). Omentin-1 was not significantly related to HF risk in the overall study population. However, the association between omentin-1 and HF risk was modified by prevalent coronary heart disease (CHD), showing that the shape of the association was linear in participants without prevalent CHD (HR doubling omentin-1: 2.11; 95%-CI: 1.36-3.27; p linear = 0.0009) and U-shaped in participants with pre-existing CHD (p non-linear = 0.006). Our study provides first evidence for a strong positive association between chemerin and risk of HF. The association between the adipokine omentin-1 and risk of HF may differ according to pre-existing CHD.

NTproBNP in insulin-resistance mediated conditions: overweight/obesity, metabolic syndrome and diabetes. The population-based Casale Monferrato Study

Background and aims

NTproBNP and BNP levels are reduced in obese subjects, but population-based data comparing the pattern of this relationship in the full spectrum of insulin-resistance mediated conditions, overweight/obesity, metabolic syndrome and diabetes, are limited.

Methods

The study-base were 3244 individuals aged 45–74 years, none of whom had heart failure, 1880 without diabetes and 1364 with diabetes, identified as part of two surveys of the population-based Casale Monferrato Study. All measurements were centralized. We examined with multiple linear regression and cubic regression splines the relationship between NTproBNP and BMI, independently of known risk factors and confounders. A logistic regression analysis was also performed to assess the effect of overweight/obesity (BMI ≥ 25 kg/m²), diabetes and metabolic syndrome on NTproBNP values.

Results

Out of the overall cohort of 3244 people, overweight/obesity was observed in 1118 (59.4%) non-diabetic and 917 (67.2%) diabetic subjects, respectively. In logistic regression, compared to normal weight individuals, those with a BMI ≥ 25 kg/m² had a OR of 0.70 (95% CI 0.56–0.87) of having high NTproBNP values, independently of diabetes. As interaction between diabetes and NTproBNP was evident (p < 0.001), stratified analyses were performed. Diabetes either alone or combined with overweight/obesity or metabolic syndrome enhanced fourfold and over the OR of having high NTproBNP levels, while the presence of metabolic syndrome alone had a more modest effect (OR 1.54, 1.18–2.01) even after having excluded individuals with CVD. In the non-diabetic cohort, obesity/overweight and HOMA-IR ≥ 2.0 decreased to a similar extent the ORs of high NTproBNP [0.76 (0.60–0.95) and 0.74 (0.59–0.93)], but the association between overweight/obesity and NTproBNP was no longer significant after the inclusion into the model of HOMA-IR, whereas CRP > 3 mg/dl conferred a fully adjusted OR of 0.65 (0.49–0.86).

Conclusions

NT-proBNP levels are lower in overweight/obesity, even in those with diabetes. Both insulin-resistance and chronic low-grade inflammation are involved in this relationship. Further intervention studies are required to clarify the potential role of drugs affecting the natriuretic peptides system on body weight and risk of diabetes.

Fragmented QRS complex is a prognostic marker of microvascular reperfusion and changes in LV function occur in patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention

The present study aimed to investigate the in-hospital and long-term prognostic value of fragmented QRS complex (fQRS) for microvascular reperfusion and changes in left ventricular (LV) function in patients with ST elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). A total of 216 patients with STEMI undergoing primary PCI were included in the current study. Patients were divided into two groups based on the presence (n=126) or absence (n=90) of fQRS following electrocardiograms (ECGs) on admission. Following primary PCI and follow up, patients were divided into four groups based on new onset, resolution, persistence and absence of fQRS. Major adverse cardiac events were defined to include cardiovascular death, arrhythmia, heart failure, reinfarction and target vessel revascularization. The percentage of patients with heart failure and microvascular reperfusion differed significantly between the fQRS(+) and fQRS(−) groups. Levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), Peak creatine kinase-MB (CK-MB) and Troponin I levels were observed to be significantly higher in the fQRS(+) group compared with the fQRS(−) group. In univariate logistic regression analysis, left ventricular ejection fraction (LVEF), NT-proBNP, Troponin I, Peak CK-MB and microvascular reperfusion were found to be associated with fQRS. Multivariate analysis identified that LVEF, NT-proBNP, Troponin I and microvascular reperfusion may be independent predictors of fQRS. The presence of fQRS was demonstrated to be associated with left ventricular dysfunction at follow up assessments. The presence of fQRS was not only significantly associated with myocardial microvascular reperfusion and left ventricular function, but was also a prognostic marker in STEMI.

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.