Brain Natriuretic Peptide Assay Research Articles

Brain natriuretic peptide and N-terminal brain natriuretic peptide for the diagnosis of haemodynamically significant patent ductus arteriosus in preterm neonates.

Brain natriuretic peptide and N-terminal brain natriuretic peptide for the diagnosis of haemodynamically significant patent ductus arteriosus in preterm neonates.

Serum brain natriuretic peptide in healthy Nigerian newborn babies

Background: Brain natriuretic peptide (BNP) is a sensitive biomarker that is valuable in the management of childhood heart failure. Studies have reported racial differences in the level of BNP, especially in the adult population. The level of BNP in healthy Nigerian newborn babies is unknown. Hence, we determined the level of BNP in healthy term appropriate for gestational age (AGA) newborn babies. Methods: This was a cross sectional study,85 healthy term AGA newborn babies aged 24 to 72 hours. The babies had relevant demographic parameters documented in a proforma and BNP assay analysed using ELISA method. Results: The median IQR serum BNP level was 341.43 (313.39 to 425.45) pg/ml. The median level in females, was higher than males, {393.86 (296.97- 460.62) pg/ml vs328.05 (313.61-389.39) pg/ml, p >0.05}.There was no significant relationship between serum BNP and birth weight, chronological age, gestational age, or mode of delivery (p>0.05 in each case). Conclusion: The study demonstrated high BNP levels in healthy term Nigerian newborns. There was no relationship between BNP, the chronological age, birth weight, gender, gestational age or mode of delivery in babies between 24 to 72 hours of life.

Pyridinium porphyrins and AuNPs mediated bionetworks as SPR signal amplification tags for the ultrasensitive assay of brain natriuretic peptide

Extension of the self-assembled bionanonetworks into surface plasmon resonance (SPR) assay investigation provides an effective signal amplification approach. Wefabricated a bionetwork by nucleic acids, organic compounds, and supramolecular gold nanoparticles for ultrasensitive SPR detection of B-type natriuretic peptide (BNP). The SPR method was developed by a sandwich-type format of aptamer-target-antibody, and the aptamer-modified bionanonetworks induced localized SPR and large refractive index for different concentrations of the target BNP. The linear concentrationrange and limit of detection were 1-10,000pg/mL (R2 = 0.9852) and 0.3pg/mL respectively. The detection recovery wasin the range 92.13 to 108.69%. The approach embraces the following main advantages: (1) Cooperative double recognition was realized by calix[4]arenes for amino aptamers and pyridinium porphyrins. (2) The approach provided the specificity for supramolecular-based nanomaterials and a simple synthesis process via the ordered self-assembly under mild conditions. (3) The bionanonetworks endowed the SPR assay with signal amplification and stable determination for trace proteins. Therefore, it is expected that this study may offer a new SPR signal-amplified platform of organic-inorganic bionanonetworks to achieve sensitive, stable, and real-time determination. Graphical abstract Schematic of bionanonetwork based on porphyrin-mediated functionalized gold nanoparticles for SPR signal amplification to quantitatively detect BNP.

Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study

Underdiagnosis and undertreatment of chronic heart failure (CHF) are common in older patients, who are usually treated by general practitioners (GPs). In 2007, the French ICAGE study explored GPs' attitudes to the management of this condition in older patients. To explore changes over time in GPs' attitudes towards the management of CHF in patients aged ≥75 and to identify barriers to optimal management. In 2015, we performed a qualitative study of 20 French GPs via semi-structured interviews and a thematic content analysis. The results were compared with the findings of a 2007 study. In 2015, the perceived barriers to diagnosis were the same as in 2007. Echocardiography was still the preferred diagnostic method but the GPs relied on the cardiologist to confirm the diagnosis. Many GPs were still unaware of the different types of CHF. In contrast, they reported greater knowledge of decompensation factors and the ultrasound criteria for CHF. They also prescribed a brain natriuretic peptide assay more frequently. Angiotensin-converting enzyme inhibitors and beta blockers were more strongly perceived to be core treatments. Few GPs initiated drug treatments and optimized dosages. Although patient education was never mentioned, the importance of multidisciplinary care was emphasized. Our results evidenced a small recent improvement in the management of older patients with CHF. Appropriate guidelines and training for GPs, patient education and multidisciplinary collaboration might further improve the care given to this population.

Role of Brain Natriuretic Peptide assay in identifying children with pneumonia complicated by congestive cardiac failure

Background: Pneumonia in children is a leading cause of morbidity and mortality in developing countries. It is often complicated by Congestive Cardiac Failure (CCF), with some of the symptoms similar to those of pneumonia. Brain Natriuretic Peptide (BNP) assay can differentiate cardiac from respiratory-related causes of respiratory distress. Objective: To determine the role of BNP in differentiating isolated pneumonia from pneumonia complicated by CCF. Methods: Over a 12-month period, consecutive children with radiologically-confirmed pneumonia were recruited for the study. Those with complicating CCF were noted. All the children had blood BNP assay done by ELISA, prior to treatment. Biodata was obtained and the children were grouped into those with isolated pneumonia and those with pneumonia complicated by CCF. Results: Fifty children were recruited; of these 26 (52.0%) had isolated pneumonia while 24 (48.0%) had pneumonia with CCF. The median age of the children was 6 months. The median BNP values for the isolated pneumonia group (229.4 ng/l), was significantly lower than that of pneumonia complicated by CCF group (917.3 ng/l); (p = 0.007). ROC showed that a BNP value >550ng/l could identify children with pneumonia complicated with CCF from those with isolated pneumonia with a sensitivity of 70.4% and specificity of 63.4%. Conclusion: A BNP assay prior to treatment of >550ng/l can differentiate children with pneumonia complicated with CCF from those without CCF.

Standardization of BNP and NT-proBNP Immunoassays in Light of the Diverse and Complex Nature of Circulating BNP-Related Peptides.

Brain natriuretic peptide (BNP) and the N-terminal fragment of the BNP precursor (NT-proBNP) are widely used as heart failure (HF) biomarkers. Since the discovery of BNP in 1988, much effort has been allocated to the precise detection of BNP and NT-proBNP levels for reliable HF diagnostics. As a result, measurements of these biomarkers are globally accepted and used in clinical practice for the diagnosis of acute and chronic HF, risk stratification, and monitoring response to therapy. Several immunoassays specific for BNP and NT-proBNP are currently commercially available. Recent comparative studies show that there are marked differences between different BNP and NT-proBNP assays and platforms, and the results of measurements are not comparable enough. The lack of equivalence between the assays complicates the interpretation of the results and renders the cut-off points for diagnostic decisions to be method dependent. Presently, there is no agreement on what kind of BNP or NT-proBNP standard should be used for calibration, and a certified reference material as well as reference measurement procedures are lacking. The aim of this chapter is to summarize the available data on the complex nature of BNP-related peptides, specificity for existing BNP and NT-proBNP immunoassays, and to discuss potential approaches for standardization of BNP and NT-proBNP measurements.

Value of Brain Natriuretic Peptide Assay for the Etiologic Diagnosis and Its Correlation with Doppler Echocardiography in Patients of Acute Onset Dyspnoea

Value of Brain Natriuretic Peptide Assay for the Etiologic Diagnosis and Its Correlation with Doppler Echocardiography in Patients of Acute Onset Dyspnoea

Beneficial effects of upgrading to His bundle pacing in chronically paced patients with left ventricular ejection fraction

Heart failure is common in patients with permanent pacemakers. Right ventricular (RV) pacing may worsen cardiac function, while the nonresponder rate of cardiac resynchronization therapy (CRT) for heart failure treatment remains 25%-30%. The purpose of this study was to assess clinical outcomes of upgrading to permanent His bundle pacing (pHBP) in patients with heart failure who underwent device upgrade from right ventricular pacing or CRT nonresponse. Eighteen patients with pacing-dependent heart failure and left ventricular ejection fraction (LVEF) <50% underwent pHBP attempts at device replacement. Of those 18 patients, 16(88.9%) received pHBP successfully and followed for a mean of 36.2 months. All these patients underwent clinical evaluation, echocardiography, brain natriuretic peptide assay, and chest radiography immediately before replacement and during follow-up visits. Of the 16 patients (mean age 70.6 ± 12.9 years; 9[56.3%] men), 11 (68.8%) patients had pacing-induced cardiomyopathy (PICM) while the remaining 5 (31.2%) patients were CRT nonresponders. After upgrading to pHBP, QRS duration was significantly shortened (from 156.9 ± 21.7 to 107.1 ± 16.5 ms; P < .01). At 1-year follow-up after HBP, left ventricular end-diastolic dimensions decreased from baseline 62.3 ± 6.9 to 55.5 ± 7.7 mm (P < .01) and LVEF increased from baseline 35.7% ± 7.9% to 52.8% ± 9.6% (P < .01). Other improvements after HBP upgrade included mitral valve regurgitation, serum brain natriuretic peptide concentrations, cardiothoracic ratios, and New York Heart Association functional class (P < .01 for all). In paced patients with clinically symptomatic heart failure and LVEF <50%, pHBP upgrade was feasible in 88.9%, with improved left ventricular function and remodeling. Hence, pHBP can be an alternative for patients with pacing-induced cardiomyopathy and CRT nonresponders.

The Utility of Brain Natriuretic Peptide in Pediatric Cardiology: A Review.

The aim of this article is to evaluate the clinical utility of brain natriuretic peptide in pediatric patients, examining the diagnostic value, management, and prognostic relevance, by critical assessment of the literature. In December 2015, a literature search was performed (PubMed access to MEDLINE citations; http://www.ncbi.nlm.nih.gov/PubMed/) and included these Medical Subject Headings and text terms for the key words: "brain natriuretic peptide," "amino-terminal pro-brain natriuretic peptide," "children," "neonate/s," "newborn/s," "infant/s," and "echocardiography." Each article title and abstract was screened to identify relevant studies. The search strategy was limited to published studies in English language concerning brain natriuretic peptide/amino-terminal pro-brain natriuretic peptide in pediatric patients. Data on age, gender, type of clinical condition, brain natriuretic peptide assay method, cardiac function variables evaluated by echocardiography, and prognosis were extracted. Brain natriuretic peptide reference values in healthy newborns, infants, and children are presented. Brain natriuretic peptide diagnostic accuracy in newborns, infants, and children suspected to have congenital heart defects is discussed, and brain natriuretic peptide prognostic value reviewed. The data suggest that the determination of brain natriuretic peptide levels improves the diagnostic accuracy in the assessment of heart disease in the pediatric population. Brain natriuretic peptide assay may increase the accuracy of neonatal screening programs for diagnosing congenital heart defects. Echocardiographic variables correlated to brain natriuretic peptide levels. Additionally, brain natriuretic peptide levels predicted adverse outcomes in the postoperative period. Brain natriuretic peptide assessment is a reliable test to diagnose significant structural or functional cardiovascular disease in children. In the integrated follow-up of these cases, several physiologic and clinical variables must be considered; brain natriuretic peptide may be an additional helpful marker. Nevertheless, larger prospective studies are warranted to elucidate the true prognostic value of brain natriuretic peptide in pediatric patients.

Utility of brain natriuretic peptide assay as a predictor of short term outcomes in patients presenting with syncope to the emergency department.

Syncope is a common condition that accounts for 3% of emergency department (ED) visits and 1-6% of hospital admissions. Current admissions practices result in marginal diagnostic and therapeutic benefit and consume healthcare resources. This prospective cohort study examined the use of brain natriuretic peptide (BNP) test as a predictor of short term serious outcome in 159 patients who presented to ED with syncope between August 2012 and August 2013 in two tertiary teaching medical centers. A total of 41 patients (36%) had serious outcomes within 1 month, 21 of them were in the low BNP group and 20 were in the high BNP group. There was a significantly higher incidence of serious outcomes, myocardial infarction (MI), and life-threatening arrhythmias in the high BNP group. Patients with BNP >250 has an 8.844 fold increase risk of serious outcomes [odds ratio (OR) 8.844, 95% CI: (3.281 to 23.8), P<0.001], a 14.8-fold increase risk of MI [OR =14.8, 95% CI: (1.57 to 139), P=0.011], and a 4.46-fold increase risk life threatening arrhythmia [OR =4.46, 95% CI: (1.15-18.8), P=0.034]. However, there was no statistically significant difference between the two groups in one month mortality, major bleeding, major cardiac procedures or stroke. Our study results further validates the ROSE rule and the utility of BNP in risk stratification of syncope patients. This study showed that measuring BNP and adding ROSE rule to the standard evaluation of syncope can sufficiently predict short-term serious outcomes for patients presenting to ED with syncope.

Quantitative assay of brain natriuretic peptide in rat cardiomyocytes in the early postreperfusion period

We studied the intensities of accumulation and secretion of brain natriuretic peptide (BNP) in the early postreperfusion period, i.e., 5 min and 1 h after the start of reperfusion in the myocardium of the right atrium of rats. Total ischemia was modeled using Korpachev’s method. Immunocytochemical detection of peptide distribution in secretory cardiomyocytes was performed in ultrathin sections using polyclonal antibodies to BNP. The immunoreactive granules of A and B types were counted in optical fields of 38 × 38 µm2 using a transmission electron microscope. Five minutes after the start of reperfusion, the number of BNPcontaining secretory granules was similar to that observed in the control animals. After a 1-h postreperfusion period, we observed active formation and release of BNP because the number of granules of A and B-types increased by 134 and 210%, respectively, as compared to the intact group. These data demonstrate the stimulating effects of ischemic and reperfusion factors on the processes of synthesis and secretion of BNP in this period.

Analyse van equine BNP met een porciene BNP “enzyme-linked immunoassay”: een pilootstudie

“Brain natriuretic peptide” (BNP) wordt gebruikt in de humane geneeskunde voor de diagnose van congestief hartfalen. Vermits er geen BNP-test voor paarden beschikbaar is, werd BNP nog nooit bepaald bij paarden. Op basis van de 90% homologie tussen equine en porciene BNP, werd in de voorliggende studie het plasma BNP-gehalte van gezonde paarden (groep 1; n=20), paarden met een hartaandoening zonder (groep 2a; n=8) en met atriale dilatatie (n=8), ventriculaire dilatatie (n=1) of beide (n=1) (groep 2b; n=10) bepaald met een porciene BNP “enzyme-linked immunoassay” (ELISA). Er werd geen significant verschil gevonden tussen de BNP-concentratie van groep 1 (77,79; 37,20-513,36 pg/mL), groep 2a (52,02; 24,69-268,37 pg/mL) of 2b (94,73; 42,88-470,66 pg/mL). In deze pilootstudie wordt aangetoond dat deze porciene BNP ELISA-test geen accurate detectie van BNP bij paarden toelaat. Een specifieke equine BNP-test zou dus ontwikkeld moeten worden om de BNP-concentratie bij paarden te meten.

Diagnosing significant PDA using natriuretic peptides in preterm neonates: a systematic review.

Echocardiogram is the gold standard for the diagnosis of hemodynamically significant patent ductus arteriosus (hsPDA) in preterm neonates. A simple blood assay for brain natriuretic peptide (BNP) or amino-terminal pro-B-type natriuretic peptide (NT-proBNP) may be useful in the diagnosis and management of hsPDA. Our objectives were to determine the diagnostic accuracy of BNP and NT-proBNP for hsPDA in preterm neonates and to explore heterogeneity by analyzing subgroups. The systematic review was performed as recommended by the Cochrane Diagnostic Test Accuracy Working Group. Electronic databases, conference abstracts, and cross-references were searched. We included studies that evaluated BNP or NT-proBNP (index test) in preterm neonates with suspected hsPDA (participants) in comparison with echocardiogram (reference standard). A bivariate random effects model was used for meta-analysis, and summary receiver operating characteristic curves were generated. Ten BNP and 11 NT-proBNP studies were included. Studies varied by methodological quality, type of commercial assay, thresholds, age at testing, gestational age, and whether the assay was used to initiate medical or surgical therapy. Sensitivity and specificity for BNP at summary point were 88% and 92%, respectively, and for NT-proBNP they were 90% and 84%, respectively. The studies evaluating the diagnostic accuracy of BNP and NT-proBNP for hsPDA varied widely by assay characteristics (assay kit and threshold) and patient characteristics (gestational and chronological age); therefore, generalizability between centers is not possible. We recommend that BNP or NT-proBNP assays be locally validated for specific patient population and outcomes, to initiate therapy or follow response to therapy.

BNP in children with congenital cardiac disease: is there now sufficient evidence for its routine use?

Interest in brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in the management of children with CHD has increased. There are, however, no current guidelines for their routine use. The aim of this review article is to provide an update on the data regarding the use of BNP/NT-proBNP in the evaluation and surgical treatment of children with CHD. BNP/NT-proBNP levels in children with CHD vary substantially according to age, laboratory assay methods, and the specific haemodynamics associated with the individual congenital heart lesion. The accuracy of BNP/NT-proBNP as supplemental markers in the integrated screening, diagnosis, management, and follow-up of CHD has been established. In particular, the use of BNP/NT-proBNP as a prognostic indicator in paediatric cardiac surgery has been widely demonstrated, as well as its role in the subsequent follow-up of surgical patients. Most of the data, however, are derived from single-centre retrospective studies using multivariable analysis; prospective, randomised clinical trials designed to evaluate the clinical utility and cost-effectiveness of routine BNP/NT-proBNP use in CHD are lacking. The results of well-designed, prospective clinical trials should assist in formulating guidelines and expert consensus recommendations for its use in patients with CHD. Finally, the use of new point-of-care testing methods that use less invasive sampling techniques - capillary blood specimens - may contribute to a more widespread use of the BNP assay, especially in neonates and infants, as well as contribute to the development of screening programmes for CHD using this biomarker.

The potential and limitations of plasma BNP measurement in the diagnosis, prognosis, and management of children with heart failure due to congenital cardiac disease: an update

The aim of this article is to review the diagnostic and prognostic relevance of measurement of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in pediatric patients with heart failure caused by various acquired and congenital heart diseases (CHD). In January 2013, we performed a computerized literature search in the National Library of Medicine (PubMed access to MEDLINE citations; http://www.ncbi.nlm.nih.gov/PubMed/ ). The search strategy included a mix of Medical Subject Headings and free-text terms for the key concepts, starting from BNP assay and 'NT-proBNP assay', children, CHD. The search was further refined by adding the keywords neonate/s, newborn/s, heart failure, cardiomyopathy, screening, prognosis, follow-up, and management. BNP values are age and method dependent, even in pediatric populations. Regardless of age, there is great variability in BNP/NT-proBNP values within CHD characterized by different hemodynamic and clinical conditions. There is enough evidence to support the use of BNP/NT-proBNP as an adjunctive marker in the integrated evaluation of patients with congenital and acquired heart disease to help define severity and progression of heart failure as well in the monitoring of response to treatment. BNP/NT-proBNP can also be used for the screening of heart failure and as a prognostic marker in children undergoing cardiac surgery; however, to date, there are studies with heterogeneous patient groups, and diverse outcome measures selected are still few. BNP/NT-proBNP can be used as adjunctive markers in the integrated screening, diagnosis, management, and follow-up of children with heart failure caused by various acquired and congenital heart disease.

Effect of hemodyalysis on precursor proBNP and glycosylated NT-proBNP in end-stage renal disease patients

Background: Brain natriuretic peptide (BNP) is established biomarker for cardiovascular diseases. Recent studies have shown that unprocessed precursor proBNP circulates in the healthy individuals, and its levels in plasma are increased in severe heart failure patients. However, since current BNP immunoassay crossreacts proBNP, it is important to consider the significance of proBNP on clinical situation of BNP elevation. In addition, recent study has shown that most proBNP is glycosylated, and that NT-proBNP is also glycosylated in human plasma, and current NT-proBNP assay underestimates the glycosylated NT-proBNP. Recent developed super-flux dialyzer can remove middle-sized molecular solutes such as β2-microgloburin. In this study, we investigated the effects of hemodialysis using super-flux dialyzer on the glycosylated proBNP, glycosylated NT-proBNP, and BNP-related other peptide in patients with end-stage renal disease (ESRD). Method: Thirty-six ESRD patients with hemodialysis were studied. We measured plasma BNP (which was defined as BNP messured with current BNP assay system), proBNP, and mature BNP (which was defined as total BNP- proBNP), by our newly developed immunoassay before and after hemodialysis. Plasma glycosylated NT-proBNP and nonglycosylated NT-proBNP was measured by Elecsys II after deglycosylating enzyme treatment such as neuramoinidase and O-glycosydase. We also measured plasma ANP and cGMP by radioimmunoassay. Results: After hemodialysis, BNP (-28%), proBNP (-20%), mature BNP (-47%), glycosylated NT-proBNP (-33%), nonglycosylated NT-proBNP (-45%), ANP (-52%), and cGMP (-63%) significantly decreased. The decreasing ratio did not correlated with any indices of reduction of plasma volume; however, these peptides decreased after hemodialysis in a molecular weight dependent manner. ProBNP/total BNP ratio and glycosylated NT-proBNP/nonglycosylated NT-proBNP ratio increased after hemodialysis. ProBNP/total BNP ratio positively correlated with hemodialysis vintage and negatively correlated with left atrial dimater and systolic blood pressure, whereas glycosylated NT-proBNP/nonglycosylated positively correlated with parathyroid hormone levels. Conclusion: These results suggest that hemodialysis modulates profile of BNP and its related peptide, and it may be important to consider the effect of this modulation on the pathological conditions in ESRD patients in super-flux dialyzer era.

Response of Cardiac Endocrine Function to Surgery Stress is Age Dependent in Neonates and Children With Congenital Heart Defects

The aim of this study was to evaluate the diagnostic and prognostic accuracy of brain natriuretic peptide assay in neonates and children undergoing surgery for congenital heart disease. Prospective, observational study. Single center. We enrolled 336 consecutive children (median age, 6 mo [range, 0-37 mo]) undergoing cardiac surgery (87 neonates; age, 7 d [5-12]; median, 25th-75th percentile; 24 infants and children; age, 11 mo [4-60]) and 436 healthy controls. Brain natriuretic peptide was measured preoperatively, on every postoperative day in the ICU, and at discharge. Intubation time was the primary outcome. Preoperative brain natriuretic peptide values in patients with congenital heart disease were higher than those in controls (p < 0.01). Brain natriuretic peptide had a good diagnostic accuracy in discriminating between patients with congenital heart disease and healthy controls with an area under the curve = 0.918 for neonates and area under the curve = 0.894 for older children. The best cutoff values, calculated by receiver operating characteristic analysis, were different for the two age subgroups with cutoff values of 363.5 ng/L for neonates and 23.5 ng/L for older children. At 24 hours after surgery, although brain natriuretic peptide decreased in neonates (baseline 2723 vs 1290 ng/L, p < 0.001), it increased in children (60 vs 365 ng/L at 24 hours, p < 0.001). Multivariable analysis identified the preoperative level of brain natriuretic peptide in infant/children and the difference in brain natriuretic peptide value (baseline 24 hours) in neonates, as independent predictors of intubation time. Furthermore, body surface area, Aristotle score, and cardiopulmonary bypass time had an independent significant effect on the endpoint in either group. Baseline cardiac endocrine function and its response to surgical stress are dependent on age in neonates and children, undergoing cardiac surgery for congenital heart disease. Brain natriuretic peptide shows a good diagnostic and prognostic accuracy in this setting, with different features in either neonates or infants/children subsets.

Diagnostic, prognostic and therapeutic relevance of B-type natriuretic hormone and related peptides in children with congenital heart diseases

The aim of this article is to review the diagnostic and prognostic relevance of measurement of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in pediatric patients with congenital cardiac diseases (CHD). A computerized literature search in the National Library of Medicine using the keywords "BNP assay" and "NT-proBNP assay"+neonate/s and newborn/s was performed. Next, we refined the analysis to include only the studies specifically designed to evaluate the clinical usefulness of BNP and NT-proBNP measurements in children with CHD. Several authors suggested that BNP/NT-proBNP is clinically helpful as a diagnostic and prognostic marker for children with suspected CHD. BNP values are age dependent, even in paediatric populations. Unfortunately, accurate reference values for BNP and NT-proBNP for neonatal ages have only recently become available. As a result, the lack of homogenous and accurate decisional levels in the neonatal period greatly limits the clinical impact of the BNP assay, and also contributed to the production of conflicting results. Regardless of age, there is great variability in BNP/NT-proBNP values among CHD characterized by different hemodynamic and clinical conditions. In particular, cardiac defects characterized by left ventricular volume and pressure overload usually show a higher BNP response than CHD which is characterized by right ventricular volume or pressure overload. BNP and NT-proBNP may be considered helpful markers in the integral clinical approach for patients with CHD. Measurement of BNP cannot replace cardiac imaging (including echocardiography, angiography and magnetic resonance), but provide independent, low cost and complementary information for the evaluation of cardiac function and clinical status.

Exercise Hemodynamics Enhance Diagnosis of Early Heart Failure With Preserved Ejection Fraction

When advanced, heart failure with preserved ejection fraction (HFpEF) is readily apparent. However, diagnosis of earlier disease may be challenging because exertional dyspnea is not specific for heart failure, and biomarkers and hemodynamic indicators of volume overload may be absent at rest. Patients with exertional dyspnea and ejection fraction >50% were referred for hemodynamic catheterization. Those with no significant coronary disease, normal brain natriuretic peptide assay, and normal resting hemodynamics (mean pulmonary artery pressure <25 mm Hg and pulmonary capillary wedge pressure [PCWP] <15 mm Hg) (n=55) underwent exercise study. The exercise PCWP was used to classify patients as having HFpEF (PCWP ≥25 mm Hg) (n=32) or noncardiac dyspnea (PCWP <25 mm Hg) (n=23). At rest, patients with HFpEF had higher resting pulmonary artery pressure and PCWP, although all values fell within normal limits. Exercise-induced elevation in PCWP in HFpEF was confirmed by greater increases in left ventricular end-diastolic pressure and was associated with blunted increases in heart rate, systemic vasodilation, and cardiac output. Exercise-induced pulmonary hypertension was present in 88% of patients with HFpEF and was related principally to elevated PCWP, as pulmonary vascular resistances dropped similarly in both groups. Exercise PCWP and pulmonary artery systolic pressure were highly correlated. An exercise pulmonary artery systolic pressure ≥45 mm Hg identified HFpEF with 96% sensitivity and 95% specificity. Euvolemic patients with exertional dyspnea, normal brain natriuretic peptide, and normal cardiac filling pressures at rest may have markedly abnormal hemodynamic responses during exercise, suggesting that chronic symptoms are related to heart failure. Earlier and more accurate diagnosis using exercise hemodynamics may allow better targeting of interventions to treat and prevent HFpEF progression.

Diagnostic accuracy and clinical relevance of brain natriuretic peptide assay in pediatric patients with congenital heart diseases

The clinical usefulness of B-type natriuretic peptide (BNP) assay in congenital heart diseases is still controversial. We evaluated the diagnostic accuracy and clinical relevance of this assay in different cardiovascular hemodynamic conditions in pediatric patients with congenital heart diseases. BNP was measured in 173 healthy individuals and in 382 pediatric patients with congenital heart diseases. We identified five subgroups of hemodynamic conditions: left ventricular volume overload, right ventricular volume overload, left ventricular pressure overload, right ventricular pressure overload, and biventricular volume overload. BNP was higher (P<0.0001) in patients (median 49.0 ng/l, range 0.45-14363 ng/l) than in the reference population (median 6.1 ng/l, range 1.0-29.7 ng/l). BNP assay showed a good diagnostic accuracy in discriminating between healthy individuals and patients (area under the receiver operating characteristic curve 0.95, SE 0.009). Lower BNP values were found in right ventricular pressure overload than in left ventricular pressure overload, left ventricular volume overload, or biventricular volume overload. In the left ventricular volume overload subgroup, BNP significantly correlated with peak systolic gradients (rho=0.622, P<0.001) and left ventricular dilatation (rho=0.35, P=0.03). In the right ventricular volume overload subgroup, BNP correlated with right ventricular pressure (rho=0.622, P<0.001) and right ventricular dilatation (rho=0.377, P=0.0077). Moreover, in cyanotic defects, BNP showed a significant correlation with O2 saturation (rho=0.204 P=0.0128). BNP assay showed a good diagnostic accuracy in discriminating between healthy individuals and patients. Congenital heart disease with left ventricular pressure overload and biventricular volume overload has higher BNP values than that with right ventricular pressure overload.