Association between natriuretic peptides and mortality among patients admitted with myocardial infarction: a report from the ACTION Registry(R)-GWTG™

Prognostic Value of Systemic Immune-Inflammation Index and NT-proBNP in Patients with Acute ST-Elevation Myocardial Infarction

Objective

Our aim was to assess systemic immune-inflammation index (SII) and NT-proBNP value either in singly or in combination to predict acute ST-elevation myocardial infarction (STEMI) patient prognosis.

Methods

Analyzed retrospectively the clinical features and laboratory data of STEMI confirmed patients in our hospital from January to December 2020. The levels of SII and NT-proBNP were detected. The Kaplan-Meier approach and Spearman's rank correlation coefficient were used to construct the overall major adverse cardiac event (MACE) curve. Multivariate Cox regression analysis was applied to detect MACE predictors. In addition, the Delong test and receiver operating characteristic (ROC) curve analyzed each factor performance on its own and composite multivariate index to predict MACEs.

Results

The MACE group showed statistically significant differences in SII, NT- proBNP in comparison to the non-MACE group (P=0.003, P <0.001). Based on Kaplan-Meier analysis, SII and NT-proBNP showed positive correlation with MACE (log-rank P < 0.001). SII and NT-proBNP were independent predicting factors for long-term MACEs in multivariate Cox regression analysis (P <0.001, HR: 2.952, 95% CI 1.565-5.566; P <0.001, HR: 2.112, 95% CI 1.662-2.683). SII and NT-proBNP exhibited a positive correlation (R = 0.187, P < 0.001) in correlation analysis. According to the ROC statistical analysis, the combination exhibited 78.0% sensitivity and 88.0% specificity in the prediction of MACE. According to the results of the AUC and Delong test, the combined SII and NT-proBNP performed better as a prognostic index than each of the individual factor indexes separately (Z = 2.622, P = 0.009; Z = 3.173, P < 0.001).

Conclusion

SII and NT-proBNP were independent indicators of clinical prognosis in acute STEMI patients, and they correlated positively. These factors could be combined to improve clinical prognosis.

Role of N-terminal pro-B-type natriuretic peptide in the prediction of outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock

Although measurements of natriuretic peptides have a role in chronic heart failure and acute coronary syndrome, their role has not been studied in ST-elevation myocardial infarction complicated by cardiogenic shock (CS-STEMI). Sixty-four patients with CS-STEMI were prospectively recruited to assess the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement after 24 h of the onset of angina or anginal equivalent. Patients who died within 24 h were excluded. The mean age was 56.9 ± 10.6 years and the median time to presentation was 22 h (Interquartile range 7–48 h). Thrombolysis was done in 51% and PCI in 31% of cases. The in-hospital mortality was 26.5%. The ROC analysis showed a strong relationship between elevated NT-proBNP and in-hospital mortality (AUC = 0.748; p = 0.003). An NT-proBNP value > 8582 pg/mL showed 76.5% sensitivity, 68% specificity, 46.4% positive predictive value, and 89% negative predictive value for in-hospital mortality. Acute kidney injury [Odds ratio (OR) 7.30; 95% confidence interval (CI) 1.42–37.37] and NT-proBNP (OR 1.12 per 1000 pg/mL; CI 1.012–1.25) were independent predictors of mortality in multivariate regression analysis. Although we found plasma NT-proBNP at 24 h to be an independent predictor of in-hospital mortality in CS-STEMI, additional studies with a larger sample are required to ascertain these findings and validate the appropriate cut-off values.

A Novel Predictive Model for In-Hospital Mortality Based on a Combination of Multiple Blood Variables in Patients with ST-Segment-Elevation Myocardial Infarction

In emergency clinical settings, it may be beneficial to use rapidly measured objective variables for the risk assessment for patient outcome. This study sought to develop an easy-to-measure and objective risk-score prediction model for in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). A total of 1027 consecutive STEMI patients were recruited and divided into derivation (n = 669) and validation (n = 358) cohorts. A risk-score model was created based on the combination of blood test parameters obtained immediately after admission. In the derivation cohort, multivariate analysis showed that the following 5 variables were significantly associated with in-hospital death: estimated glomerular filtration rate <45 mL/min/1.73 m², platelet count <15 × 10⁴/μL, albumin ≤3.5 g/dL, high-sensitivity troponin I >1.6 ng/mL, and blood sugar ≥200 mg/dL. The risk score was weighted for those variables according to their odds ratios. An incremental change in the scores was significantly associated with elevated in-hospital mortality (p < 0.001). Receiver operating characteristic curve analysis showed adequate discrimination between patients with and without in-hospital death (derivation cohort: area under the curve (AUC) 0.853; validation cohort: AUC 0.879), and there was no significant difference in the AUC values between the laboratory-based and Global Registry of Acute Coronary Events (GRACE) score (p = 0.721). Thus, our laboratory-based model might be helpful in objectively and accurately predicting in-hospital mortality in STEMI patients.

B-type natriuretic peptide molecular forms for risk stratification and prediction of outcome after acute myocardial infarction

BACKGROUND

B-type natriuretic peptide (BNP) is known to be a risk marker following acute myocardial infarction (MI). More recently, truncated molecular forms of the BNP molecule have been identified, with the association of these forms and outcome in acute MI not known. The present study investigated their use as risk stratifying biomarkers of this condition.

METHODS

BNP molecular forms (BNP 5-32, BNP 4-32 and BNP 3-32) were measured in plasma from 1078 acute MI patients using immunocapture followed by MALDI-ToF-mass spectrometry. Associations of molecular forms with short-term and long-term adverse outcomes were assessed.

RESULTS

BNP molecular forms were independent predictors of mortality/reinfarction, mortality/rehospitalization due to heart failure, and a composite of all events at 6 months, 1 year and 2 years and showed prognostic ability comparable with conventional BNP measurements (P<.001-0.026 vs. N-terminal [NT]-proBNP P<.001-0.020, respectively). Reclassification analyses showed BNP molecular forms successfully reclassified patient risk when used in addition to the GRACE clinical risk score (P≤.005). BNP 5-32 showed utility as a secondary risk stratification biomarker when used in combination with the GRACE score and NT-proBNP by successful down-classification of high-risk patients.

CONCLUSIONS

BNP molecular forms were associated with poor prognosis at 6 months, 1 year and at 2 years in patients with acute MI. BNP 5-32 showed successful utility as a secondary marker in combination with NT-proBNP after GRACE scoring. This study suggests a potential role for BNP molecular forms in prognosis and risk stratification after acute MI.

Role of B-Type Natriuretic Peptide and N-Terminal Prohormone BNP as Predictors of Cardiovascular Morbidity and Mortality in Patients With a Recent Coronary Event and Type 2 Diabetes Mellitus

BACKGROUND

Natriuretic peptides are recognized as important predictors of cardiovascular events in patients with heart failure, but less is known about their prognostic importance in patients with acute coronary syndrome. We sought to determine whether B-type natriuretic peptide (BNP) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) could enhance risk prediction of a broad range of cardiovascular outcomes in patients with acute coronary syndrome and type 2 diabetes mellitus.

METHODS AND RESULTS

Patients with a recent acute coronary syndrome and type 2 diabetes mellitus were prospectively enrolled in the ELIXA trial (n=5525, follow-up time 26 months). Best risk models were constructed from relevant baseline variables with and without BNP/NT-proBNP. C statistics, Net Reclassification Index, and Integrated Discrimination Index were analyzed to estimate the value of adding BNP or NT-proBNP to best risk models. Overall, BNP and NT-proBNP were the most important predictors of all outcomes examined, irrespective of history of heart failure or any prior cardiovascular disease. BNP significantly improved C statistics when added to risk models for each outcome examined, the strongest increments being in death (0.77-0.82, P<0.001), cardiovascular death (0.77-0.83, P<0.001), and heart failure (0.84-0.87, P<0.001). BNP or NT-proBNP alone predicted death as well as all other variables combined (0.77 versus 0.77).

CONCLUSIONS

In patients with a recent acute coronary syndrome and type 2 diabetes mellitus, BNP and NT-proBNP were powerful predictors of cardiovascular outcomes beyond heart failure and death, ie, were also predictive of MI and stroke. Natriuretic peptides added as much predictive information about death as all other conventional variables combined.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01147250.

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.

ST elevation myocardial infarction: recent advances and updates

ST elevation myocardial infarction (STEMI) remains a leading cause of morbidity, mortality and disability worldwide. Statistically, a trend towards improvements in morbidity and mortality has been consistent over the years, which is attributed primarily to the modification of risk factors, healthier lifestyles, treatment advances and better management of door-to-balloon times via STEMI systems. However, a major challenge in the coming years will be the baby boomers (born between the years 1946 and 1964) coming into old age. The first baby boomers turned 65 in year 2011. As the baby boomers age in the coming years, the incidence of coronary heart disease is likely to increase, and so there will be a greater need to have major advances in the management of coronary heart disease in order to deal with this additional incidence. The scope of this article is to review recent advances in the management of STEMI and to provide an updated overview.

[Comparison of the clinical characteristics and hospital treatment of myocardial infarction with and without ST-segment elevation in Hungary. National Registry of Myocardial Infarction]

INTRODUCTION

Afew data have been published on the clinical characteristics of different types of myocardial infarction in Hungary.

AIM

To compare clinical data of patients with ST-segment elevation and non-ST-segment elevation myocardial infarction based on the National Myocardial Infarction Registry database.

METHOD

Data recorded in the National Myocardial Infarction Registry between January 1, 2010 and June 30, 2012 were included in the analysis.

RESULTS

Patients treated with non-ST-segment elevation myocardial infarction (n = 5237) were older and had more comorbidities compared to those with ST-segment elevation myocardial infarction (n = 6670). Coronarography and percutaneous coronary intervention were performed more frequently in the latter group. There was no significant difference in in-hospital mortality between the two groups (5.3% and 4.9%). Medication for secondary prevention after myocardial infarction was applied in nearly 90% of the patients in both groups. Dual antiplatelet therapy was more often applied after ST-segment elevation myocardial infarction.

CONCLUSIONS

The study confirmed important differences in the clinical characteristics and similar hospital prognosis between the two patient groups.

Cardiac biomarkers for infarct diagnosis and early exclusion of acute coronary syndrome

The acute coronary syndrome (ACS) represents a diagnostic challenge: on the one hand patients need to be quickly identified to initiate treatment and on the other hand early exclusion of patients without ACS is important to relieve patient stress as well as overcrowded emergency departments. A growing number of biomarkers are becoming available to aid physicians with this task. This review gives an overview of the current research concerning early exclusion with an emphasis on the clinically most important biomarker: cardiac troponin.

Physiology of natriuretic peptides: The volume overload hypothesis revisited

The discovery of the natriuretic peptide system in the early 1980s aroused great interest among clinical cardiologists. The heart was not a mechanical pump alone, but also an endocrine organ that had powerful effects on blood circulation. Natriuretic peptides caused both natriuresis and diuresis, and they responded to a volume overload which caused either stretch or pressure on the heart. As a result, the findings led to the conclusion that the human body had a hormone with effects similar to those of a drug which treats high blood pressure. Later, it became evident that the volume contraction was fortified by extrarenal plasma shift. Here, a hypothesis is presented in which the role of natriuretic peptides is to regulate oxygen transport as the volume contraction leads to hemoconcentration with an increased oxygen-carrying capacity. Wall stress, either chemical or mechanical, changes the oxygen gradient of the myocardium and affects the diffusion of oxygen within a myocyte. In support of this hypothesis, hypoxia-response elements have been found in both the atrial natriuretic peptide and the brain natriuretic peptide genes.

The role of cardiac biomarkers in the diagnosis and management of patients presenting with suspected acute coronary syndrome

Myocardial infarction (MI) is the leading cause of death in the developed world. Biomarkers have an essential role in diagnosis, risk stratification, guiding management and clinical decision making in the setting of patients presenting with signs and symptoms of MI. Cardiac troponin (cTn) rose to prominence during the 1990s and has evolved to be the cornerstone for diagnosis of MI. The current criteria for MI diagnosis include a rise and/or fall in cTn with at least one value above the 99th percentile of the upper reference limit. Along with cTn, the natriuretic peptides B-type natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) have an important role in determining prognosis and guiding management. As assays for cTn have been evolved that are capable of reliably detecting smaller and smaller quantities in the blood, a dilemma has emerged as to how to use this new information. Several studies have attempted to answer this question and have shown that these lower concentrations of cTn have important prognostic significance and, more importantly, that intervention in these patients leads to improved clinical outcomes. New algorithms incorporating BNP, NT-proBNP, and more sensitive cTn assays hold promise for more rapid diagnosis or rule-out of MI, allowing for appropriate management steps to be initiated and more efficient and effective utilization of healthcare resources.