Natriuretic peptides as predictors of clinical course in patients with end-stage heart failure

Abstract

The optimal time-point for HTx or implantation of a VAD in patients with end-stage heart failure is a key issue. In 73 patients with heart failure requiring inotropic support blood was sampled daily and big endothelin-1 (big ET) and natriuretic peptides were measured at the end of the study. Clinical parameters were also evaluated daily. The patients were divided into groups with regard to the following endpoints: Group I immediate VAD placement due to profound cardiogenic shock on admission (n 9); Group II deterioration into cardiogenic shock after an initially stable clinical course (n 21); Group III stable clinical course allowed urgent HTx or VAD implantation (n 35); Group IV weaning from inotropic support (n 8). The parameters were evaluated as potential predictors for clinical course. On admission there were no significant predictors for the clinical course except lower ANP level in group IV compared to group II (p 0-005). Among the parameters evaluated, only BNP and big ET showed significant differences between groups II and III during follow up. BNP was elevated in group II compared to the group III three days, two days and one day before profound cardiogenic shock occurred (p 0.04; p 0.05; p 0.019 resp.). Big ET was elevated in group II only 1 day before profound cardiogenic shock occurred (p 0.02). ProBNP remained unchanged during treatment in groups II and III, but decreased significantly in group IV (p 0.9, p 0.6 and p 0.025 resp.). While clinical parameters on admission did not predict the clinical course, lower ANP was found in patients weaned from inotropic support. A decrease of proBNP was also found in these patients. Elevated BNP indicated cardiogenic shock up to 3 days before its occurrence. Daily measurement of natriuretic peptides may be used for determination of optimal time-point for VAD implantation in patients with severe end-stage heart failure.