Elevated Brain Natriuretic Peptide Levels Research Articles

Transthoracic echocardiogram in syncope patients with normal initial evaluation

ObjectivesDespite the low diagnostic yield of echocardiogra0, it is often used in the evaluation of syncope. This study determined whether patients without abnormalities in the initial evaluation benefit from transthoracic echocardiogram (TTE) and the clinical factors predicting an abnormal TTE. MethodsThis study enrolled 241 patients presenting to the emergency department with syncope. The TTE results were analyzed based on risk factors suggesting cardiogenic syncope in the initial evaluation. ResultsOf the 115 patients with at least one risk factor, 97 underwent TTE and 27 (27.8%) had TTE abnormalities. In comparison, of the 126 patients without risk factors, 47 underwent TTE and only 1 (2.1%) had TTE abnormalities. Significantly different factors between patients with normal and abnormal TTE findings were entered in a multiple logistic regression analysis, which yielded age [adjusted odds ratio (aOR), 1.09; 95% CI, 1.02–1.15; p=0.006], an abnormal electrocardiogram (ECG) (aOR, 7.44; 95% CI, 1.77–31.26; p=0.010), and a brain natriuretic peptide (BNP) level of >100pg/mL (aOR, 2.64; 95% CI, 1.21–5.73; p=0.011) as independent predictors of TTE abnormalities. The cutoff value of age predicting an abnormal TTE was 59.0years (area under the curve, 0.777; p<0.001). ConclusionA patient who is older than 59years or has an abnormal ECG or an elevated BNP level may benefit from TTE. Otherwise, TTE should be deferred in patients with no risk factors in the initial evaluation.

Factors associated with postoperative requirement of renal replacement therapy following off-pump coronary bypass surgery

Cardiopulmonary bypass usage provokes a systemic inflammatory response resulting in deterioration of renal function. However, risk factors for requiring renal replacement therapy (RRT) following off-pump coronary artery bypass graft surgery (CABG) have not yet been fully elucidated. We reviewed 718 consecutive patients undergoing elective off-pump CABG at our institution, excluding patients on chronic hemodialysis preoperatively. Sub-analysis of patients with preserved renal function, defined as a creatinine level below a cut-off value of 1.12mg/dL (obtained by receiver operating characteristic curve), was also performed. Of the 718 patients, 41 (5.7%) required RRT. There were 556 patients (77.4%) with preserved renal function preoperatively, and 13 (2.4%) of these required postoperative RRT. Multivariate analysis revealed that age (years) and preoperative serum creatinine (mg/dL) and brain natriuretic peptide (BNP) levels (pg/dL) were associated with RRT [odds ratios (OR) 1.052, 95% confidence interval (CI) 9.064 and 1.001, respectively, all p<0.05] in the total population, whereas low albumin concentration was the only independent predictor for RRT in patients with preserved renal function (OR 0.062, p<0.0001). When creatinine levels were below 1.5mg/dL, the predictive power of hypoalbuminemia for RRT requirement overwhelmed that of creatinine or BNP levels. Older age, preoperative elevated creatinine and BNP levels were associated with a requirement for RRT following off-pump CABG. In patients with preserved renal function, hypoalbuminemia was most significantly related to the RRT requirement.

Abstract 332: Characteristics of Patients with Submassive Pulmonary Embolism with Early Re-hospitalization After tPA Administration

Background: Evidence for clinical predictors of early re-hospitalization after tissue plasminogen activator (tPA) therapy in patients with submassive pulmonary embolism (SMPE) is currently lacking. We sought to explore the characteristics of these patients in a retrospective cohort study at our hospital Methods: Clinical, biochemical, hemodynamic, echocardiographic characteristics and clinical course of consecutive patients with SMPE [as defined by Acute PE without systemic hypotension (systolic blood pressure &gt;90 mm Hg) but with either Right Ventricular strain/dysfunction demonstrated on echocardiography obtained within 24 hours of presentation or myocardial necrosis as evidenced by elevated cardiac troponins and/or elevated brain natriuretic peptide levels)] were studied in a retrospective cohort study. Unplanned all cause re-hospitalizations after the index hospitalization for SMPE were captured Results: A total of 145 (in past 5 years) patients with pulmonary embolism diagnosed with spiral CT angiography or ventilation perfusion scan were screened for patients with SMPE. 17 patients with SMPE were identified in whom tPA was administered. No patient had major bleeding, one patient suffered gross hematuria during the tPA administration. After a mean 2.1 years of follow up 5 (29%) patients suffered unplanned all cause re-hospitalizations among which 4 were within one year from the index hospitalization for SMPE. Baseline characteristics are shown in table 1. No patients had recurrent PE after the index hospitalization Conclusion: A significant proportion of patients were re-hospitalized within one year after tPA administration in patients with SMPE. Further studies in larger cohorts are needed to identify independent clinical predictors of re-hospitalization in patients with submassive pulmonary embolism

Incidence of chronic heart failure with preserved left ventricular ejection fraction in patients with hypertension and isolated mild diastolic dysfunction

Heart failure (HF) with preserved ejection fraction (HFPEF) is still a challenge in clinical practice. The prognosis of patients with HFPEF is similar to or only slightly better than that of patients with HF with reduced ejection fraction (HFREF). Impaired relaxation is the mildest form of diastolic dysfunction, which should not be accompanied by symptoms of HFPEF. The aim of the study was to assess the incidence of chronic HFPEF in patients with hypertension and isolated mild diastolic dysfunction. It was a cross-sectional study including 210 patients (mean age, 56.11 ±6.24 years; women, 58%) with isolated abnormalities of left ventricular relaxation and arterial hypertension. In addition, we identified patients with type 2 diabetes to compare the incidence of HFPEF between patients with and without diabetes. HFPEF was diagnosed when clinical symptoms of HF were present simultaneously with echocardiographic markers of elevated left ventricular diastolic pressure, pulmonary congestion on chest X-ray, or elevated serum brain natriuretic peptide (BNP) levels. HFPEF was diagnosed in 42% of the patients with impaired relaxation. An elevated left atrial volume index (>34 ml/m²) was observed in 38% of the patients; E/e' ratio exceeding 8, in 37%; elevated BNP levels, in 39%; and pulmonary congestion on chest X-ray, in 41%. Independent predictors of HFPEF were age, systolic blood pressure of 140 mmHg or higher, type 2 diabetes, coronary artery disease, and an estimated glomerular filtration rate of less than 60 ml/min/1.73 m². In diabetic patients, a positive correlation was found between an insulin dose (>80 units/day) and BNP levels. Patients with isolated relaxation abnormalities constitute a clinically heterogeneous group because some of these individuals present with symptoms of HFPEF and a simultaneous increase in BNP levels. Therefore, the question of whether diastolic dysfunction is mild should be readdressed, and it should be emphasized that these patients have a serious prognosis with the risk of HF. In diabetic patients, a positive correlation between high insulin doses and BNP levels requires further research.

How does serum brain natriuretic peptide level change under nasal continuous positive airway pressure in obstructive sleep apnea-hypopnea syndrome?

BackgroundObstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with cardiovascular morbidity and mortality, which can be improved by using continuous positive airway pressure (CPAP) therapy. However, the pathophysiological links between the two kinds of disease and the mechanism of the CPAP effect remain incompletely understood. We aimed to inquire into the myocardial involvement in this relationship. We suggested that serum brain natriuretic peptide (BNP) is sensitive enough to detect myocardial stress caused by OSAHS.Design and methodsSixty-four subjects without cardiovascular disease (21 controls, 24 normotensive OSAHS patients, and 19 hypertensive OSAHS patients) were analyzed for serum BNP at baseline and serially over 6 months. CPAP was applied to 23 patients with severe OSAHS.ResultsAt baseline, the serum BNP levels were significantly higher (p=0.0001) in the OSAHS group (22.3±14.79 pg/ml) than in the control group (9.2±6.75 pg/ml). Increased serum BNP levels were significantly associated with mean transcutaneous oxygen saturation (SpO2) (p<0.0001), minimal SpO2 (p=0.002), oxygen desaturation index (p=0.001), and total sleep time spent with SpO2 lower than 90% (p=0.002). All patients with elevated BNP levels (≥37 pg/ml) had moderate or severe OSAHS (11/43 OSAHS patients). The more severe the OSAHS, the higher the BNP levels were. However, only the difference between severe and mild OSAHS was statistically significant (p=0.029). Hypertensive OSAHS patients had the highest baseline BNP levels (27.7±16.74 pg/ml). They were significantly higher (p=0.001) than in normotensive OSAHS patients (18±11.72 pg/ml) (p=0.039) and the controls (9.2±6.75 pg/ml). As compared with baseline, treatment with CPAP significantly decreased BNP levels in both hypertensive and normotensive OSAHS patients (respectively, from 36±16.10 to 29.7±14.29 pg/ml, p<0.001, and from 20±10.09 to 16±8.98 pg/ml, p<0.001). In contrast, the BNP levels slightly increased in the controls (from 9.2±6.75 to 9.5±7.02 pg/ml, p=0.029), but there was no statistically significant difference in comparison with the baseline value. The effect of CPAP on BNP levels was more marked in patients with higher baseline BNP levels and those with the most prolonged nocturnal desaturation (p=0.001, r=0.65). It was also more marked in hypertensive OSHAS patients (p=0.015, r=0.72) in comparison with normotensive OSAHS patients (p=0.03, r=0.62).ConclusionBNP seems to be sensitive enough to detect myocardial stress caused by OSAHS. As such, it is a potential marker for screening of preclinical cardiovascular damage in patients with untreated OSAHS. Application of CPAP decreases levels significantly in normotensive and particularly in hypertensive OSAHS. These findings are consistent with previous results suggesting the potential benefits of CPAP on cardiovascular outcome in OSAHS patients.

A case of markedly elevated brain natriuretic peptide level

A case of markedly elevated brain natriuretic peptide level

Levels of brain natriuretic peptide as a marker for the diagnosis and prognosis of acute ischemic stroke.

IntroductionThe relationships between plasma levels of brain natriuretic peptide (BNP) and severity and location of stroke, prognosis, and infarct volume were investigated in acute ischemic stroke patients who presented within the first 24 hours (h) of stroke.Material and methodsBrain natriuretic peptide levels were tested in 40 patients and 30 healthy controls. Infarct volume was automatically calculated by multi-slice computed tomography. Disease severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at presentation, 24 h, 72 h and the 28th day. Progression was defined as an increase of more than two points in the NIHSS scores.ResultsThe mean BNP levels were 284.16 ±382.79 at presentation and 273.78 ±451.91 at 72 h in the patient group, whereas the mean BNP level was 25.29 ±13.47 in controls. There was a statistically significant difference between the two groups (p < 0.001). Differences in BNP levels among patient subgroups according to the TOAST and OCSP classifications were not statistically significant (p = 0.534, p = 0.943, respectively). There was no significant correlation between plasma BNP level and infarct volume or NIHSS scores (p = 0.5, p = 0.07). A positive correlation was found between BNP levels and the length of the hospitalization period (p = 0.03 and r = 0.33). There was no statistically significant relationship between elevated plasma BNP levels and progression of disease (p = 0.08).ConclusionsPlasma BNP levels were increased in the acute phase of stroke; therefore, BNP could be used as a biomarker for morbidity and mortality, even in patients without cardiac failure.

Brain Natriuretic Peptide: Structure, Action and Role in the Diagnosis and Prognosis of Heart Failure

Brain natriuretic peptide (BNP) is a peptide hormone secreted by cardiomyocytes in response to atrial or ventricular wall stretch. It promotes a number of systemic effects, including vasodilatation, increase in urinary output and sodium excretion as well as inhibition of the sympathetic nervous system and the renin–angiotensin–aldosterone system. Plasma BNP levels have been reported to be elevated in patients with left ventricular hypertrophy, congestive heart failure, acute coronary syndromes, atrial fibrillation and impaired renal function. Moreover, elevated BNP levels have been shown to be a strong predictor of morbidity and mortality in patients with heart failure. Interestingly, it has also been found that the N-terminal peptide of BNP is slightly superior to BNP for predicting death or re-hospitalization for heart failure. Presumably, it is the longer half-life of NT-pro-BNP that may promote it as a more accurate index of ventricular stress and therefore a better predictor of prognosis.

Cerebral salt wasting syndrome in a child with SSPE

Cerebral salt-wasting syndrome is a disorder characterized by severe hyponatremia, volume depletion, and elevated brain natriuretic peptide but normal antidiuretic hormone levels. In this manuscript, we report the case of a six-year-old patient with cerebral salt-wasting syndrome associated with subacute sclerosing panencephalitis. The patient showed dehydration, tachycardia, pyrexia, polyuria, severe hyponatremia, and a significant loss of urinary sodium. He was successfully treated with sodium and fluid replacement therapy.

Abstract W P186: Elevated Brain Natriuretic Peptide Is An Independent Marker For Cardioembolism And Poor Outcome In Acute Ischemic Stroke

Background: Brain natriuretic peptide (BNP) is believed to be a diagnostic marker for cardiovascular diseases, including atrial fibrillation (AF). Recent studies have incriminated BNP as a marker of cardioembolic stroke. We aimed at investigating association of plasma BNP levels in acute ischemic stroke subtypes and their outcome in Indian patients. Methods: We recruited 270 acute ischemic stroke patients within 48 hours of symptom onset and compared with 110 age and sex matched control subjects. This study was carried out at Yashoda Hospital, Hyderabad, India between April 2011 and March 2013. Serum BNP levels were estimated in stroke patients and control subjects. Good functional outcome at 3-months was defined as modified Rankin score (mRS) ≤2. Results: Elevated BNP levels was significantly more in patients with acute ischemic stroke patients 119 (44%) compared to controls 4 (3.6%) (p&lt;0.0001). Among stroke subtypes, elevated BNP levels were observed in 75% of cardioembolic strokes, 45.8% of small artery disease and 43.1 % of larger artery atherosclerosis, 34.5% of stroke of undetermined etiology. On multiple logistic regression analysis, elevated BNP levels was significantly associated with acute ischemic stroke (OR: 13.0, 95%CI:8.1 -15.4). Among stroke subtypes, significant association was seen with cardioembolic stroke (OR: 3.5, 95%CI: 2.2-7.2). Elevated BNP levels were independently associated with poor outcome (OR 3.4, 95%CI:1.2-13.7; p&lt;0.0001) and higher mortality (OR 3.4,95%CI:1.2-13.7; p&lt;0.0001). Conclusions: Elevated BNP level is an independent marker for cardioembolic stroke and poor outcome at 90 days follow-up. No significant association was seen with other stroke subtypes.

0363: Acute coronary syndrome complicated with left ventricular diastolic dysfunction: what is the contribution of brain natriuretic peptid?

The utility of Brain Natriuretic Peptide (BNP) for detecting leftventricular (LV) diastolic dysfunction in patients presenting an acute coronary syndrome without heart failure symptoms is unclear. In this study, we investigated the relation between BNP plasma levels and LV diastolic dysfunction in patients with postmyocardial infarction without systolic dysfunction. We studied 81 patients (12 women, mean age 55±11.79) admitted in our center for myocardial infarction with or without ST segment elevation. Patients with heart failure symptoms or abnormal systolic function were excluded. LV diastolic function was assessed with conventional Doppler, by means of mitral inflow and with tissue Doppler echocardiography by means of mitral annulus. The ratio of early diastolic transmitral E wave velocities to tissue Doppler mitral annulus early diastolic E’ wave velocities (E/E’), was used to detect LV filling pressures. Patients were divided in three groups according to E/E’ ratios < 10 (group I), E/E’ ratios between 10 and 15 (group II) and E/E’ ratios >15 (group III). Abstract 0109 – Table: Patients’ baseline characteristics Patients’baseline characteristics BMS (n=30) DES (n=300) p Sex, M/F 30/0 30/0 1 Age, y 52,03±6,35 50,2±8,45 0,34 Body mass index*, kg/m 2 25,79±2,56 25,00±2,97 0,28 Hypertension, % 16,66 1,66 1 Dyslipidemia, % 33,33 33,33 1 Diabetes mellitus, % 0 0 1 Family history, % 26,66 6,66 0,07 Cigarette smoking, % 73,33 60 0,41 Previous CAD, Stroke, PAOD, % 0 0 1 Indication of coronary angiography AMI (STEMI/NSTEMI, % 86,66 76,66 0,5 UA, % 13,33 16,66 1 SCAD, % 0 6,66 0,49 Time interval between PCI and blood sampling, d 39,16±7,68 38,73±6,76 0,81 Stent length, mm 16,3±4,24 17,56±5,71 0,33 LVEF, % 58,66±7,30 61,13±6,18 0,16 Drug therapies * Statin, % 100 100 1 ASA, % 100 100 1 Second anti-platelet drug Clopidogrel, % 46,66 43,33 1 Prasugrel, % 53,33 50 1 Ticagrelor, % 0 6,66 0,49 β-blocker, % 85,71 (n=28) 60 (n=25) 0,059 ACE inhibitor, % 0 (n=28) 0 (n=26) 1 OAC, % 0 0 1 Blood tests * LDL cholesterol, g/L 0,75±0,18 0,68±0,19 0,19 HDL cholesterol, g/L 0,39±0,10 0,43±0,11 0,19 Triglyceride, g/L 0,96±0,32 0,93±0,29 0,72 Hemoblogin, g/dl 14,34±0,97 14,4±0,83 0,82 Platelets, G/L 242,93±55,90 239,56±49,61 0,8 Serum creatinine, μmol/L 2,07±2,02 1,39±1,30 0,12 Fasted glycaemia, g/L 0,97±0,11 1,01±0,09 0,14 HbA1c, % 5,74±0,39 5,73±0,40 0,92 Continuous variables are presented as sample mean and standard deviation. P-values reflect comparisons between patients with a BMS and patients with DES and are derived from Student’s t-tests for continuous variables whereas qualitative data were compared with Fisher’s exact test. The characteristics marked with an asterisk were collected on the same day that blood was sampled (one month after PCI) The BNP blood levels were positively correlated significantly with E/E’ ratio (p < 0.02). Patients with elevated LV end diastolic pressure (LVEDP), defined as E/E’ >15 (n = 27) had highest BNP (302±68 pg/ml) levels. E/E’ 10 to 15 group (n = 24) had a mean BNP level of 136.4±27 pg/ml, and those with E/E’ < 10 (n = 29) had 82±20 pg/ml. A BNP value of 107.8 pg/ml had a sensitivity of 89%, a specificity of 61% for predicting E/E’ >15. The area under the ROC curve for BNP to detect any diastolic dysfunction was 0.757. A BNP value of 72.7 pg/ml had a sensitivity of 82.2% and a specificity of 66.7% for detecting a diastolic dysfunction. A rapid assay for BNP can detect the presence of diastolic abnormalities on echocardiography. In patients with preserved systolic function post myocardial infarction, elevated BNP levels might help to reinforce the diagnosis of LV diastolic dysfunction.

Association of Plasma Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Subtypes and Outcome

Brain natriuretic peptide (BNP) is believed to be a diagnostic marker for cardiovascular diseases, including atrial fibrillation (AF). Recent studies have incriminated BNP as a marker of cardioembolic stroke. We aimed at investigating association of plasma BNP levels in acute ischemic stroke subtypes and their outcome in Indian patients. We recruited 270 acute ischemic stroke patients within 48 hours of symptom onset and compared with 110 age- and sex-matched control subjects. This study was carried out at Yashoda Hospital, Hyderabad, India between April 2011 and March 2013. Serum BNP levels were estimated in stroke patients and control subjects. Good functional outcome at 3 months was defined as modified Rankin score (mRS) 2 or less. Elevated BNP levels was significantly more in patients with acute ischemic stroke patients 119 (44%) compared with controls 4 (3.6%; P < .0001). Among stroke subtypes, elevated BNP levels were observed in 75% of cardioembolic strokes, 45.8% of small artery disease, 43.1% of larger artery atherosclerosis, and 34.5% of stroke of undetermined etiology. On multiple logistic regression analysis, elevated BNP levels were significantly associated with acute ischemic stroke (odds ratio [OR], 13.0; 95% confidence interval [CI], 8.1-15.4). Among stroke subtypes, significant association was seen with cardioembolic stroke (OR, 3.5; 95% CI, 2.2-7.2). Elevated BNP levels were independently associated with poor outcome (OR, 3.4; 95% CI, 1.2-13.7; P < .0001) and higher mortality (OR, 3.4; 95% CI, 1.2-13.7; P < .0001). Elevated BNP level is an independent marker for cardioembolic stroke and poor outcome at 90 days follow-up. No significant association was seen with other stroke subtypes.

Characterization of cardiac oxidative stress levels in patients with atrial fibrillation.

Atrial fibrillation (AF) is associated with oxidative stress and elevated brain natriuretic peptide (BNP) levels. However, the exact cardiac origin of oxidative stress and its association with BNP levels in AF patients remain unclear. Therefore, we investigated the chamber-specific plasma oxidative stress levels in patients with paroxysmal AF (PAF) and persistent AF (PSAF). Diacron-reactive oxygen metabolite (dROM) levels were measured in patients with PAF (n = 50) and PSAF (n = 35) at different cardiac sites before ablation and in peripheral vein 3 months after ablation. For all sites, dROM levels were higher in PSAF patients than in PAF patients; the levels were the highest in the coronary sinus at 429.0 (interquartile range: 392.0-449.0) vs. 374.0 (357.0-397.8) Carratelli units (P < 0.05). dROM levels in the coronary sinus were related to the BNP levels (r = 0.436, P < 0.001). Furthermore, the reduction in the peripheral dROM levels was related to that in the peripheral BNP levels in patients with symptomatic improvement (r = 0.473, P < 0.001). Cardiac oxidative stress may either be a cause or consequence of prolonged AF, and cardiac oxidative stress levels correlated with BNP levels, though a possible source of oxidative stress in AF patients may be systemic circulation.

Elevated brain natriuretic peptide level in patients undergoing atrial fibrillation ablation: is it a predictor of failed ablation or a mere function of atrial rhythm and rate at a point in time?

Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4-6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44-79) pg/ml vs. 30(18-47) pg/ml, p < 0.001). Postablation restoration of SR in patients presenting in AF reduced median BNP levels from 54(44-79) pg/ml to 40(37-51) pg/ml, (p < 0.001). However, no change was noted in patients who presented in and maintained SR throughout the procedure (30(18-47) pg/ml to 27(16-40) pg/ml, p = 0.270). At 4-6 months, BNP measured in patients in SR was not significantly different from postablation BNP (35(22-53) pg/ml vs. 38(20-52) pg/ml, p = 0.656), although 35% of them had AF recurrence in 1-year follow-up. Median BNP level measured in five patients while in atrial arrhythmia was elevated compared to postablation BNP (464(421-464) pg/ml to 37(36-37) pg/ml, p = 0.043). BNP levels and ventricular rates are positively correlated at all times pre- and postablation. BNP level rises acutely during AF and with rapid ventricular rates. BNP level seems to be a function of atrial rhythm and ventricular rate rather than short- or long-term predictor of AF ablation success.

C-reactive protein and brain natriuretic peptide as predictors of adverse events after lower extremity endovascular revascularization

High-sensitivity C-reactive protein (hsCRP) and brain natriuretic peptide (BNP) have been shown to be independent predictors of adverse cardiovascular outcomes and increased risk of secondary interventions or limb loss in patients with peripheral arterial disease (PAD). To assist clinicians in decision-making about treatment approaches and predicting postprocedure mortality and morbidity, we retrospectively examined patients with preprocedure hsCRP and BNP levels who underwent elective angioplasty or stent placement for lower extremity PAD. The study period was from January 1, 2007, to December 31, 2012, and patients were included who had angioplasty or stenting for PAD. Minimal required follow-up for study inclusion was at least one postoperative ankle-brachial index, contrast angiography, or duplex imaging of the treated limb. Events of interest included major adverse limb events (MALE), defined as target vessel revascularization, amputation, or disease progression by 1 year, and major adverse cardiovascular events (MACE; stroke, myocardial infarction, or death) by 2 years. Elevated/abnormal values for our biomarkers of interest were established by the upper limits of our institution's clinical laboratory reference range (hsCRP, >0.80 mg/dL; BNP, >100 pg/mL). A total of 159 limbs in 118 patients were included in analysis (42% men; median age [range], 64 [42-87] years). All limbs were symptomatic (Rutherford classification: 1-6). Iliac artery revascularization without other adjunct lower extremity intervention was performed in 60% of the limbs. High hsCRP levels (>0.80 mg/dL) were present in 32 patients (27%) and high BNP values (>100 pg/mL) in 24 patients (20%). Kaplan-Meier analysis with log-rank comparison demonstrated that elevated hsCRP levels were associated with MALE but only in limbs receiving interventions distal to the iliac arteries (P = .005). High BNP levels did not affect MALE rates (P = .821). Conversely, both elevated BNP levels (hazard ratio, 5.6; 95% confidence interval [CI], 2.0-5.8; P = .001) and hsCRP levels (hazard ratio, 2.9; 95% CI, 1.1-7.6; P = .034) predicted MACE at 2 years in the presence of confounders in Cox proportional hazards multivariate analysis. Patients with high preintervention values of hsCRP and BNP were 10.6 times (95% CI, 2.6-42.9; P = .001) more likely to experience MACE than were patients with normal hsCRP and BNP values. After lower extremity endovascular interventions, elevated preprocedural hsCRP levels are associated with MALE (femoral-popliteal interventions), and elevated levels of hsCRP and BNP are associated with late cardiovascular events.

Diagnostic Performance of Brain Natriuretic Peptide in Patients Suspected to Sepsis

Background: One of the main components involving in the pathogenesis and prognosis of sepsis and septic shock is natriuretic peptide. Hemodynamic changes in sepsis or septic shock might explain increased plasma levels of these peptides circulations. Objectives: The present study aimed to assess the value of brain natriuretic peptide (BNP) in prediction of sepsis state and its related morbidity. We also attempted to determine the best cutoff point of BNP for diagnosis of sepsis state in those with critical illnesses, admitted to the hospital. Patients and Methods: In a cross-sectional study on critically ill patients referred to infections unit of Hazrat Rasoul Akram Hospital, the enrolled patients were assigned to one of the sepsis (n = 30) and nonsepsis (n = 30) groups, based on their results of blood culture and clinical manifestations. Plasma level of BNP was measured by immunoassay. Results: In-hospital mortality was only observed in one patient suffering from sepsis. Hospital length of stay (LOS) was significantly longer in the sepsis group compared with the nonsepsis one (17.47 ± 10.10 days versus 7.93 ± 2.92 days). The plasma BNP level, as a marker, was significantly higher in the sepsis group than the nonsepsis one (786.87 ± 164.11 ng/mL versus 154.57 ± 44.67 ng/mL, P = 0.039). The BNP level was significantly correlated with some baseline variables including respiratory rate (beta = 0.295, P = 0.022) and ESR measurement (beta = 0.296, P = 0.022), but not with other characteristics. Through multivariable linear regression analysis, having other patients’ variables information including demographics and hemodynamic parameters, the BNP level was significantly higher in the sepsis group compared with the nonsepsis one (odds ratio = 1.008, P = 0.046). According to the receiver operating characteristic (ROC) curve analysis, BNP measurement had an acceptable value for discriminating sepsis and nonsepsis states (c = 0.734, 95% CI: 0.605-0.864, P = 0.002). The optimal cutoff point of BNP for discriminating sepsis and nonsepsis states was 170 ng/mL, yielding a sensitivity of 66.7% and a specificity of 60.0%. Conclusions: Elevated BNP level was associated with a significantly increased risk of sepsis state in critically ill patients.

Brain Natriuretic Peptide in Acute Ischemic Stroke

Elevated serum brain natriuretic peptide (BNP) levels are associated with cardioembolic stroke mainly because of atrial fibrillation (AF). However, the mechanisms of increased serum BNP levels are hitherto unclear. We aimed to identify the factors associated with increased BNP levels in patients with acute ischemic stroke. We measured serum BNP levels in consecutive patients aged 18years or older. Stroke subtypes were classified using the Trial of ORG 10172 in Acute Stroke Treatment criteria. Categorical variables included age, sex, smoking status, alcohol consumption status, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease (CAD), AF, antiplatelet therapy, and anticoagulant therapy. Continuous variables included hemoglobin, creatinine (Cr), β-thromboglobulin, platelet factor 4, thrombin-antithrombin complex, and d-dimer levels. We further determined the relationship between serum BNP and intima-media thickness, left ventricular ejection fraction, size of infarction, National Institutes of Health Stroke Scale score on admission, and modified Rankin Scale (mRS) score at discharge. Of the 231 patients (mean age, 71±12years) with acute ischemic stroke (AIS), 36% were women. Serum BNP levels significantly correlated with CAD, AF, Cr, mRS, and cardioembolism (CE) (Dunnett method, P = .004). BNP levels were significantly higher in patients with larger infarcts, higher mRS scores, and higher CHADS2 scores. The levels were higher in patients with larger infarcts, higher mRS scores at discharge, and higher CHADS2 scores among AF patients.

A combination of P wave electrocardiography and plasma brain natriuretic peptide level for predicting the progression to persistent atrial fibrillation: comparisons of sympathetic activity and left atrial size

Development of atrial fibrillation (AF) is complexly associated with electrical and structural remodeling and other factors every stage of AF development. We hypothesized that P wave electrocardiography with an elevated brain natriuretic peptide (BNP) level would be associated with the progression to persistence from paroxysmal AF. P wave electrocardiography such as a maximum P wave duration (MPWD) and dispersion by 12-leads ECG, heart/mediastinum (H/M) ratio by delayed iodine-123 metaiodobenzylguanidine scintigraphic imaging, left ventricular ejection fraction (LVEF), and left atrial dimension (LAD) by echocardiography, and plasma BNP level were measured to evaluate the electrical and structural properties and sympathetic activity in 71 patients (mean ± standard deviation, age: 67 ± 13years, 63.4% males) with idiopathic paroxysmal AF. Over a 12.9-year follow-up period, AF developed into persistent AF in 30 patients. A wider MPWD (>129ms) (p = 0.001), wider P wave dispersion (>60ms) (p = 0.001), LAD enlargement (>40mm) (p = 0.001), higher BNP level (>72pg/mL) (p = 0.002), lower H/M ratio (≤2.7) (p = 0.025), and lower LVEF (≤60%) (p = 0.035) were associated with the progression to persistent AF, and the wide MPWD was an independently powerful predictor of the progression to persistent AF with a hazard ratio (HR) of 5.49 [95% confidence interval (CI) 2.38-12.7, p < 0.0001] after adjusting for potential confounding variables, such as age and sex. The combination of wide MPWD and elevated BNP level was additive and incremental prognostic power with 13.3 [2.16-13, p < 0.0001]. The wide MPWD with elevated BNP level was associated with the progression to persistent AF.

Avaliação prognóstica do tromboembolismo pulmonar por ecocardiograma com Doppler tecidual e peptídeo atrial natriurético tipo B

ABSTRACTObjective:To assess prognosis of pulmonary thromboembolism using tissue Doppler echocardiography and brain natriuretic peptide.Methods:Patients aged over 18 years were evaluated within 24 hours of confirmed diagnosis (chest tomography/pulmonary scintigraphy) of pulmonary embolism using two-dimensional echocardiography and tissue Doppler for right ventricular systolic (s') velocities, strain, tissue tracking and myocardial performance index. Plasma brain natriuretic peptide was also obtained within 24 hour. The influence of echocardiographic and clinical variables on mortality was examined (up to 12 months) using Cox regression analysis.Results:Out of 118 patients, 100 patients were included in the study (60 males, aged 55±17 years). Right ventricular dysfunction was observed in 28% using two-dimensional echocardiography. Tissue Doppler right ventricular variables (s' velocities, tissue tracking and strain) were decreased only for patients with right ventricular dysfunction, whereas myocardial performance index and systolic pulmonary artery pressure were increased. Mean brain natriuretic peptide value was 66±111pg/mL, also increased in patients with right ventricular dysfunction (136±146pg/mL). Mortality was 11% and related to age, malignancy and brain natriuretic peptide levels. The only echocardiographic variables capable of predicting events by univariate analysis were pulmonary pressure and right ventricular s' velocity. However, multivariate analysis showed only malignancy to predict mortality in this group.Conclusion:Lower tissue Doppler systolic velocities and elevated brain natriuretic peptide levels are associated with poorer prognosis in patients with pulmonary thromboembolism; but only malignancy emerged as an independent predictor of mortality.

Stress Echocardiography in Regurgitant Valve Disease

Because of its wide availability, low cost, versatility, and clinical use, stress echocardiography has become increasingly recognized as a valuable tool in the assessment of patients with regurgitant valvular heart disease. Exercise testing is favored compared with pharmacological stress testing for risk stratification in asymptomatic patients and can identify what might otherwise be considered as a moderate valve disease. It has been shown to provide insights into exertional symptoms disproportionate to resting hemodynamics in these patients and to facilitate individual risk stratification. Aggravation of valvular regurgitation severity, exercise-induced pulmonary hypertension (PHT), impaired left ventricular (LV) contractile reserve, inducible ischemia, dynamic LV dyssynchrony, and altered exercise capacity, together with the development of symptoms during exercise echocardiography, provide the clinician with straightforward prognostic information, therefore enabling a more accurate definition of the optimal timing of intervention in patients with valvular regurgitation.1,2 In contrast, dobutamine stress echocardiography has little value in cases of valvular regurgitation. Dobutamine infusion is almost systematically associated with a decrease in the severity of regurgitation; however, it might be of interest in the detection of LV contractile reserve and inducible ischemia. The most common form of exercise used in conjunction with echocardiography is immediate postexercise imaging on a treadmill or upright bicycle ergometer. However, semisupine exercise testing on an appropriate tilted table allows continuous echocardiographic monitoring, which represents an advantageous tool for quantifying changes in valvular regurgitation severity, LV function, and pulmonary pressure (Table). This exercise stress echocardiography modality (ie, per-exercise echocardiography) is the most used in Europe, and we strongly suggest this approach in the setting of valvular heart disease to detect evanescent changes. A symptom-limited graded exercise test is recommended, and ≥80% of the age-predicted upper heart rate should be reached in the absence of symptoms. The test is adapted to the clinical conditions …