Abstract
Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100 ± 687 days.Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p = 0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p < 0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p < 0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p < 0.0001] and [HR 1.48 (95% CI 1.16–1.90), p = 0.0001], HFmrEF and HFpEF, respectively.Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.Key pointsIt is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF > 40%, HFpEF) managed in primary care.We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.The clinical use is however limited due to large standard deviations, many co-morbidities and high age.Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.
Highlights
Natriuretic peptides (NPs), commonly BNP or NTproBNP, are quantitative markers of cardiac dysfunction and are widely recognized as key regulators of blood pressure, water and salt homeostasis [1,2]
NPs are mainly produced by cardiovascular, brain and renal tissues in response to wall stretch and other causes, and this is observed both in heart failure (HF) with reduced ejection fraction (HFrEF) and in HF with preserved ejection fraction (HFpEF) [5] In the latest ESC guidelines, patients with an EF in the range of 40–49% are defined as HFmrEF and patients with EF ! 50% are defined as HfpEF [6]
All patients were managed in primary care (PC) by general practitioners (GP’s) and all patients were registered at an out-patient visit
Summary
Natriuretic peptides (NPs), commonly BNP or NTproBNP, are quantitative markers of cardiac dysfunction and are widely recognized as key regulators of blood pressure, water and salt homeostasis [1,2]. They have been widely used in the management of heart failure (HF) during the last 20 years as a ‘rule-out analysis’ in the process of diagnosing HF [3,4]. Low values exclude the presence of HF and high values have high positive predictive value for diagnosing HfrEF, but it must be kept in mind that elevated levels of NP are associated with a variety of cardiac (acute pulmonary embolus, acute coronary syndrome, primary pulmonary hypertension) and noncardiac causes (renal failure) and that further diagnostic measurements, preferably echocardiography, often are recommended [10,11]
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