Using NT-proBNP as a criterion for heart failure hospitalization

B-type natriuretic peptide is released from the cardiac ventricles in response to increased wall tension. We conducted a prospective study of 1586 patients who came to the emergency department with acute dyspnea and whose B-type natriuretic peptide was measured with a bedside assay. The clinical diagnosis of congestive heart failure was adjudicated by two independent cardiologists, who were blinded to the results of the B-type natriuretic peptide assay. The final diagnosis was dyspnea due to congestive heart failure in 744 patients (47 percent), dyspnea due to noncardiac causes in 72 patients with a history of left ventricular dysfunction (5 percent), and no finding of congestive heart failure in 770 patients (49 percent). B-type natriuretic peptide levels by themselves were more accurate than any historical or physical findings or laboratory values in identifying congestive heart failure as the cause of dyspnea. The diagnostic accuracy of B-type natriuretic peptide at a cutoff of 100 pg per milliliter was 83.4 percent. The negative predictive value of B-type natriuretic peptide at levels of less than 50 pg per milliliter was 96 percent. In multiple logistic-regression analysis, measurements of B-type natriuretic peptide added significant independent predictive power to other clinical variables in models predicting which patients had congestive heart failure. Used in conjunction with other clinical information, rapid measurement of B-type natriuretic peptide is useful in establishing or excluding the diagnosis of congestive heart failure in patients with acute dyspnea.

Summary : Lifelong exercise training maintains a youthful compliance of the left ventricle (LV), whereas a year of exercise training started later in life fails to reverse LV stiffening, possibly because of accumulation of irreversible advanced glycation end products. Alagebrium is a novel drug that breaks advanced glycation end product crosslinks and improves LV stiffness in aged animals. In this study, the authors prescribed alagebrium (200 mg daily) or placebo combined with aerobic exercise training or contact control in healthy, sedentary older individuals for 1 year. The authors evaluated overall cardiac function by the use of several modalities, including invasive pressure–volume measurements, exercise testing, and cardiac MRI before and after the training. To the authors’ knowledge, this is the first study to evaluate the effects of alagebrium and exercise training in healthy aged humans. After intervention, exercise training significantly increased exercise capacity, LV mass, and LV end-diastolic volume. Conversely, alagebrium had little effect on exercise capacity or LV geometry. However, alagebrium showed a modest improvement in LV stiffness compared with placebo. This favorable effect of alagebrium on LV stiffness was most prominent in individuals with combined alagebrium and exercise training. Conclusions : Alagebrium had no effect on hemodynamics, LV geometry, or exercise capacity in healthy, previously sedentary seniors. However, it did show a modestly favorable effect on age-associated LV stiffening.1 Summary : Maximum oxygen consumption (peak VO2) and efficiency of ventilation (VE) during exercise (VE/VCO2 slope) are known to stratify adults in heart failure for 1-year survival. On the basis of adult data, a recent American Heart Association scientific statement suggested that peak VO2<50% predicted for age and sex should be considered substantial impairment in exercise performance in children with heart disease and therefore a class I indication for heart transplant listing. This single-center study examined the association of …

Treatment of Diabetes in People with Heart Failure

Objective: To compare head to head the diagnostic accuracy of B type natriuretic peptide (BNP) and the amino terminal fragment of its precursor hormone (NT-proBNP) for congestive heart failure (CHF)...

BackgroundDiagnosing early stages of heart failure with mild symptoms is difficult. B-type natriuretic peptide (BNP) has promising biochemical test characteristics, but its diagnostic yield on top of readily available diagnostic...

Research Highlights

To evaluate the importance of chronic obstructive pulmonary disease for prognosis and diagnosis of congestive heart failure in patients with acute myocardial infarction. Prospective registration of 6669 consecutive patients admitted with infarction and screened for a randomised controlled trial. A history of COPD was present in 765 (11.5%) patients. Thirty-day and 5-year survival in patients with chronic obstructive pulmonary disease was 86.3 and 42.9%. In patients without pulmonary disease the figures were 87.7 and 57.5%, respectively, giving a relative risk of 1.49 (1.35-1.65). In multivariate analysis the relative risk was 1.15 (1.04-1.28). The prevalence of congestive heart failure was 65.9% in patients with chronic obstructive pulmonary disease and 52.0% in patients without. This difference was most distinct in patients with normal or only slightly decreased left ventricular systolic function. In patients without congestive heart failure, chronic obstructive pulmonary disease was of prognostic importance [RR=1.44 (1.17-1.78)], but not in patients with congestive heart failure [RR=1.09 (0.96-1.23)]. Chronic obstructive pulmonary disease is a predictor of long-term mortality in patients with acute myocardial infarction without congestive heart failure, but is also a confounding factor for the diagnosis of congestive heart failure.

Comparison of Nt-proBNP Concentrations When in or out of Heartlogic Alerts

Lipolytic Effects of B-Type Natriuretic Peptide1–32 in Adipose Tissue of Heart Failure Patients Compared With Healthy Controls

Background Serum Brain Natriuretic Peptide (BNP) level is associated with various cardiovascular events. Because elevated BNP level reflects increased left ventricular end-diastolic pressure and LA pressure promoting left atrial (LA) remodeling, BNP level might be associated with the extent of arrhythmogenic substrate in patients with atrial fibrillation (AF). We hypothesized that elevated BNP level has impact on outcome after catheter ablation (CA) for AF. Purpose We investigated the impact of baseline BNP level on outcome after multiple CA for paroxysmal atrial fibrillation (PAF), and assessed the association between baseline BNP level and extent of LA remodeling. Methods This was a retrospective, single-center observational study. A total of 287 patients who underwent CA for PAF in our institute from March 2012 to March 2014. All patients had dataset of baseline BNP level and LA volume measured by multi-detector computed tomography (MDCT) in sinus rhythm. First we performed receiver operating characteristic (ROC) analysis for recurrence after multiple CA and obtained the best cut-off value of BNP. Patients were divided into Low BNP and High BNP group based on BNP cut-off value, and AF-free survival was analyzed with log-rank test. To assess the impact of BNP level on recurrence, multivariate Cox regression model were performed. Finally, we assessed the extent of baseline LA remodeling in low BNP and high BNP group. Results During follow-up period, AF recurred in 65/287 patients (26.2%) after multiple CA procedure (follow up 3.4 [2.2, 4.0] years, total number of sessions: 1.39±0.63). Patients with recurrence had greater baseline BNP than those without recurrence (99.8 pg/mL [30.0, 128] vs. 60.7 pg/mL [17.3, 80.8], recurrence vs. no-recurrence, P&lt;0.05). In ROC analysis, baseline BNP had mild accuracy for the prediction of recurrence (AUC: 0.63, P=0.002, best cut-off value: 57.3 pg/mL). We divided patients into High BNP group (BNP≥57.3, N=106) and Low BNP group (BNP&lt;57.3, N=181). AF-free survival was higher in Low BNP than in High BNP (Figure 1) (83.4% vs. 67.0%, Low vs. High, P&lt;0.001). After adjustment with age, gender, hypertension, heart failure, body mass index, LA diameter and LV ejection fraction, High BNP (BNP≥57.3) was associated with recurrence (Hazard ratio: 2.31, 95% CI 1.42–3.75, P&lt;0.001). In baseline parameters of LA remodeling measured with MDCT, Low BNP group had higher LA emptying fraction (41.7±9.5 vs. 32.0±8.5%, Low vs. High, P&lt;0.001) and lower indexed maximum LA volume (48.5±12.0 vs. 61.3±16.7 mL/m2, P&lt;0.001) (Figure 2). Conclusion Baseline serum BNP level was associated with recurrence after multiple procedures for PAF. The baseline extent of LA remodeling was greater in High BNP than in Low BNP. Elevated BNP level might reflect the severe LA remodeling causing ablation-refractory AF even after multiple CA. The preoperative assessment of BNP might be helpful for prediction of multiple CA outcome.

This study compared two different methods, namely the immunoradiometric (IRMA) and fluorimetric (FIA), in order to determine plasma brain natriuretic peptide (BNP) in congestive heart failure (CHF) patients. CHF in-patients underwent echocardiography and plasma BNP determination using both two methods. The echocardiograms analysed left ventricular end-systolic (LVESV) and end-diastolic (LVEDV) volumes and systolic dysfunction [left ventricular ejection fraction (LVEF) <50%]. Seventy-three (71% males, age 67 ± 9.6 yr) patients were enrolled, 31.5% affected by valvular heart disease. The mean LVEF was 39.8 ± 14.1%; in 26 (35%) a hypertensive etiology emerged. The immunoradiometric assay (IRMA) BNP was found to be significantly lower than the FIA determination 116.5 ± 149 pg/ml vs 267.3 ± 285.6 pg/ml; p=0.0001) and the two methods were closely correlated (r=0.89; p=0.00001). Logistic regression demonstrated a significant correlation between BNP, LVEF, and LVESV/LVEDV (r=-0.45, p=0.0003; r=-0.48, p=0.00001; r=0.22 p=0.003; r=0.34 p=0.0001; r=0.13 p=0.02; r=0.28 p=0.001 IRMA and FIA, respectively). IRMA BNP and FIA BNP significantly increased according to the worsening functional class [from 34.3 ± 60.2 pg/ml in NYHA (New York Heart Association) I to 555.5 ± 273.1 pg/ml in NYHA IV; from 86.1 ± 162.1 pg/ml in NYHA I to 1070 ± 42.2 pg/ml in NYHA IV, respectively]. In severe systolic dysfunction (LVEF<30%), receiver operating characteristic analysis revealed a satisfactorily sensitivity and specificity using a cut-off point of 50.6 pg/ml with IRMA and 243 pg/ml with FIA. In mild systolic dysfunction (LVEF<50%), a good sensitivity and specificity using a cut-off point of 42 pg/ml with IRMA and 182 pg/ml with FIA emerged. In CHF patients both BNP methods correlated with NYHA class, LVEF, and ventricular volumes.

1. Wayne Gade, PhD MT(ASCP)[⇑][1] 1. is assistant Professor of Clinical Laboratory Science, University of Illinois at Springfield, Springfield IL 2. Charis Hainaut, CLS(NCA) 1. is a CLS in the Clinical Laboratory, Decatur Memorial Hospital, Decatur IL 3. Jean Gade, MS RN 1. is an Instructor in the Chemistry Department, Northern Kentucky University, Highland Heights, KY 1. Address for correspondence: Wayne Gade PhD MT(ASCP) Clinical Laboratory Science Program, HSB 314, University of Illinois at Springfield, Springfield, IL 62703-5407. (217) 206-7349. After reading the following articles, the reader will demonstrate his/her understanding of the material by achieving the following: 1. Describe the biochemistry of the BNP and the other natriuretic peptides. 2. Describe the major physiologic responses to the elevation of BNP levels. 3. Discuss the mechanism by which the binding of BNP to the target cell results in alteration of Na+ and water reabsorption. 4. Describe the formation of arterial plaque and the development of coronary artery disease and acute coronary syndromes (ACS). 5. Describe the physiological conditions that develop into CHF and cause the release of BNP. 6. Describe and interpret the diagnostic accuracy, sensitivity, specificity, and negative predictive values reported for rapid BNP assays. 7. Describe the trend toward “accelerated cardiac protocols,” including which markers are suggested, and the suggested time-course of sequential testing. 8. Evaluate patient data and derive appropriate diagnostic conclusions. 9. Discuss the use of BNP for prognosis and screening of patients for LV dysfunction. 10. Discuss the interpretations of slightly elevated levels of troponin and C - reactive protein (CRP) as they relate to ACS and risk analysis. This paper illustrates the diagnostic dilemmas in a small hospital emergency department when four patients present with similar symptoms of dyspnea, angina, and edema. These cases illustrate a new role for the clinical laboratory, as the new cardiac markers and protocols help overcome the ambiguity of symptoms, delays in diagnosis, and high costs of imaging tests that may be unavailable in many small hospitals. Frequently, dyspnea and chest pain are associated with cardiac disorders such as congestive heart failure (CHF), unstable angina, and acute myocardial infarction (MI). However, these same presenting symptoms may also be seen in obstructive pulmonary disorders, pulmonary embolism, pneumonia, and non-pulmonary disorders as diverse as anemia and anxiety. The recent addition of troponin and myoglobin to cardiac panels and the increasing use of accelerated cardiac protocols have improved speed and accuracy in the diagnosis of MI. While certain aspects of the interpretation of troponin data remain controversial, the use of accelerated testing protocols is gaining acceptance, following the recommendations of the National Academy of Clinical Biochemistry in 1999. With the introduction of rapid laboratory testing for B-type natriuretic peptide (BNP) in 2000, the diagnosis of CHF has also become faster, easier, and more reliable. A companion paper in this issue reviews plaque development, acute coronary syndromes (ACS), and pathophysiology of CHF.1 In addition, the biochemistry and physiology of BNP, and the clinical evidence supporting its use in the diagnosis, risk stratification, staging, and therapeutic monitoring of CHF patients are also reviewed. Rapid BNP assays and high… ABBREVIATIONS: ABG = arterial blood gas; ACS = acute coronary syndromes; BNP = B-type natriuretic peptide; CBC = complete blood count; CHD = coronary heart disease; CHF = congestive heart failure; CLS = clinical laboratory science; CMP = comprehensive metabolic profile; COPD = chronic obstructive pulmonary disease; ECG = electrocardiogram; ED = emergency department; EMT = emergency medical technician; hsCRP = high sensitivity C-reative protein; MI = myocardial infarction; NPV = negative predictive value; RAAS = renin-angiotensin-aldosterone system; UA = urinalysis; WBC = white blood count;. After reading the following articles, the reader will demonstrate his/her understanding of the material by achieving the following: 1. Describe the biochemistry of the BNP and the other natriuretic peptides. 2. Describe the major physiologic responses to the elevation of BNP levels. 3. Discuss the mechanism by which the binding of BNP to the target cell results in alteration of Na+ and water reabsorption. 4. Describe the formation of arterial plaque and the development of coronary artery disease and acute coronary syndromes (ACS). 5. Describe the physiological conditions that develop into CHF and cause the release of BNP. 6. Describe and interpret the diagnostic accuracy, sensitivity, specificity, and negative predictive values reported for rapid BNP assays. 7. Describe the trend toward “accelerated cardiac protocols,” including which markers are suggested, and the suggested time-course of sequential testing. 8. Evaluate patient data and derive appropriate diagnostic conclusions. 9. Discuss the use of BNP for prognosis and screening of patients for LV dysfunction. 10. Discuss the interpretations of slightly elevated levels of troponin and C - reactive protein (CRP) as they relate to ACS and risk analysis. [1]: #corresp-1

Is the Measurement of B-Type Natriuretic Peptide in the Emergency Room Useful in Established Congestive Heart Failure Exacerbation?

Background. Congenital heart defects (CHD) are the most common type of developmental anomalies in children. At present the early diagnosis of congestive heart failure (CHF) and CHF-associated pathologic conditions is becoming increasingly important for optimization of protocols for following up pediatric patients in the primary health care settings.Objective. The study aimed at determining the prognostic role of brain natriuretic peptide (BNP) as a diagnostic marker of CHF progression and development of CHF-associated pathological conditions in babies with CHD during the first year of life.Methods. A prospective cohort study was carried out in a total of 114 children of the first year of life. The main study group was comprised of 61 children with confirmed diagnosis of CHD, and the control group of 53 health status group I–IIA children without CHD.Results. Diagnostic role of BNP elevation &gt; 30 pg/mL was determined. At this BNP level the risk for developing stage 2A CHF increased 7-fold (OR 7.5 [1.8–31.5]), for developing functional class (FC) 2 CHF — nearly 5-fold (OR 4.6 [1.3–16.0]), and for FC 3 CHF such risk increased 9-fold (OR 9.2 [2.3–36.1]). Our results demonstrated that the BNP level measurements can be used in clinical practice to determine the likelihood of persistence of symptoms of perinatal CNS injuries during the first year of life (OR 7.6 [1.7–34.5]) and protein and energy deficit (PED) (OR 9.5 [2.5–35.5]) in children with CHD.

Funding Acknowledgements Type of funding sources: None. Background The presence of acute kidney injury in the setting of acute heart failure (AHF) is common occurrence and was termed type 1 cardiorenal syndrome (CRS1). Neutrophil gelatinase-associated lipocalin (NGAL) is one of the earliest biomarkers of acute kidney injury due to ischemia or renal toxicity. NT-proBNP has a role in the diagnosis of acute heart failure. Does the combination of NGAL and NT-proBNP increase diagnostic value of CRS1? This study was aimed to evaluate the diagnostic value of plasma NGAL and NT-proBNP in diagnosis of CRS1. Methods there were 139 patients with AHF in the department of Cardiovascular resuscitation and Interventional cardiology Ho Chi Minh City Vietnam 115 People Hospital from September 2018 to March 2019. This was a prospective cohort study. Results the optimal cut-off plasma NGAL to diagnosing CRS1 was 353.23 ng/ml, Area Under Curve (AUC) 0.732 (95% CI 0.65-0.80, p &amp;lt; 0.001), sensitivity 74.47%, specificity 68.48%, positive predictive value 54.7%, negative predictive value 84%. The optimal cut-off NT-proBNP to diagnosing CRS1 was 17681 pg/ml, AUC 0.710 (95% CI 0.627-0.784, p &amp;lt; 0.001), sensitivity 54.2%, specificity 80.2%, positive predictive value 59.1%, negative predictive value 76.8%. Combination of plasma NGAL and NT-proBNP in diagnosing CRS1 with AUC 0.756 (95% CI 0.676-0.825, p &amp;lt; 0.001), sensitivity 77.1%, specificity 69.2%, positive predictive value 56.9%, negative predictive value 85.1%. Conclusions Combination of plasma NGAL and NT-proBNP in the diagnosis of type 1 cardiorenal syndrome with higher sensivity than each biomarker.