Blood B-type Natriuretic Peptide Research Articles

B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Events in Pediatric Outpatients With Chronic Left Ventricular Systolic Dysfunction

Plasma B-type natriuretic peptide (BNP) levels are elevated in adults with heart failure and correlate with functional classification and prognosis. The range and predictive power of BNP concentrations in children with chronic heart failure, however, are not known. Whole blood BNP concentrations were measured in 53 consecutive patients with chronic left ventricular (LV) systolic dysfunction (biventricular hearts, ejection fraction < 50%, > 3 months since diagnosis). Children who had been hospitalized within 3 months before potential enrollment and those < 2 months or > 21 years of age were excluded. BNP concentrations were measured with the Triage assay (Biosite Diagnostics, Inc, San Diego, Calif). Echocardiographers and clinicians were blinded to BNP levels. An adverse cardiovascular event was defined as cardiac death, cardiac-related hospitalization, or listing for cardiac transplantation. The median age of patients with LV dysfunction was 9.3 years (interquartile range [IQR], 2.7 to 15.1 years). BNP levels were elevated in children with LV dysfunction compared with healthy controls (median, 78 pg/mL [IQR, 22 to 551 pg/mL] versus median, 7 pg/mL [IQR, 5 to 11 pg/mL]; P < 0.0001). Whole blood BNP concentrations were increased in patients who had a 90-day adverse cardiovascular event compared with those who did not (median, 735 pg/mL [IQR, 685 to 1510 pg/mL] versus median, 37 pg/mL [IQR, 14 to 92 pg/mL]; P < 0.001). Patients with a BNP concentration > or = 300 pg/mL were at increased risk of death, hospitalization, or listing for cardiac transplantation (adjusted hazard ratio, 63.6; P < 0.0001). BNP concentrations are elevated in children with chronic LV systolic dysfunction and predict the 90-day composite end point of death, hospitalization, or listing for cardiac transplantation.

Clinical Implication of Blood Levels of B-Type Natriuretic Peptide in Pediatric Patients on Mechanical Circulatory Support

B-type natriuretic peptide (BNP) is a marker of heart failure. In adult patients with heart failure, decreased BNP levels after implantation of ventricular assist devices may be indicative of recovery. However, BNP levels among pediatric patients receiving mechanical support are largely unknown. Fifteen pediatric patients with cardiogenic shock who were supported by extracorporeal membrane oxygenation (ECMO) were evaluated. The BNP levels were determined before ECMO initiation, during ECMO support, and after ECMO removal. All patients had elevated BNP levels before initiation of ECMO (median, 1,430 pg/mL; range, 361 to 5,000 pg/mL). Among the 15 patients, 1 received heart transplantation. Extracorporeal membrane oxygenation was withdrawn in 2 patients, and the other 12 patients were weaned from ECMO. Four patients died after initially successful weaning from ECMO. The BNP levels of the nonsurvivors (median, 3,685 pg/mL; range, 2,494 to 5,000 pg/mL) were higher than those of the survivors (median, 1,127pg/mL; range, 108 to 3,030 pg/mL) on the next few days after ECMO removal (p = 0.016). The BNP levels on the fourth day after removal of ECMO among the survivors (median, 498 pg/mL; range, 108 to 890 pg/mL) were lower than those among the nonsurvivors (median, 3,900 pg/mL; range, 3,230 to 5,000 pg/mL; p = 0.017). Among pediatric patients supported with ECMO, the survivors had lower BNP levels than those who did not survive. We suggest that serial blood BNP levels can be potential markers for monitoring pediatric patients on mechanical circulatory support, and the concept merits further study.

Prognostic Value of B-type Natriuretic Peptide in Patients with Acute Coronary Syndromes

B-type natriuretic peptide (BNP) is released from the cardiac ventricles in response to increased wall tension in patients with heart failure. The significance of blood BNP in predicting cardiac death in patients with acute coronary syndromes (ACS) in Chinese patients is yet to be established. Blood BNP concentration was measured in 106 ACS patients 1-3 days after onset of ischemic symptoms. Patients were followed-up for 6 months on mortality and other cardiovascular events. During the follow-up, cardiac death occurred in 13 patients (non-survival group). Another 12 patients were hospitalized due to recurrence of ACS or heart failure. The mean blood BNP concentration in the non-survival group was significantly higher than that of the survival group (median 1132 vs. 116 ng/L, p <0.001). Multivariate logistic regression analysis incorporating age, gender, history of hypertension, diabetes, left ventricular ejection fraction, troponin I and therapeutic regimens indicated that BNP was an independent predictor of cardiac death in these patients (odds ratio = 21.19, 95% confidence interval 4.53-99.06, p <0.001). BNP is a useful parameter in predicting cardiac death in Chinese patients with ACS.

Relationship Between Accurate Auscultation of a Clinically Useful Third Heart Sound and Level of Experience

Poor performance by physicians-in-training and interobserver variability between physicians have diminished clinicians' confidence in the value of the third heart sound (S3). To determine whether auscultation of a clinically useful S3 improves with advancing levels of experience, we performed a prospective, blinded, observational study of 100 patients undergoing left-sided heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), phonocardiography, measurement of blood B-type natriuretic peptide levels, echocardiography for measurement of left ventricular ejection fraction, and cardiac catheterization for measurement of left ventricular end-diastolic pressure. Whereas residents' and interns' auscultatory findings demonstrated no significant agreement with phonocardiographic findings, an S3 auscultated by cardiology fellows (kappa = 0.37; P<.001) and cardiology attendings (kappa = 0.29; P = .003) agreed with phonocardiographic findings. Although the sensitivities of the S3 were low (13%-52%) for identifying patients with abnormal measures of left ventricular function, the specificities were high (85%-95%), with the best test characteristics exhibited by phonocardiography and more experienced physicians. The S3 detected by attendings and fellows was superior in distinguishing an elevated B-type natriuretic peptide level, a depressed left ventricular ejection fraction, or an elevated left ventricular end-diastolic pressure (P = .002-.02 for attendings and .02-.03 for fellows) compared with residents (P = .02-.47) or interns (P = .09-.64). The S3 auscultated by more experienced physicians demonstrated fair agreement with phonocardiographic findings. Although correlations were superior for phonocardiography, the associations between the S3 and abnormal markers of left ventricular function improved with each level of auscultator experience.

Overview of B‐Type Natriuretic Peptide as a Blood Test

A roundtable discussion was convened in December 2005 to discuss current and future applications of blood B-type natriuretic peptide testing in the diagnosis and treatment of cardiovascular disease. Dr. Peter McCullough, consulting cardiologist and Chief of the Division of Preventive Medicine at William Beaumont Hospital in Royal Oak, MI, chaired the discussion. Dr. Christian Mueller, consultant cardiologist and active researcher in the area of cardiac natriuretic peptides at the Department of Internal Medicine, University Hospital, Basel, Switzerland; and Dr. Clyde Yancy, Associate Dean for Medical Affairs at the University of Texas Southwestern Medical Center, Dallas, TX, participated in the discussion.

Flow-Mediated Vasodilation Predicts Outcome in Patients With Chronic Heart Failure: Comparison With B-Type Natriuretic Peptide

The aim of this study was to assess the predictive potency of impaired endothelium-dependent flow-mediated vasodilation (FMD) in patients with chronic heart failure (CHF). Chronic heart failure is associated with reduced FMD; the prognostic impact of this observation is unknown. Seventy-five ambulatory CHF patients (United Network of Organ Sharing [UNOS] status 2) with a left ventricular ejection fraction (LVEF) < or =30%, despite optimized medical therapy (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, 100%; beta-blocker, 81%), were evaluated. Using high-resolution ultrasound, FMD of the brachial artery was assessed in addition to other neurohormonal, clinical, and hemodynamic variables. Age, gender, New York Heart Association (NYHA) functional class, LVEF, hemodynamic variables, B-type natriuretic peptide (BNP) levels, medical therapy, cardiovascular risk factors, and FMD were analyzed for prediction of the combined end point conversion to UNOS status 1 or death in a multivariate Cox model. Up to three years, 21 patients (28%) converted to UNOS status 1, and 6 patients (8%) died. Univariate risk factors for the combined end point were log BNP (p = 0.0032), FMD (p = 0.0033), NYHA functional class (p = 0.0132), beta-blocker therapy (p = 0.0367), and mean blood pressure (p = 0.0406). In the multivariate analysis, only FMD (p = 0.0007), log BNP (p = 0.0032), and mean blood pressure (p = 0.0475) were independently related to the combined end point. In the Kaplan-Meier plot, significantly more patients with FMD <6.8% (median) reached the combined end point, as compared with patients with FMD >6.8% (p = 0.004). In CHF, impaired FMD is a strong, independent predictor of conversion to UNOS status 1 or death.

&lt;b&gt;Blood B-Type Natriuretic Peptide Changes in Different Periods and Different Cardiac Pacing Modes&lt;/b&gt;

To observe blood B-type natriuretic peptide (BNP) level changes and the clinical implications in different periods and different cardiac pacing modes, the BNP levels of 105 patients with permanent cardiac pacing were assayed before pacemaker implantation and 1 day, 1 week, 1 month, 3 months, 6 months, and 9 months postoperatively. BNP level changes were compared in different periods and during different pacing modes. DDD(R) pacing mode was performed in 32 patients for 9 months and then changed to AAI(R) and VVI(R) pacing modes for 2 months, respectively. BNP levels were assayed during three different pacing modes. BNP levels did not change at any time with any pacing mode in patients with New York Heart Association (NYHA) heart functional class I to II before pacemaker implantation, however, BNP levels did change significantly with physiologic pacing mode and nonphysiologic pacing mode in patients with NYHA heart functional class III to IV before pacemaker implantation. BNP levels during physiologic pacing mode decreased significantly while it increased during nonphysiologic pacing mode. BNP levels were the lowest in AAI(R) pacing and the highest in VVI(R) pacing among the three pacing modes. The BNP level in DDD(R) pacing was between that for AAI(R) pacing and VVI(R) pacing. The results indicate that physiologic pacing should first be chosen in patients with bradycardia and congestive heart failure (CHF), and that AAI(R) was the best pacing mode if atrioventricular conduction function was normal.

Elevation in blood urea nitrogen predicts a lower discharge rate from the observation unit

Study objectives: Heart failure is a cause of about 1 million admissions per year. The use of a clinical decision unit (CDU) for these patients decreases 90-day revisits and rehospitalizations and results in a shorter inhospital length of stay. The purpose of this study is to identify laboratory and clinical parameters that predict successful observation unit discharge. Methods: This was a retrospective study of 385 patients, drawn from all acute decompensated heart failure admissions to the CDU observation unit from January 1, 2002, to July 1, 2003. This is a 20-bed urban observation unit immediately adjacent to the emergency department (ED). A computer search identified all adult admissions for decompensated heart failure. Details of medical history, clinical course, patient treatment, laboratory data, and disposition destination were gathered through review of electronic medical records. Recorded laboratory data included sodium, creatinine, blood urea nitrogen (BUN), hemoglobin, and B-type natriuretic peptide levels and initial ED systolic blood pressure. Data were analyzed for ability to predict the requirement of hospital admission after CDU management. Multivariate analysis was performed on those factors associated by univariate analysis with the need for hospital admission. Results: Patients had a mean age of 69.7 years, 50.1% were female patients, and 69.0% had evidence of pulmonary edema by chest radiograph at presentation to the ED. Age, sex, serum sodium level, and B-type natriuretic peptide levels did not predict the need for hospital admission. Elevations in creatinine and BUN levels had statistically significant associations with admission; however, on multivariable analysis, only a BUN level greater than 30 mg/dL significantly predicted failure of CDU management, with subsequent requirements for inpatient management. With each decile of increase in BUN, there was an increase in the need for admission. Conclusion: Our results demonstrate that a BUN greater than 30 mg/dL is associated with an increased likelihood of admission for patients with acute decompensated heart failure, which provides the emergency physician with a practical prognostic tool for disposition planning in decompensated heart failure patients.

Correlation of B-type natriuretic peptide level to 6-min walk test performance in patients with left ventricular systolic dysfunction

Background: B-type natriuretic peptide (BNP) is a neurohormone that can be measured in blood and is useful in patients with congestive heart failure (CHF). We compared whole blood BNP concentrations to distance walked during a 6-min walk test in patients with CHF. Methods: Forty-four patients with CHF underwent a 6-min walk test. The distance walked was compared to the BNP concentration on blood collected prior to the walk test. Patients were followed for 16±2.8 months after testing. Results: A significant correlation was observed between the BNP concentration and the distance walked ( r=−0.47, p<0.001). One patient without congestion died suddenly. Two patients died of progressive heart failure, and two other patients underwent cardiac transplantation. Each of the latter four patients had high BNP concentrations (median 1080 ng/l) and walked short distances (median 183 m). This study indicates that the BNP concentration in blood correlates inversely with the degree of physical capability of patients with heart failure. Conclusions: The BNP concentration could be used as an alternative to the 6-min walk test to assess the severity of heart failure. The assay for BNP is non-invasive, inexpensive, and results are available at the bedside or in a heart failure clinic.

B-Type Natriuretic Peptide Blood Concentrations in Differential Diagnosis of Dyspnea and its Association to 6 Minute Walk

Background and Objectives:This study was performed to, 1) evaluate the diagnostic value of the Brain Natriuretic Peptide (BNP), which is known to be present in the heart ventricle, for patients with dyspnea for the assessing its causes;diastolic or systolic heart failure or pulmonary disease, and 2) find if the BNP is correlated with the distance walked in 6 minutes, which is known to be a prognostic indicator for heart failure. Subjects and Methods:Fifty-seven patients who admitted to the Kangbuk Samsung Medical Center, with the chief complaint of dyspnea, were enrolled in the study. The subjects were classified into three groups according to the causes of their dyspnea, which were systolic heart failure, diastolic heart failure and chronic obstructive pulmonary disease. The plasma BNP levels were measured by a radioimmunoassay, both at admission and discharge. The BNP levels at admission were compared among the three groups. The presence of a correlation between the distance walked in 6 minutes and the BNP at discharge were also evaluated. Results:The patients group with systolic heart failure had the highest mean BNP concentration of 934.6±386.7 pg/mL. The other two groups had significantly lower levels of BNP. The patients group with chronic obstructive pulmonary disease had significantly lower level than the group with diastolic heart failure (33.2±25.6 vs. 181.8±222.2 pg/mL). The BNP concentrations at discharge, and the distance walked in 6 minutes, between the three groups showed no statistical significance (p=0.69). Conclusion:This study showed that the mean plasma BNP level was highest in the group with systolic heart failure, followed by diastolic heart failure and lastly chronic obstructive pulmonary disease. These findings suggest that diagnostic value of the plasma BNP concentration in the assessment of the causes of dyspnea. Although this study has failed to show a correlation between the plasma BNP concentration at discharge and the distance walked in 6 minutes, prospective cohort studies, with larger sample sizes, need to be performed to establish the relationship, if any. (Korean Circulation J 2003;33 (4):302-310)

Intérêt diagnostique du dosage rapide du peptide natriurétique de type B (BNP) sur sang total dans un service de cardiologie

Diagnostic value in the cardiology department of rapid whole blood B-type natriuretic peptide (BNP) testing. BNP, or B-Type natriuretic peptide, is a “cardiac hormone” released into the blood in response to left ventricular stretch. Its concentration increases with heart failure severity. A new quantitative rapid test, which may be used in an emergency setting, delivers results within 15 minutes using whole blood samples. We have used it to determine its diagnostic value in a population of patients admitted to the hospital in the cardiology department. It has allowed us to rule-out or confirm heart failure for 56 patients presenting with acute dyspnea and therefore to avoid more expensive cardiological investigations. BNP is systematically increased (mean of 1,648 pg/mL) for patients presenting with a typical clinical picture of heart failure. The level is proportional to the severity of the cardiopathy as determined by left ventricular ejection fraction. Inversely, a normal BNP level allows to rule-out heart failure. Patients with chronic cardiopathy have moderately elevated BNP levels (223 pg/mL). Knowing the level of BNP during the stability phase of chronically ill heart failure patients can be of significant help in linking the symptoms to a new decompensation event when a patient is readmitted. Levels of BNP have also been measured in patients with acute coronary syndrome. However the values where too heterogenic to be able to draw any conclusions and warrant further studies.

Differential regulation of cardiac adrenomedullin and natriuretic peptide gene expression by AT1 receptor antagonism and ACE inhibition in normotensive and hypertensive rats.

To study the effects of long-term treatment with the type 1 angiotensin (AT1) receptor antagonist losartan and the angiotensin-converting enzyme (ACE) inhibitor enalapril, on cardiac adrenomedullin (ADM), atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) gene expression. Spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) rats were given losartan (15 mg/kg per day) or enalapril (4 mg/kg per day) orally for 10 weeks. The effects of drugs on systolic blood pressure, cardiac hypertrophy, ANP, BNP and ADM mRNA and immunoreactive-ANP (IR)-ANP, IR-BNP and IR-ADM levels in the left ventricle and atria were compared. Losartan and enalapril treatments completely inhibited the increase of systolic blood pressure occurring with ageing in SHR. The ratio of heart to body weight was reduced in both losartan- and enalapril-treated SHR and WKY rats. Treatment with losartan or enalapril reduced left ventricular ANP mRNA and IR-ANP in both strains, and ventricular BNP mRNA levels in SHR rats. Inhibition of ACE, AT1 receptor antagonism, changes in blood pressure or cardiac mass had no effect on left ventricular ADM gene expression in SHR and WKY rats. In addition, atrial IR-ANP and IR-ADM levels increased in SHR whereas IR-BNP levels decreased in WKY and SHR rats in response to drug treatments. Our results show that ventricular ADM synthesis is an insensitive marker of changes in haemodynamic load or cardiac hypertrophy. Furthermore, the expression of ADM, ANP and BNP genes is differently regulated both in the left ventricle and atria in response to AT1 receptor antagonism and ACE inhibition.