Diagnosis Of Heart Failure In Patients Research Articles

Value of inferior vena cava collapsibility index as marker of heart failure in chronic obstructive pulmonary disease exacerbation

IntroductionInferior vena cava (IVC) diameter variability with respiration measured by ultrasound was found to be useful for the diagnosis of heart failure (HF) in ED patients with acute dyspnea. Its value in identifying HF in acute exacerbation of chronic obstructive pulmonary disease exacerbation (AECOPD) was not specifically demonstrated.ObjectiveTo determine the value of ΔIVC in the diagnosis of HF patients with AECOPD.MethodsThis is a prospective study conducted in the ED of three Tunisian university hospitals including patients with AECOPD. During this period, 401 patients met the inclusion criteria. The final diagnosis of HF is based on the opinion of two emergency experts after consulting the data from clinical examination, cardiac echocardiography, and BNP level. The ΔIVC was calculated by two experienced emergency physicians who were blinded from the patient’s clinical and laboratory data. A cut off of 15% was used to define the presence (< 15%) or absence of HF (≥ 15%). Left ventricular ejection fraction (LVEF) was also measured. The area under the ROC curve, sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic and predictive accuracy of the ΔIVC in predicting HF.ResultsThe study population included 401 patients with AECOPD, mean age 67.2 years with male (68.9%) predominance. HF was diagnosed in 165 (41.1%) patients (HF group) and in 236 patients (58.9%) HF was excluded (non HF group). The assessment of the performance of the ΔIVC in the diagnosis of HF showed a sensitivity of 37.4% and a specificity of 89.7% using the threshold of 15%. The positive predictive value was 70.9% and the negative predictive value was 66.7%. The area under the ROC curve was 0.71(95%, CI 0.65–0.76). ΔIVC values were not different between HF patients with reduced LVEF and those with preserved LVEF.ConclusionOur results showed that ΔIVC has a good value for ruling out HF in ED patients consulting for AECOPD.

CAN ANEMIA BE A CONFOUNDER IN NT-PROBNP INTERPRETATION?

Heart failure is a major clinical issue of concern worldwide. Many biomarkers are used to aid the diagnosis of heart failure patients. One of the increasingly used biomarkers is the biologically inactive NT-proBNP. Several confounding factors affect plasma NT-proBNP levels, and hence, the validity of its interpretation. Heart failure and anemia are well correlated, as evidenced by variety of studies. In, anemia can yield some degree of cardiac stress that leads to the expression of NT-proBNP levels above the cut-off values. This study aimed to test whether anemia can be associated with an elevated peptide level in patients without heart failure. A cross-sectional study in which a total of 108 randomly selected patients, irrespective of their hemoglobin levels, were recruited. Males comprised 39.8% of the total, and the patients were divided based on their hemoglobin levels into anemic (55 patients) and non-anemic (53 patients) groups. Plasma NT-proBNP levels were assessed using ELISA, and the results were interpolated and analyzed against hemoglobin levels. The NT-proBNP level was significantly higher in patients with anemia (p &lt; .0001) where it was 268.7 ± 38.9 vs. 93.55 ± 17.4 ng/dl for both the anemic and non-anemic groups, respectively. Hemoglobin level showed a negative correlation with plasma peptide level ([F (1, 107) = 28.63, p &lt; .0001)], with an r2 of 0.358. Anemia is inversely correlated with the plasma NT-proBNP level. In fact, anemia can raise the peptide level beyond its recommended cutoff levels making the interpretation of the raised NT-proBNP more challenging.

Anatomopathological Consequences of the Change in the Clinical-Demographic Profile of Chagasic Patients Who Are Candidates for Heart Transplantation in Recent Years

<h3>Purpose</h3> Chagasic cardiomyopathy is considered the most aggressive etiology of heart failure (HF). As there is no etiological treatment capable of reversing the evolution of the disease, cardiac replacement therapy such as heart transplantation (HT) may be needed. In recent years, changes in the clinical and demographical profiles of chagasic patients who are candidates for HT have been noticed. This study aims to evaluate the histopathological implications of the change in the clinical-demographic profile of chagasic patients in recent years. <h3>Methods</h3> This is a retrospective observational study in which 313 chagasic patients undergoing HT from 1/1/2010 to 12/31/2019 were included and divided into 2 groups according to the time when HT was performed: a) HT until 12/31/2016; b) HT from 12/1/2017 to 12/31/2019. The pathological characteristics of all 313 explanted hearts were evaluated. Furthermore, they were correlated with laboratory diagnoses of Chagas disease performed in all patients. <h3>Results</h3> In a previous study, we demonstrated a change in the clinical-demographic profile of chagasic patients who are candidates for HT in recent years. When evaluating the pathological diagnoses of the explanted hearts, of the 289 patients in group A, 285 (98.6%) were in agreement with the laboratory diagnosis of Chagas disease, but in group B, of the 24 patients, 16 (66.7%) did not agree between the laboratory diagnosis of Chagas disease and the anatomopathological diagnosis. Of these 24 patients, 7 (29.1%) had histopathological features suggestive of ischemic cardiomyopathy, 9 (37.5%) had histopathological features of nonspecific dilated cardiomyopathy and only 8 (33.4%) patients had agreement between laboratory and histopathological diagnosis of Chagas disease. <h3>Conclusion</h3> In addition to older age and more comorbidities, another objective finding corroborates the change in the clinical-demographic profile of chagasic patients who are candidates for heart transplantation is the significant disagreement between laboratory and anatomopathological diagnoses, making it challenging to confirm the etiological diagnosis of HF in patients with a serological diagnosis of Chagas disease.

Real world diagnostic investigations pattern in patients hospitalized for HF: Interim review of National Malaysia Heart Failure (MYHF) registry

Heart Failure (HF) contributes to 6–10% of acute hospital admissions in Malaysia. Effective management of HF is challenging and timely assessment of patients would be important to achieve optimal care. Echocardiography & biomarker evaluation plays central role in diagnosis of HF patients.

Short-term prognostic value of heart failure diagnosis in a contemporary cohort of patients with ACHD

Abstract Background Heart failure (HF) is one of the primary causes of premature death in patients with adult congenital heart disease (ACHD), yet population-specific data remains scarce. This study aims at assessing the short-term value of prognostic value of a heart failure diagnosis in patients with adult congenital heart disease, and its relation to ACHD classification systems such as the Bethesda disease complexity classification and the physiological severity classification. Methods This study included 3995 patients under active follow-up at our institution. We used a standardized definition of ACHD-HF. Predictors of the composite primary outcome: death, transplant or ventricular assist device (VAD) were identified using uni- and multivariable Cox proportional hazard models. Results Mean age was 35.7±13.3 years. According to the Bethesda disease complexity classification 33.5% of patients had simple defects, 55.6% moderate defects, and 10.9% severe defects. Based on the physiological severity classification, 18.0% of patients were in physiological stage A, 35.6% in physiological stage B, 42.2% in physiological stage C, and 4.2% in physiological stage D. The overall prevalence of ACHD-HF was 6.4%. During a median follow up of 1.8 (IQR 1.3–2.9) years, patients with ACHD-HF had a worse outcome with 27.3% reaching the composite primary endpoint of death, heart transplant or VAD implantation, compared to 1.4% of ACHD patients without HF. Event-free survival was 91.1%, 72.0% and 46.1% at 2, 4 and 6 years in patients with ACHD-HF, compared to 99.5%, 98.7% and 95.1% in ACHD patients without HF. In multivariable analysis the presence of heart failure (HR 4.6; 95% CI 2.9–7.2; p&amp;lt;0.001) and the physiological severity classification (HR 3.1; 95% CI 2.3–4.1; p&amp;lt;0.001) were independently associated with the composite primary outcome, whereas the Bethesda disease complexity classification was not (HR 0.9; 95% CI 0.7–1.3; p=0.701). Conclusion The risk of mortality, transplant and VAD is substantially increased in ACHD-HF patients. Our data provides insight into the short term prognostic value of a HF diagnosis in ACHD patients, helping physicians to gauge the prognosis in ACHD-HF and thereby guide management decisions. In addition to the physiological severity classification, the presence of HF proves to be a valuable prognostic marker in patients with ACHD. Funding Acknowledgement Type of funding sources: None. Kaplan–Meier analysesUni- and multivariable Cox regression

Value of nitroglycerin test in the diagnosis of heart failure in emergency department patients with undifferentiated dyspnea.

BackgroundRapid diagnosis of heart failure (HF) in acutely dyspneic patients can be challenging for emergency department (ED) physicians.HypothesisCardiac output (CO) change with sublingual nitroglycerin (NTG) could be helpful in the diagnosis of HF in patients with acute undifferentiated dyspnea.Materials and MethodsA prospective study of patients >18 years admitted to the ED for acute dyspnea. Using thoracic bioimpedance, we measured CO change at baseline and after sublingual administration of 0.6 mg of NTG. HF was defined on the basis of clinical examination, pro‐brain natriuretic peptide levels, and echocardiographic findings. Diagnostic performance of delta CO was calculated by sensitivity, specificity, likelihood ratio and receiver operating characteristic (ROC) curve.ResultsThis study included 184 patients with mean age of 64 years. Baseline CO was comparable between the HF group and the non‐HF group. At its best cutoff (29%), delta CO showed good accuracy in the diagnosis of HF with a sensitivity, specificity, positive and negative likelihood ratios of 80%, 44%, 57%, and 66% respectively. Area under ROC curve was 0.701 [95% CI 0.636–0.760]. The decrease of CO with sublingual NTG was significantly higher in patients with HFpEF compared with those with HFrEF. Multivariate analysis, showed that delta CO was an independent factor associated with HF diagnosis [OR 0.19 (95% CI 0.11–0.29); p < .001].ConclusionsOur study showed that CO change with sublingual nitroglycerin is a simple tool that may be helpful for the diagnosis of HF in ED patients with undifferentiated dyspnea.

Prognosis and outcome determinants after heart failure diagnosis in patients who underwent aortic valvular intervention.

AimsTo study clinical phenotype, prognosis for all‐cause and cardiovascular (CV) mortality and predictive factors in patients with incident heart failure (HF) after aortic valvular intervention (AVI) for aortic stenosis (AS).Methods and resultsIn this retrospective, observational study we included patients from the Swedish Heart Failure Registry (SwedeHF) recorded 2003–2016, with AS diagnosis and AVI before HF diagnosis. The AS diagnosis was established according to International Classification of Diseases 10th revision (ICD‐10) codes, thus without information concerning clinical or echocardiographical data on the aortic valve disease. The patients were divided into two subgroups: left ventricular ejection fraction (LVEF) ≥ 50% (AS‐HFpEF) and <50% (AS‐HFrEF). We individually matched three controls with HF from the SwedeHF without AS (control group) for each patient. Baseline characteristics, co‐morbidities, survival status and outcomes were obtained by linking the SwedeHF with two other Swedish registries. We used Kaplan–Meier curves to present time to all‐cause mortality, cumulative incidence function for time to CV mortality and Cox proportional hazards model to evaluate the relative difference between AS‐HFrEF and AS‐HFpEF and AS‐HF and controls. The crude all‐cause mortality was 49.0%, CV mortality 27.9% in AS‐HF patients, respectively 44.7% and 26.6% in matched controls. The adjusted risk for all‐cause mortality and CV mortality was similar in HF, regardless of LVEF vs. controls. No significant difference in factors predicting higher all‐cause mortality was observed in AS‐HFrEF vs. AS‐HFpEF, except for diabetes (only in AS‐HFrEF), with statistically significant interaction predicting death between the two groups.ConclusionsIn this nationwide SwedeHF study, we characterized incident HF population after AVI. We found no significant differences in all‐cause and CV mortality compared with general HF population. They had virtually the same predictors for mortality, regardless of LVEF.

Diagnostic accuracy of inferior vena cava ultrasound for heart failure in patients with acute dyspnoea: a systematic review and meta-analysis

BackgroundDyspnoea is the most common sign of heart failure (HF). Patients accessing the ED for HF-related symptoms require fast diagnosis and early treatment. Transthoracic echocardiography has a crucial role in...

N-Terminal Pro-Brain Natriuretic Peptide Levels in Patients Presenting with Acute Breathlessness in Emergency Department

Introduction: Breathlessness is one of the most common symptoms in patients presenting to the emergency department. Differentiating Congestive Heart Failure (CHF) from other causes of dyspnea is of extreme importance. N-Terminal pro-Brain Natriuretic Peptide (NT-proBNP) levels may be valuable for the diagnosis of Heart Failure (HF) in patients with acute breathlessness when used in combination with other clinical information. Aim: To find the utility of NT-proBNP levels in patients presenting with acute breathlessness. Materials and Methods: This cross-sectional study was conducted on 255 patients presenting with acute breathlessness. Details of clinical history, clinical examination, laboratory tests, Electrocardiogram (ECG), X-ray chest, and 2D echocardiogram were collected from each patient. A 5 mL sample of peripheral venous blood was taken from the patients for the quantitative determination of NT-proBNP levels. Mann-Whitney U test was used to compare medians of continuous variables. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracy were determined for NT-proBNP levels. Results: The mean age of the patients was 58.9 years. The median NT-proBNP level was significantly higher in patients who had HF compared to respiratory failure and Hyperventilation Syndrome (HVS). The sensitivity and specificity of NT-proBNP level &gt;450 pg/mL was 76.9% and 90.0%, respectively for patients &lt;50 years of age. The sensitivity and specificity of NT-proBNP level &gt;900 pg/mL was 82.9% and 92.3%, respectively for patients 50-75 years of age. The sensitivity and specificity of NT-proBNP level &gt;1800 pg/mL was 61.5% and 100.0%, respectively for patients &gt;75 years of age. Conclusion: NT-proBNP measurement is a useful biochemical tool for the emergency room physician in the rapid and reliable diagnosis of HF in patients with acute breathlessness.

Prevalence of heart failure and the diagnostic value of MR-proANP in outpatients with type 2 diabetes.

The prevalence of heart failure (HF) in patients with type 2 diabetes (T2DM) is debatable and no data exist concerning the diagnostic value of mid-regional pro-atrial natriuretic peptide (MR-proANP). We aimed to identify HF prevalence and evaluate the diagnostic value of MR-proANP in outpatients followed in two specialized diabetes clinics. HF was pre-defined as HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). The prevalence of HFrEF and HFpEF was 2.4% and 17.5%, respectively. An MR-proANP <60 pmol/L ruled out HFrEF in the total population (n = 806) and in patients reporting dyspnea (n = 311) with a sensitivity of 94.7% and 87.5%, a negative predictive value of 99.7% and 99.0%, a specificity of 39.5% and 33.0%, and a positive predictive value of 3.6% and 3.3%, respectively. In a multivariable model including age, sex, T2DM duration, albuminuria, uncontrolled systolic blood pressure, abnormal electrocardiogram and ischaemic heart disease for diagnosis of HF in patients reporting dyspnea, adding MR-proANP increased the area under the curve from 0.69 to 0.78 (P < 0.001). In conclusion, HFrEF was rare among outpatients with T2DM. MR-proANP rules out HFrEF and contributes independent information relevant to diagnosis of HF in patients reporting dyspnea.

Identification of Potential Gene Interactions in Heart Failure Caused by Idiopathic Dilated Cardiomyopathy.

BackgroundMany heart failure (HF) cases are caused by idiopathic dilated cardiomyopathy (iDCM). This study explored the mechanisms of the development and progression of HF caused by iDCM.Material/MethodsThe gene expression profiles of 102 samples were downloaded from the GEO database (GSE5406). Differentially expressed genes (DEGs) were identified through GO analysis and a KEGG pathway analysis, respectively. A protein–protein interaction (PPI) network was constructed and analyzed to screen potential regulatory proteins. In addition, MCODE and a cytoHubba plugin were used to identify the module and hub genes of DEGs. Finally, transcription factors (TFs) were predicted using PASTAA. We did not perform whole-exome sequencing (WES) for detecting mitochondrial DNA (mtDNA).ResultsA total of 197 DEGs were screened, and 3 modules, and 4 upregulated and 11 downregulated hub genes were screened. The GO analysis focused on the terms and 12 KEGG pathways were enriched. The FOS, TIMP1, and SERPINE1 hub genes, as well as some key TFs, demonstrated important roles in the progression of HF caused by iDCM. CEBPD, CEBOB, CDC37L1, and SRGN may be new targets for HF in iDCM patients.ConclusionsThe identified DEGs and their enriched pathways provide references for exploring the mechanisms of the development and progression of HF patients with iDCM. Moreover, modules, hub genes, and TFs may be useful in the treatment and diagnosis of HF patients with iDCM. However, mtDNA was not investigated.

Comparative study of galectin-3 and B-type natriuretic peptide as biomarkers for the diagnosis of heart failure.

BackgroundHeart failure (HF) is a common disease with complex pathophysiological causes. The diagnosis of HF commonly relies on comprehensive analyses of medical history and symptoms, and results from echocardiography and biochemical tests. Galectin-3, a relatively new biomarker in HF, was approved by the US Food and Drug Administration in 2010 as a marker in the stratification of risk for HF. We assessed galectin-3 as a biomarker for HF diagnosis in patients with preserved ejection fraction (pEF) and compared its performance with that of B-type natriuretic peptide (BNP).MethodsThirty-five pEF patients with HF (HFpEF group) and 43 pEF patients without HF (control group) were enrolled. Plasma levels of galectin-3 and BNP in HFpEF and control subjects were determined. Sensitivity, specificity, predictive values, and accuracy of galectin-3 and BNP as markers for HF diagnosis were calculated and compared.ResultsLevels of galectin-3 and BNP were 23.09 ± 6.97 ng/mL and 270.46 ± 330.41 pg/mL in the HFpEF group, and 16.74 ± 2.75 ng/mL and 59.94 ± 29.93 pg/mL in the control group, respectively. Differences in levels of galectin-3 and BNP between the two groups were significant (P < 0.01). As a biomarker for HF diagnosis in study subjects, galectin-3 showed sensitivity and specificity of 94.3% and 65.1%, respectively, at a cutoff value of 17.8 ng/mL. BNP showed sensitivity and specificity of 77.1% and 90.7%, respectively, at a cutoff value of 100 pg/mL. Galectin-3 was a significantly more sensitive (P < 0.05) but less specific (P < 0.01) biomarker compared with BNP. Differences in positive predictive value, negative predictive value, and accuracy between galectin-3 and BNP markers were not significant (P > 0.05). Areas under the receiver operating characteristic curve (95% confidence interval) were 0.891 (0.808–0.974) and 0.896 (0.809–0.984) for galectin-3 and BNP, respectively, with no significant difference between the two values (P > 0.05).ConclusionsThe level of galectin-3 is significantly elevated in patients with HF. Galectin-3 and BNP are useful biomarkers for the diagnosis of HF in patients with pEF.

Using NT-proBNP to Detect Chronic Heart Failure in Elderly Patients with Chronic Obstructive Pulmonary Disease.

Objective. To detect chronic heart failure in elderly patients with a registered diagnosis of chronic obstructive pulmonary disease (COPD) treated in Swedish primary health care using natriuretic peptide NT-proBNP. Design. A cross-sectional study. Setting. Two primary health care centres in southeastern Sweden each with about 9000 listed patients. Subjects. Patients aged 65 years and older with a registered diagnosis of COPD. Main Outcome Measures. Percentage of patients with elevated NT-proBNP, percentage of patients with abnormal left ventricular function assessed by echocardiography, and association between elevated NT-proBNP and symptoms, signs, and electrocardiography. Results. Using NT-proBNP threshold of 1200 pg/mL, we could detect and confirm chronic heart failure in 5.6% of the study population with concurrent COPD. An elevated level of NT-proBNP was only associated with nocturia and abnormal electrocardiography. Conclusions. We found considerably fewer cases of heart failure in patients with COPD than could be expected from the results of previous studies. Our study shows the need for developing improved strategies to enhance the validity of a suspected heart failure diagnosis in patients with COPD.

Comparative study of NT-proBNP and BNP assays for heart failure diagnosis in patients complicated with acute cerebral infarction

Objective To compare the capabilities of NT-proBNP and BNP in diagnosis of heart failure when complicated with acute cerebral infarction. Methods EP15-A2 document, was employed to verify the precision and accuracy of NT-proBNP and BNP assays on chemiluminescence analyzer Cobas E601 and ADVIA Centaur respectively for 363 samples from patients with chronic heart failure, cerebral hemorrhage and acute cerebral infarction, cerebral infarction complicated with heart failure and normal controls were collected and analyzed by Cobas E601 and ADVIA Centaur, and then determined the changing trends of NT-proBNP and BNP.Moreover, ROC curve was employed in diagnostic value comparison of NT-proBNP and BNP in heart failure groups. Results Cobas E601 and ADVIA Centaur showed good repeatability and accuracy in the detection of NT-proBNP and BNP that both total non-precision were below 3.5% and the deviations to calibrator were below 3.91%.The level of NT-proBNP an BNP didn′t elevate in normal people and cerebral hemorrhage patients.However, they significant elevated in heart failure, acute cerebral infarction and cerebral infarction complicated with heart failure patients(P<0.01).Their levels were heart failure grade dependent.The levels of NT-proBNP in cerebral infarction complicated with grade Ⅰ to Ⅲ heart failure patients were significantly higher than those in chronic heart failure patients, with same heart failure(P<0.05).However, compared to chronic heart failure patients, the level of BNP in cerebral infarction complicated with heart failure patients didn′t elevate significantly until grade Ⅲ heart failure happened.Areas under the ROC curve （AUCs） of NT-proBNP and BNP were both above 93% in the diagnosis of chronic heart failure.But for patients who suffered cerebral infarction complicated with heart failure, the diagnostic value of NT-proBNP and BNP were decreased due to cerebral infarction interference.However, the ROC area of BNP was larger than that of NT-proBNP(P<0.05). Conclusion In the diagnosis of cerebral infarction complicated with heart failure, BNP could be a better choice to determine the degree of heart failure.（Chin J Lab Med，2012,35：890-893） Key words: Brain infarction; Heart failure; Natriuretic peptide; brain

Patterns of Care and Outcomes Differ for Urban Versus Rural Patients With Newly Diagnosed Heart Failure, Even in a Universal Healthcare System

Access to medical care differs between urban and rural residents, but the magnitude of these differences and whether they affect outcomes are unknown. We aimed to determine whether outcomes differ for patients with incident heart failure (HF) by urban-rural status. This cohort study used administrative data from Alberta, Canada. Patients with incident HF were identified from April 1, 1999, to December 31, 2005, and followed for 1-year. Multivariable logistic regression was used to assess differences in 1-year outcomes after initial HF diagnosis in patients living in rural versus urban settings. We identified 72 043 patients with incident HF (mean age, 72±14; male sex, 50%) of whom 12 173 (17%) died and 29 074 (39%) were hospitalized within 1 year. Although crude all-cause 1-year mortality rates were higher in urban than in rural residents (17.3% versus 15.6%, P<0.001), after adjustment for comorbidities, no significant differences were observed (adjusted odds ratio [aOR], 0.95; 95% CI, 0.90 to 1.00). However, sex-specific analyses indicated that urban men had a significantly lower risk of mortality than rural men (aOR, 0.89; 95% CI, 0.83 to 0.96). In contrast, no difference was observed between urban and rural women (aOR, 1.02; 95% CI, 0.94 to 1.10). Urban patients were more likely to have office-based physician visits in the first year after HF diagnosis (aOR, 1.09; 95% CI, 1.02 to 1.17) and exhibited lower rates of hospitalization (aOR, 0.71; 95% CI, 0.68 to 0.74) and emergency department visits (aOR, 0.62; 95% CI, 0.60 to 0.65) than rural patients. Even within a universal healthcare system, there are differences in outcomes after HF diagnosis based on location of residence. Urban patients with HF are more likely to receive outpatient care and less likely to be hospitalized or present to the emergency department in the first year after diagnosis than rural patients with HF.

Clinical features and left ventricular (LV) dysfunction in heart failure patients with normal ejection fraction

100 inpatients with heart failure were divided into two groups: 50 with preserved LVEF and 50 with reduced LVEF. Another 50 age-matched healthy subjects served as the control group. The severity and etiology of heart failure, tissue Doppler imaging indexes (Sm;Ea;Aa;E/Ea) and plasma BNP concentrations were compared among the three groups. There was no difference in terms of NYHA classification between groups of preserved LVEF and reduced LVEF. Hypertension and DM are more common in the group of preserved LVEF. The index of Sm decreased most significantly in the group of reduced LVEF, and was negatively correlated with the BNP concentration (r = -0. 35, P ＜ 0. 05 ). The ratio of E/Ea increased gradually among the three groups, and was positively correlated with the BNP concentration ( r = 0. 728, P ＜ 0. 05 ). The LV filling index E/Ea and the BNP concentration may be helpful in the diagnosis of heart failure patients with preserved LVEF. Key words: Heart failure ; Ventricular function,Left ; Echocardiography ;

Laboratory diagnostics in the elderly: cardiovascular disease

Increased life expectancy in industrialized countries has led to the progressive aging of the general population, this event is associated with a concomitant increase of Cardiovascular Disease (CVD) that represents not only the main cause of death but also one of the major causes of morbidity, inability and reduction of life quality in the elderly population. In the Western countries, Arterial Hypertension (AH) affects more than 50% of the elderly, and Heart Failure (HF) represents the most frequent diagnosis among hospital discharges among the elderly. The prevalence of type 2 diabetes mellitus (DM) also increases in the elderly population, reaching about the 7-10%. In this context, the role of laboratory diagnostics is fundamental to support the diagnosis, for monitoring drug therapy and its possible side effects. In patients with recent diagnosis of AI, it is crucial to perform a complete hemocromocytometric analysis, the evaluation of lipid and glucidic metabolism parameters, serum electrolytes, and creatinine and uric acid to evaluate renal function. Hemoglobin and hematocrit values can establish the presence of anemia, which can be a sign of renal disease. Fasting glucose can be used to define the diagnosis of DM, and in patients with previous a diagnosis it is useful to control the metabolic status that is correlated to the development of cardiovascular complications. Moreover in hypertensive patients, the presence of high blood glucose levels can mask a secondary form of AH, as do the potassium serum levels. In addition, in the elderly an impairment of the thyroid function should also be evaluated, as a possible cause of atrial fibrillation, that is the most frequent tachyarrhythmia in over 65 year olds. Finally, the diagnosis of HF in the elderly with different comorbidities can represent a very strong challenge; in this case, laboratory diagnostics can support the clinician in the diagnostic and therapeutic process. It is advisable to measure BNP/NT-proBNP to exclude/confirm the diagnosis of HF in patients with ambiguous clinical signs and symptoms that can be confused with other clinical conditions. Moreover, it is important to dose some laboratory parameters related to renal function to monitor possible side effects of drugs employed in chronic HF (CHF). Thus, in the management of the elderly affected by CVD, the laboratory is crucial and the kind and the frequency of laboratory tests are above all oriented by the patient’s clinical symptoms and signs, by the presence of target organ damage and the possible side effects of the employed drugs.

B-Type Natriuretic Peptide for Diagnosis and Therapy

Brain natriuretic peptide (BNP) plays an important role in cardiovascular homeostasis. Plasma BNP increases markedly in left ventricular dysfunction from several causes, and its levels in heart failure (HF) correlate with symptoms severity. BNP has recently emerged as a potentially important clinical marker for the diagnosis of HF in patients with unexplained dyspnea. Other clinical applications of BNP, such as screening for asymptomatic ventricular dysfunction, establishing the prognosis or guiding the titration of drug therapy, are under investigation and have not yet been sufficiently validated for widespread clinical use. Laboratory-based and point-of-care analyses are available for BNP and N-terminal proBNP as fully-automated immunoassays. Several patented inventions and reagents for the diagnosis of various heart pathologies provide helpful information, particularly in conjunction with other clinical tests. They also have prognostic value for future cardiovascular events. Patents owned by Scios Inc. recommended recombinant BNP for managing acute decompensated HF. However, this treatment apparently has safety problems and no proven clinical advantage over existing treatments in terms of improved survival and prevention of subsequent hospitalizations.

Prognostic value of NT-proBNP and big ET-1 in severe heart failure: significance of NT-proBNP and big ET-1 in cardiovascular diseases combining with severe heart failure

目的 探讨两检测指标血浆N末端B型钠尿肽原(NT-proBNP)和大内皮素-1(big ET-1)之间,两指标与心力衰竭(心衰)伴心房颤动(Af)、心衰伴肺动脉高压(PAH)等心血管病的关系,以及两指标对严重心衰患者半年期预后的预测价值.方法 阜外医院严重心衰患者132人,测定他们入院时的血浆LgNT-proBNP和big ET-1浓度(酶联免疫法)以及纽约心脏病协会心功能分级(NYHA分级)、左室射血分数(LVEF)等指标.随访观察患者出院后半年内心血管事件的再发生.结果 严重心衰患者132人(NYHA Ⅲ-Ⅳ级,年龄24～80岁,男83人,女49人,LVEF 13%～66%),其血浆LgNT-proBNP与big ET-1呈正相关(r=0.414,P=0.000).有、无Af的两组间big ET-1水平比较差异有统计学意义(P=0.022);有、无PAH的两组间LgNT-proBNP和big ET-1浓度差异均有统计学意义(P=0.019,P=0.000).以big ET-1诊断严重心衰患者伴PAH的ROC曲线下面积为0.74(95%CI:0.65～0.83,P=0.000),以4.09 fmol/ml为big ET-1诊断心衰伴PAH的cutoff值时,灵敏度为71.4%,特异度67.8%.经过6个月的随访,132例严重心衰患者中,有20例发生心源性死亡(15.2%),有25例因心脏原因再住院(18.9%).Cox比例风险模型分析显示,包括了年龄、性别、NYHA分级、LVEF、LgNT-proBNP、big ET-1等指标后,只有NT-proBNP是独立的心脏事件再发生的预后因素,RR为5.30(95%CI:2.07～13.55,P=0.001).Logistic回归显示也只有NT-proBNP是独立的心源性死亡发生的危险因素,OR为13.67(95%CI:2.59～72.25,P=0.002).big ET-1、LVEF、NYHA分级等指标对严重心衰患者心血管事件再发生没有预后价值.结论 NT-proBNP与big ET-1间可能存在相互作用;严重心衰伴Af的患者可能有内皮细胞损伤和功能异常;big ET-1可辅助诊断严重心衰患者伴发PAH;NT-proBNP可用于严重心衰患者半年期预后的评估,而big ET-1没有此预测价值。

Identification, diagnosis and treatment of heart failure: could we do better?

Numerous studies have shown that it is very difficult to diagnose mild heart failure accurately on clinical grounds alone. Routine echocardiography would help to solve this problem but studies have shown that this technique is greatly underused. Providing open access echocardiography, and/or targeting this resource to the most deserving cases by measuring plasma natriuretic peptides may help to optimize the use of this technique while improving the diagnosis of heart failure patients. Studies have also demonstrated the value, but apparent underuse, of angiotensin-converting enzyme (ACE) inhibitor therapy. Further questions for the management of heart failure patients have been presented by these investigations. Uncertainty remains over the appropriate timing of ACE inhibitor therapy and whether low or high doses are more effective. The ongoing ATLAS study aims to answer these questions and promotes an improvement in the treatment of heart failure patients.