Natriuretic peptides predict future heart failure and cardiovascular death in an unselected population of patients presenting to hospital: interactions with atrial fibrillation

Aims

Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their interpretation, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and to outcomes.

Methods and results

Consecutive patients with cardiovascular conditions presenting to a large teaching hospital (median age 70 [IQR 60–78] years, 40% women) underwent clinical assessment, 7-day ECG-monitoring, and echocardiography to diagnose AF and HF. N-terminal pro B-type natriuretic peptide (NT-proBNP) was centrally quantified. Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data was available in 1611/1616 patients (99.7%) and analysis performed at 2.5 years. Based on a literature review, four NT-proBNP groups were defined (<300pg/ml, 300–999pg/ml, 1000–1999pg/ml and ≥2000pg/ml).

Multivariate Cox proportional hazards analysis of the composite outcome against AF and HF phenotype groups. This was adjusted for confounding factors including age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, severe valvular heart disease, left bundle branch block, hyponatraemia, urea, haemoglobin, estimated glomerular filtration rate, NT-proBNP, medical treatment with ACE inhibitors or angiotensin receptor blockers, beta-blockers, diuretic (thiazide or loop diuretics), and anticoagulants (novel oral anticoagulant or vitamin K antagonist). Cox proportional hazards analysis adjusted for confounding variables for the composite outcome against baseline NT-proBNP concentration ranges was also performed in each patient group based on AF and HF status.

HF hospitalization or cardiovascular death increased from patients with neither AF nor HF (36/488, 3.2/100 person-years), to 55/353 (7.1/100 person-years) in patients with AF only, 91/366 (12.1/100 person-years) in patients with HF only, and, 128/404 (17.7/100 person-years) in patients with AF plus HF (p<0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic 0.82 [95% CI 0.77 to 0.86], p-value<0.001) and in other phenotype groups (C statistic in AF plus HF 0.66 [95% CI 0.61 to 0.70], p-value<0.001)). Sensitivity analyses confirmed these findings.

Conclusion

Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF. In line with previous studies in HF, an NT-proBNP threshold of 1000 pg/ml is useful to identify high-risk patients with AF whether or not they are diagnosed with HF at the time of assessment. Pending external validation, these findings encourage the routine quantification of NT-proBNP in the initial assessment of patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1) This study was partially supported by European Union BigData@Heart and 2) CATCH ME (Characterising Afib by Translating its Causes into Health Modifiers in the Elderly)

Cross-sectional and longitudinal characterisation of cognitive function and outcomes in patients presenting to hospital with cardiovascular risk factors

Background/Introduction

Cardiovascular (CV) diseases including atrial fibrillation and arteriosclerosis are associated with impaired cognitive function. Cognitive dysfunction can impact the process of shared clinical decision making, reduce adherence to polypharmacy, and decrease quality of life. The prevalence of cognitive dysfunction in contemporary patients with CV diseases and its implication on future CV events is not well known.

Purpose

We 1) quantified cognitive function in patients presenting to hospital with CV diseases, 2) identified clinical variables and blood biomarkers associated with cognitive dysfunction, and 3) quantified the hazard of abnormal cognitive function for predicting MACCE (major adverse CV and cerebrovascular events).

Methods and results

Of 1625 consecutive patients presenting acutely to a large teaching hospital with CV diseases, 614 patients (median age [Q1, Q3] 68 [58, 76] years; 66% male) who completed the Montreal Cognitive Assessment (MoCA) were analysed. The median [Q1, Q3] MoCA score was 25 points [21, 27]. 360 patients (59%) had an abnormal score (<26). At baseline, patients with abnormal scores were more likely to be female (odds ratio, OR [95% confidence intervals], 1.874 [1.287, 2.728]), have BMI<30 (OR 0.584 [0.410, 0.831]), heart failure (OR 1.492 [1.043, 2.135]), diabetes (OR 2.212 [1.529, 3.199]), chronic kidney disease (CKD-EPI<60 ml/min, OR 1.553 [1.021, 2.361]), and have more CV co-morbidities (OR per additional co-morbidity 1.415 [1.246, 1.605]). Amongst 12 CV biomarkers tested, elevated Bone Morphogenetic Protein 10 (OR 1.325 [1.022, 1.719]) and Growth Differentiation Factor 15 (OR 1.419 [1.054, 1.912]) increased odds of abnormal scores.

Cox proportional hazards model adjusted for competing risk of non-CV death assessed the relationship between abnormal cognitive function and MACCE (stroke, TIA, myocardial infarction, hospitalisation for heart failure, CV death). Follow-up time ranged from 2.7 to 6.1 years. Patients were censored at 2.5 years for this analysis. 130 out of 614 patients experienced a MACCE (21%) and 71 had a non-CV death (12%). Patients with abnormal MoCA scores were at higher risk for MACCE (subhazard ratio, sHR [95% CI] 1.827 [1.253, 2.664]). The hazard remained significant after adjustment for age, sex, obesity, atrial fibrillation, stroke, heart failure, hypertension, coronary artery disease, diabetes, peripheral artery disease and renal dysfunction (sHR 1.367 [1.056, 2.326]; Figure). All-cause mortality was 1.785 times higher for those with abnormal MoCA scores [1.061, 3.002].

Conclusion

In this study, 3 out of 5 patients with CV diseases had abnormal MoCA scores at baseline. Abnormal cognitive scores significantly predicted patients who went on to experience a MACCE within 2.5 years of follow-up. These observations call for further research and action to provide additional diagnostics, support and early intervention to address cognitive dysfunction in CV patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU H2020 CATCH ME Cumulative incidence function

Identifying the value of RVEF for the prediction of major cardiovascular outcomes: a study of 7,131 patients undergoing cardiovascular magnetic resonance imaging

Background

Right ventricular (RV) function remains poorly recognized for its value in predicting cardiovascular events at a population level. Cardiovascular Magnetic Resonance (CMR) imaging is the gold standard for RV assessment.

Purpose

To define the independent prognostic value of RVEF for the prediction of major adverse cardiovascular events (MACE) as primary outcome in patients with known or suspected cardiovascular disease.

Methods

Data was obtained from the Cardiovascular Imaging Registry of Calgary (CIROC). Patients underwent standardized CMR imaging protocols and analysis. Clinical events were identified from administrative data.

Results

7,131 patients were included. 870 primary outcome events occurred over 2.5 years follow-up. RVEF provided equivalent predictive utility versus LVEF (Table 1). There was an increase in events with worsening severity of RVEF (Figure 1), with a significant “threshold-effect” at an RVEF of 40%.

Conclusions

RVEF is a strong and independent predictor of MACE at a population level.

Figure 1

Funding Acknowledgement

Type of funding source: None