Higher Natriuretic Peptide Levels Research Articles

Prevalence, Temporal Change, and Determinants of Anxiety and Depression in Hospitalized Patients With Heart Failure

BackgroundAnxiety and depression may be under-recognized in patients with heart failure (HF). We therefore investigated the prevalence and temporal change of these symptoms in hospitalized patients with HF. Methods and ResultsWe prospectively evaluated consecutive hospitalized patients with HF using the Hospital Anxiety and Depression Scale (HADS) on admission and at discharge. The HADS-A (anxiety) and HADS-D (depression) scores were categorized as follows; 0–7, no symptoms; 8–10, mild; and 11–21, significant anxiety or depression. Symptom worsening was defined as the HADS category at discharge being poorer than that on admission. Of 224 patients (mean age 77.5 years), 35 (16%) and 62 (28%) had significant symptoms of anxiety and depression, respectively. During hospitalization, the HADS-A significantly decreased (on admission; median 6 [interquartile range (IQR) 3–9] vs at discharge; median 4 [IQR 2–7], P < .01), whereas the HADS-D did not improve (on admission; median 8 [IQR 5–11] vs at discharge; median 8 [IQR 4–11], P =.82). Anxiety and depression worsened during hospitalization in 19 (10%) and 40 (21%) patients, respectively. Advanced age, higher natriuretic peptide levels, and acute-on-chronic HF were associated with worsening anxiety, and longer hospitalization length was associated with worsening depression. ConclusionsAnxiety and depression were common and depression persisted during HF hospitalization.

Gender-Related Differences in Heart Failure Biomarkers

Important differences in comorbidities and clinical characteristics exist between women and men with heart failure (HF). In particular, differences in the kinetics of biological circulating biomarkers—a critical component of cardiovascular care—are highly relevant. Most circulating HF biomarkers are assessed daily by clinicians without taking sex into account, despite the multiple gender-related differences observed in plasma concentrations. Even in health, compared to men, women tend to exhibit higher levels of natriuretic peptides and galectin-3 and lower levels of cardiac troponins and the cardiac stress marker, soluble ST2. Many biological factors can provide a reliable explanation for these differences, like body composition, fat distribution, or menopausal status. Notwithstanding, these sex-specific differences in biomarker levels do not reflect different pathobiological mechanisms in HF between women and men, and they do not necessarily imply a need to use different diagnostic cut-off levels in clinical practice. To date, the sex-specific prognostic value of HF biomarkers for risk stratification is an unresolved issue that future research must elucidate. This review outlines current evidence regarding gender-related differences in circulating biomarkers widely used in HF, the pathophysiological mechanisms underlying these differences, and their clinical relevance.

Prevalence and prognosis of iron deficiency in acute myocardial infarction

Coronary artery disease (CAD) and iron deficiency (ID) are two common pathologies, but the potential role of iron in the pathophysiology of CAD through inflammation and atherosclerosis is still being debated. To evaluate the prevalence and prognosis of ID in CAD patient after acute myocardial infarction (AMI). Patients hospitalised for AMI in two cardiology centres were screened for ID in the first 48 hours after admittance. ID was defined as transferring saturation less than 20% (T-SAT < 20%). All-cause mortality 6 months after MI was the primary end-point. GRACE and CRUSADE scores, left ventricular ejection fraction (LVEF), severity of CAD (defined by TIMI and SYNTAX angiographic scores), length of hospital stay (LOS), increased C-reactive protein (CRP), troponin IC, and natriuretic peptides were the secondary endpoints. Half (49%) of the 145 patients included were diagnosed with ID (average age 66.5 ± 13.4 years, 30% were women and 30% over 75 years- old). Six months overall survival of ID patients was impaired: 83.1% vs. 100%, in non-ID patients ( P < 0.001). On admittance, ID patients also had increased GRACE and CRUSADE scores ( P < 0.0001 and < 0.01, respectively); lower LVEF ( P < 0.01); more frequent coronary occlusions ( P < 0.004); higher SYNTAX score ( P < 0.0001); more common multi-vessel involvement ( P < 0.007); LOS often over one week ( P < 0.001); more severe inflammation ( P < 0.0001); higher natriuretic peptides levels ( P < 0.03) ( Fig. 1 ). ID is highly prevalent among patients hospitalised for MI and associated with higher mortality at 6 months and greater severity of CAD. Whether its presence impacts long-term survival needs further studies.

Natriuretic peptide system and cardiovascular risk: Higher natriuretic peptides levels is associated with a favorable lipid profile

Natriuretic peptide system and cardiovascular risk: Higher natriuretic peptides levels is associated with a favorable lipid profile

Abstract 13943: Elevated Natriuretic Peptides in Covid-19 Patients With Severe or Critical Illness

Introduction: The worldwide pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in an extraordinary increase in the number of severe and critically ill patients in a relatively short span of time. Cardiovascular risk factors and outcomes are noted as being key contributing features of many patients who ultimately develop severe illness. As such, laboratory markers for cardiac damage and failure have been described as being elevated in this subset of patients. Hypothesis: The purpose of this meta-analysis is to identify and compare the values of natriuretic peptides in severely ill patient infected with the SARS-CoV-2 compared to those who are identified as being not severe. Methods: PUBMED and Medrxiv were searched through April 15th 2020. The outcome of interest is the difference of BNP or NT-pro BNP in severe versus non-severe Results: We identified 9 eligible retrospective cohort studies that observed a total of 1,575 patients that had their natriuretic peptides measured and who were classified by disease severity. Patients who were identified as having a non-severe status with the SARS-CoV-2 infection had a mean difference of -69.56 (95% CI) [-137.35, -1.77, P =0.04, I2=83%) in B-type natriuretic peptide (BNP) levels compared to those with severe status. Similarly, patients who had their N-terminal-pro BNP (NT-proBNP) levels measures had a mean difference of -518.65 (95% CI) [ -884.90, -152.40, P=0.006, I2=86%) when compared to those whom NT-proBNP levels were measured with severe status. Conclusions: In conclusion, patients infected with the SARS-CoV-2 virus and were classified as severe had higher levels of natriuretic peptides than patients who were classified as not severe.

Artificial Intelligence Predicts Atrial Fibrillation Development from the 12-lead Electrocardiogram in Heart Failure with Preserved Ejection Fraction

Introduction An artificial intelligence (AI) algorithm that utilizes data contained within a single 12-lead ECG during normal sinus rhythm has recently shown to identify patients with occult AF. Patients with HFpEF frequently display AF in association with left atrial (LA) dysfunction. Hypothesis Patients with HFpEF and a higher probability of AF according to their AI-enabled ECG display more advanced LA remodeling and dysfunction, putting them at greater risk for AF development. Methods This retrospective cohort study includes 613 patients with definite HFpEF: 184 ambulatory patients diagnosed through invasive hemodynamic testing and 429 inpatients admitted because of decompensated HFpEF. A previously validated AI algorithm that predicts current AF risk based on ECG analysis was applied to estimate future AF risk during long-term follow-up, with patients grouped into quartiles of risk. Cardiac structure and function, as well as incident AF rates were compared. Results AI-predicted AF risk was 42% (14−69%) overall. Patients with higher risk were older, with more comorbidities, lower blood pressure, higher natriuretic peptide levels, greater conduction delays, a higher prevalence of pacing, and more frequent use of diuretics. In addition, underlying structural heart disease was more severe, with more pronounced left ventricular hypertrophy, larger LA volumes, lower LA reservoir and booster strain, higher cardiac filling pressures (confirmed through invasive measurements ambulatory patients), and more tricuspid regurgitation. Echocardiography images from a representative patient within each AF risk quartile are presented in the Figure. Invasive hemodynamic measurements in the ambulatory cohort showed additionally that patients with higher AI-predicted AF risk had lower cardiac output (10.01±2.85L/min and 6.94±2.49L/min in the lowest and highest risk quartile, respectively) and a higher pulmonary vascular resistance at peak effort (121±102dynes/s/cm−5 and220±133 dynes/s/cm−5 in the lowest and highest risk quartile, respectively). Over a median follow-up of 41months (11-71months), AI-predicted AF risk was associated with new-onset AF [HR(95%CI) = 1.31(1.20-1.41); p<0.001] and all-cause death [HR (95%CI) = 1.12(1.08-1.17); p<0.001]. Conclusions An AI-risk score based upon a single 12-lead ECG reflects the severity of underlying LA myopathy in HFpEF and predicts new-onset AF. These data suggest that application of an AI-enabled ECG may be useful to identify patients with the AF/LA myopathy phenotype in HFpEF. An artificial intelligence (AI) algorithm that utilizes data contained within a single 12-lead ECG during normal sinus rhythm has recently shown to identify patients with occult AF. Patients with HFpEF frequently display AF in association with left atrial (LA) dysfunction. Patients with HFpEF and a higher probability of AF according to their AI-enabled ECG display more advanced LA remodeling and dysfunction, putting them at greater risk for AF development. This retrospective cohort study includes 613 patients with definite HFpEF: 184 ambulatory patients diagnosed through invasive hemodynamic testing and 429 inpatients admitted because of decompensated HFpEF. A previously validated AI algorithm that predicts current AF risk based on ECG analysis was applied to estimate future AF risk during long-term follow-up, with patients grouped into quartiles of risk. Cardiac structure and function, as well as incident AF rates were compared. AI-predicted AF risk was 42% (14−69%) overall. Patients with higher risk were older, with more comorbidities, lower blood pressure, higher natriuretic peptide levels, greater conduction delays, a higher prevalence of pacing, and more frequent use of diuretics. In addition, underlying structural heart disease was more severe, with more pronounced left ventricular hypertrophy, larger LA volumes, lower LA reservoir and booster strain, higher cardiac filling pressures (confirmed through invasive measurements ambulatory patients), and more tricuspid regurgitation. Echocardiography images from a representative patient within each AF risk quartile are presented in the Figure. Invasive hemodynamic measurements in the ambulatory cohort showed additionally that patients with higher AI-predicted AF risk had lower cardiac output (10.01±2.85L/min and 6.94±2.49L/min in the lowest and highest risk quartile, respectively) and a higher pulmonary vascular resistance at peak effort (121±102dynes/s/cm−5 and220±133 dynes/s/cm−5 in the lowest and highest risk quartile, respectively). Over a median follow-up of 41months (11-71months), AI-predicted AF risk was associated with new-onset AF [HR(95%CI) = 1.31(1.20-1.41); p<0.001] and all-cause death [HR (95%CI) = 1.12(1.08-1.17); p<0.001]. An AI-risk score based upon a single 12-lead ECG reflects the severity of underlying LA myopathy in HFpEF and predicts new-onset AF. These data suggest that application of an AI-enabled ECG may be useful to identify patients with the AF/LA myopathy phenotype in HFpEF.

Response to beta-blockers and natriuretic peptide level in acute heart failure: analysis of data from the Korean acute heart failure registry.

To investigate the effect of beta-blockers according to NP levels and HF phenotypes because natriuretic peptide (NP) level can be used to risk-stratify HF patients regardless of left ventricular ejection fraction (LVEF). Of 5,625 patients in the Korean acute heart failure registry, we included patients with LVEF and NP levels. HF phenotypes were defined as HF with reduced ejection fraction (HFrEF) (EF ≤ 40%), HF with midrange ejection fraction (HFmrEF) (40% < EF < 50%), and HF with preserved EF (HFpEF) (EF ≥ 50%). Patients were further stratified by NP tertiles. Primary outcome was 5-year all-cause mortality according to beta-blocker use at discharge. Both B-type NP (BNP) (r = -0.279, P < 0.001) and N-terminal pro-BNP (r = -0.186, P < 0.001) levels correlated inversely with LVEF. During a median follow-up duration of 961days, 1560 (35.3%) patients died. In HFrEF, patients taking beta-blockers showed better survival regardless of NP levels. Regarding HFmrEF, there was no mortality difference between those taking and not taking beta-blockers. In HFpEF, beta-blocker use demonstrated lower mortality in those in the 3rd NP tertile (log-rank P = 0.041) but not in those in the 1st and 2nd NP tertiles (log-rank P > 0.05). After adjusting covariates, the use of beta-blockers was associated with a 38%-reduced mortality (hazard ratio: 0.62; 95% confidence interval: 0.39-0.98; P = 0.040) in HFpEF patients in the 3rd NP tertile but not in those in 1st and 2nd tertiles. We confirm that the use of beta-blockers is beneficial in patients with HFrEF. Furthermore, we extend the benefits of beta-blockers to patients with HFpEF and high NP levels. ClinicalTrial.gov identifier: NCT01389843 URL: https://clinicaltrials.gov/ct2/show/NCT01389843.

Inflammation and Circulating Natriuretic Peptide Levels.

NPs (natriuretic peptides) are cardiac-derived hormones that promote natriuresis, diuresis, and vasodilation. Preclinical evidence suggests that nonhemodynamic triggers for NP release exist, with a few studies implicating inflammatory stimuli. We examined the association between inflammation and NP levels in humans. The associations between inflammation and NP levels were examined in 3 independent studies. First, in 5481 MESA (Multi-Ethnic Study of Atherosclerosis) participants, the cross-sectional (exam 1) and longitudinal (exams 1 to 3) associations between circulating IL6 (interleukin-6) and NT-proBNP (N terminal pro B-type natriuretic peptide) levels were examined in multivariable-adjusted models. Second, in a prospective study of 115 healthy individuals, changes in NP levels were quantified following exposure to lipopolysaccharide as an inflammatory stimulus. Third, in 13 435 hospitalized patients, the association between acute inflammatory conditions and circulating NP levels was assessed using multivariable-adjusted models. At the baseline MESA exam, each 1-unit higher natural log IL6 was associated with 16% higher NT-proBNP level ([95% CI, 10%-22%]; P=0.002). Each 1-unit higher baseline natural log IL6 level also associated with 6% higher NT-proBNP level ([95% CI, 1%-11%]; P=0.02) at 4-year follow-up. In the lipopolysaccharide study, median NT-proBNP levels rose from 21 pg/mL pre-lipopolysaccharide to 54 pg/mL post-lipopolysaccharide, P<0.001. In the hospitalized patient study, acute inflammatory conditions were associated with 36% higher NP levels ([95% CI, 17%-60%]; P<0.001). Inflammation appears to be associated with NP release. Interpretation of NP levels should therefore take into account inflammatory conditions.

Prognostic impact of plasma volume estimated from hemoglobin and hematocrit in heart failure with preserved ejection fraction.

Plasma volume (PV) estimated from Duarte's formula (based on hemoglobin/hematocrit) has been associated with poor prognosis in patients with heart failure (HF). There are, however, limited data regarding the association of estimated PV status (ePVS) derived from hemoglobin/hematocrit with clinical profiles and study outcomes in patients with HF and preserved ejection fraction (HFpEF). Patients from North and South America enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT) with available hemoglobin/hematocrit data were studied. The association between ePVS (Duarte formula and Hakim formula) and the composite of cardiovascular mortality, HF hospitalization, or aborted cardiac arrest was assessed. Among 1747 patients (age 71.6years; males 50.1%), mean ePVS derived from Duarte formula was 4.9 ± 1.0mL/g. Higher Duarte-derived ePVS was associated with prior HF admission, diabetes, more severe congestion, poor renal function, higher natriuretic peptide level, and E/e'. After adjustment for potential covariates including natriuretic peptide, higher Duarte-derived ePVS was associated with an increased rate of the primary outcome [highest vs. lowest ePVS quartile: adjusted-HR (95%CI) = 1.79 (1.28-2.50), p < 0.001]. Duarte-derived ePVS improved prognostic performance on top of clinical and routine variables (including natriuretic peptides) (NRI = 11, p < 0.001), whereas Hakim-derived ePVS did not (p = 0.59). The prognostic value of Duarte-derived ePVS was not modified by renal function (P interaction > 0.10 for all outcomes). ePVS from Duarte's formula was associated with congestion status and improved risk stratification regardless of renal function. Our findings suggest that Duarte-derived ePVS is a useful congestion variable in patients with HFpEF.

Cardiovascular risk factors among cancer patients qualified for systemic treatment. Analysis of a cardiovascular disease-free cohort from the Polish multicentre study ONCOECHO

IntroductionCancer therapies are currently more efficient at increasing the survival of patients (pts) with cancer. Unfortunately, the cardiovascular (CV) complications of cancer therapies may adversely affect improving results of treatment. The aim of the study was to evaluate the prevalence of classical CV risk factors among pts with de novo diagnosis of cancer and thus identify the cohort of pts with potentially increased future risk of CV complications.Material and methodsThe analysis is based on the database of the multicentre ONCOECHO study. Pts before systemic treatment (chemotherapy or targeted therapy) were included. The diagnostic datasets of resting electrocardiogram, blood samples, and transthoracic echocardiogram were analysed in 343 consecutive pts who were free from any cardiovascular disease that could adversely affect the introduced treatment.ResultsOur cohort included 4.4% of pts with kidney cancer, 7.3% with colorectal cancer, 26.5% with haematological malignancies (HM), and 61.8% with breast cancer. The risk estimated by SCORE was 4.56 ±5.07%. Breast cancer pts had lower cardiovascular risk than those with HM (p = 0.001) and kidney cancer (p = 0.002). Additionally, the HM group had much higher levels of natriuretic peptides (p < 0.001) and creatinine (p = 0.008) than pts with breast cancer. The comparison with the NATPOL population data showed that our pts were more often smokers, hypertensives, and diabetics, but less frequently presented with hypercholesterolaemia.ConclusionsPatients with new diagnosis of cancer, who are candidates for potentially cardiotoxic medical treatment, have increased prevalence of significant cardiovascular risk factors and therefore should be followed by a multidisciplinary team during the therapeutic process.

Association Between Cardiac Natriuretic Peptides and Lipid Profile: a Systematic Review and Meta-Analysis

Cardiac natriuretic peptides (NPs) play a fundamental role in maintaining cardiovascular (CV) and renal homeostasis. Moreover, they also affect glucose and lipid metabolism. We performed a systematic review and meta-analysis of studies investigating the association of NPs with serum lipid profile. A PubMed and Scopus search (2005–2018) revealed 48 studies reporting the association between NPs and components of lipid profile [total cholesterol (TC), low-density lipoprotein cholesterol (LDLc), high-density lipoprotein cholesterol (HDLc) and triglycerides (TG)]. Despite high inconsistency across studies, NPs levels were inversely associated with TC [k = 32; pooled r = −0.09; I2 = 90.26%], LDLc [k = 31; pooled r = −0.09; I2 = 82.38%] and TG [k = 46; pooled r = −0.11; I2 = 94.14%], while they were directly associated with HDLc [k = 41; pooled r = 0.06; I2 = 87.94%]. The relationship with LDLc, HDLc and TG lost significance if only studies on special populations (works including subjects with relevant acute or chronic conditions that could have significantly affected the circulating levels of NPs or lipid profile) or low-quality studies were taken into account. The present study highlights an association between higher NP levels and a favorable lipid profile. This confirms and extends our understanding of the metabolic properties of cardiac NPs and their potential in CV prevention.

Plasma natriuretic peptide levels reflect the status of the heart failure in fetuses with arrhythmia

Objectives To evaluate the significance of natriuretic peptide (NP) levels in fetal arrhythmia. Study design Cardiovascular profile (CVP) scores and umbilical vein (UV) NP levels at birth were compared by different fetal arrhythmia statuses. Results Fetal tachyarrhythmia (n = 22), bradyarrhythmia (n = 12), extrasystole (n = 12) and controls (n = 127) were enrolled in this study. Fetal antiarrhythmic therapy was performed in fetuses with tachyarrhythmia (n = 18) and bradyarrhythmia (n = 5). Fetal arrhythmias were divided into three groups: group A (arrhythmia controlled at birth, n = 17), Group B (arrhythmia uncontrolled at birth, n = 9) and Group C (fetal therapy not indicated, n = 20). Group B had significantly lower CVP scores and higher NP levels than the other two groups and controls (p < .01). Groups A and C had significantly lower CVP scores than controls, but NP levels in Groups A and C showed no differences compared with controls. Conclusions UV NP concentrations reflect the severity of fetal arrhythmia and responses to fetal therapy.

The β-blocker uptitration in elderly with heart failure regarding biomarker levels: CIBIS-ELD substudy.

We investigated if the baseline value of mid-regional pro-atrial natriuretic peptide (NP),N-terminal pro-B-type NP and copeptin may be helpful in optimizing β-blocker uptitration in elderly patients with heart failure. According to the biomarkers' levels, 457 patients were divided into three subgroups and compared with each other at baseline and 3 months after. All mid-regional pro-atrial NP and N-terminal pro-B-type NP subgroups had significant amelioration of left ventricle ejection fraction and New York Heart Association (NYHA) class after 3 months of β-blocker uptitration (p<0.001). More prominent improvement of left ventricle ejection fraction and New York Heart Association class was observed in subgroups with lower versus higher NPs levels. NPs levels, unlike copeptin levels, might be useful tool for objective selection of elderly heart failure patients who could have the greatest benefit of forced uptitration.

Plasma natriuretic peptide levels in fetuses with congenital heart defect and/or arrhythmia.

Diagnosing fetal heart failure remains challenging because it is difficult to know how well the fetal myocardium will perform as loading conditions change. In adult cardiology, natriuretic peptides (NPs) are established markers of heart failure. However, the number of studies investigating NP levels in fetuses is quite limited. The aim of this study was to evaluate the significance of plasma NP levels in the assessment of heart failure in fetuses with a congenital heart defect (CHD) and/or arrhythmia. This was a prospective observational study conducted at a tertiary pediatric cardiac center. A total of 129 singletons with CHD and/or arrhythmia and 127 controls were analyzed between 2012 and 2015. Umbilical cord plasma atrial NP, brain NP and N-terminal pro-brain NP levels at birth were compared with ultrasonography findings indicating fetal heart failure, such as cardiovascular profile (CVP) score and morphological characteristics. Fetuses with CHD and/or arrhythmia had higher NP levels than did controls (P < 0.01). NP levels of fetuses with CHD and/or arrhythmia were correlated inversely with CVP score (P for trend < 0.01). No differences in NP levels were found in fetuses with CHD and/or arrhythmia and a CVP score of ≥ 8 in comparison to controls. Multivariate analysis showed that a CVP score of ≤ 5, tachy- or bradyarrhythmia at birth, preterm birth and umbilical artery pH < 7.15 were associated independently with high NP levels (P < 0.01). Among fetuses with a CVP score of ≤ 7, abnormal venous Doppler sonography findings were significantly more common and more severe in fetuses with tachy- or bradyarrhythmia than in those with CHD, and those with tachy- or bradyarrhythmia had higher NP levels than did those with CHD (P = 0.01). Fetuses with right-heart defect and moderate or severe tricuspid valve regurgitation had significantly higher NP levels than did fetuses with other types of CHD (P < 0.01). Plasma NP levels in fetuses with CHD and/or arrhythmia are correlated with the severity of fetal heart failure. Elevated NP levels are attributed mainly to an increase in central venous pressure secondary to arrhythmia or atrioventricular valve regurgitation due to CHD, rather than to the morphological abnormality itself. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

122 - Prediction of Heart Failure Readmission Using Echocardiographic Variables in Patients with Heart Failure with Preserved Ejection Fraction in an Urban Inner City Teaching Hospital

Objective: The purpose of this study was to determine the relationship between echocardiographic variables and hospital readmission rates in patients with Heart Failure with preserved EF (HFpEF) admitted for acute decompensated heart failure (HF). Background: Acute HF exacerbation in patients with HFpEF is caused by congestion which may be not clinically evident. Congestion is due to elevated LV filling pressure which is often reflected by high levels of natriuretic peptides. Using the echocardiogram to determine specific parameters such as LVEDP, E/e' ratio, left atrial volume index can help to identify patients with elevated filling pressures that are congested but may not be reflected clinically and may be increased risk for HF readmission. Methods: One hundred sixteen patients with HFpEF who were admitted for acute HF exacerbation with an echocardiogram done during initial presentation were included. Patients were divided based on readmission in 60 days. Continuous variables were analyzed using Wilcoxon rank sum test and categorical variables(atrial fibrillation, coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia, gender, race) were analyzed using Fisher's exact test. The best subset selection method was performed to assess the best predictive model of readmission. Results: There were no significant relationship between readmission and any of the categorical variables. A significant relationship was noted between readmission and both NT pro-BNP and left atrial (LA) Volume index (ml/m2). The best fit model predicting readmission was applied to E/e' ratio and LA volume index (ml/m2). For every unit increase in E/e' ratio, the odds of readmission decreased. For every unit increase in LA Volume index, the odds of readmission increased. Conclusion: Our results reveal that LA volume index predicted HF readmission in HFpEF patients, while E/e' ratio did not. This could be due to the dynamic nature of E/e' being volume related and unclear timing of the echocardiogram in relation to diuresis. Increased LA volume index correlating with readmission appropriately reflects the pathophysiology of HFpEF and LA remodeling in these patients. The analysis showed significant correlation with HF readmission rates in patients with higher NT proBNP levels. LA volume index can be considered as an additional prognostic marker for HF readmission. Further studies are warranted to evaluate echocardiographic variables at the time of admission for acute decompensated HF in HFpEF patients.

The prognostic role of extremely high levels of the B-type natriuretic prohormone with regard to the in-hospital mortality of patients hospitalized for heart failure

Patients hospitalized for heart failure have a very high in-hospital as well as one-year mortality. Natriuretic peptides play both a diagnostic and a prognostic role in this disease. Changes of natriuretic peptide levels in response to therapy are a well-known prognostic marker. Regarding in-hospital mortality, however, little is known about the prognostic value of extremely high levels of natriuretic peptides measured on admission. To decide whether extremely high levels of B-type natriuretic peptide have a prognostic value with regard to in-hospital mortality. NT-proBNP levels on admission and in-hospital mortality were extracted retrospectively from the data of patients treated with heart failure in the cardiology department of the Hospital of St. John of God in Budapest. We separately analyzed the data of patients hospitalized for heart failure in 2015 with extremely high initial NT-proBNP levels. The cut-off value in this regard was 10 000 ng/l. We also analyzed the comorbidities of these patients. The median NT-proBNP level of those patients who survived beyond the index hospital stay in the last 10 years was 4842 ng/l, whereas the median NT-proBNP level of those 182 patients who died during their hospital stay was 10 688 ng/l (p<0.001). In the year 2015, we treated 118 patients with an NT-proBNP level above 10 000 ng/l. Thirteen of these patients died, which means that their in-hospital mortality exceeded 10%. In comparison, the in-hospital mortality of all heart failure patients was 5.8%. The difference of median NT-proBNP levels of surviving versus deceased patients in this group with extremely high NT-proBNP levels was no longer significant (17 080 ng/l vs. 19 152 ng/l). Patients with an NT-proBNP level of >10 000 ng/l on admission have a significantly higher in-hospital mortality. The difference of NT-proBNP levels of surviving versus deceased patients in the group with admission NT-proBNP levels >10 000 ng/l is no longer significant. We could not identify any etiological factors that would explain these extremely high NT-proBNP levels or the excess in-hospital mortality. Orv Hetil. 2017; 158(20): 779-782.

A novel heart-adipose tissue axis: Atrial natriuretic peptide and leptin interactions in man

Increased levels of leptin are common features of obesity and type 2 diabetes, reflecting leptin resistance. Reduced circulating natriuretic peptide (NP) concentrations are independently associated with type 2 diabetes and obesity, while increased natriuretic peptide levels appear to be protective. Observational studies suggest that high NP levels are associated with reduced leptin concentrations. Whether or not this is a causal relationship is unknown.

Surgical myectomy improves pulmonary hypertension in obstructive hypertrophic cardiomyopathy

Characterization of pulmonary hypertension (PH) and the effects of myectomy in hypertrophic cardiomyopathy (HCM) remain poorly defined. The aim of the study was to investigate the effect of myectomy on PH in HCM. This is a retrospective analysis of 306 consecutive symptomatic HCM patients (70% NYHA class III-IV) with evaluation of echocardiographic right ventricular systolic pressure (RVSP) both preceding (median 3 days) and following (median 4 days) myectomy. Compared with patients without PH (RVSP <35 mmHg, n = 145, 47%), patients with moderate or severe PH (RVSP ≥50 mmHg, n = 51, 17%) were older, predominantly female, had a greater prevalence of atrial fibrillation, higher natriuretic peptide levels, higher left ventricular outflow tract gradient, higher E velocity, and larger left atria. Reduction of RVSP post-myectomy was evident in patients with moderate or severe PH [59 (IQR 54-71) to 50 (IQR 39-62) mmHg, P < 0.0001] and in all patients with PH [RVSP ≥ 35 mmHg, n = 161, 43 (IQR 39-54) to 41 (IQR 35-52) mmHg, P < 0.0001]. In a subgroup of patients with long-term data, PH continued to decline during follow-up. Clinical variables associated with improvement in PH in these patients were higher left atrial volume index (R = 0.43, P = 0.0069) and moderate or severe mitral regurgitation (R = 0.33, P = 0.038). Surgical myectomy is associated with improvement in PH, most pronounced in moderate or severe PH. These data provide insight into pulmonary haemodynamics following obstruction relief and can help to guide therapeutic expectations.

The Prognostic Significance of Heart Rate in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in Sinus Rhythm: Insights From the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) Trial

The purpose of this study was to characterize the relationship between heart rate and post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction (EF) in sinus rhythm. A reduction in heart rate improves clinical outcomes in patients with chronic heart failure and in sinus rhythm, but the association between heart rate and post-discharge outcomes in patients with HHF is presently unclear. This post-hoc analysis of the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial examined 1,947 patients with HHF and EF≤40% not in atrial fibrillation/flutter or pacemaker dependent. The median follow-up period was 9.9 months. At baseline, patients with a higher heart rate tended to be younger with lower EF and were more likely to have worse New York Heart Association functional class and higher natriuretic peptide levels. After adjustment for clinical risk factors, baseline heart rate was not predictive of all-cause mortality (p≥ 0.066). However, at≥70 beats/min, every 5-beat increase in 1-week post-discharge heart rate was independently associated with increased all-cause mortality (hazard ratio: 1.13 [95% confidence interval: 1.05 to 1.22]; p= 0.002). Similarly, every 5-beat increase≥70 beats/min in 4-week post-discharge heart rate was predictive of all-cause mortality (hazard ratio: 1.12 [95% confidence interval: 1.05 to 1.19]; p= 0.001). In this large cohort of patients with HHF with reduced EF and in sinus rhythm, baseline heart rate did not correlate with all-cause mortality. In contrast, at≥70 beats/min, higher heart rate in the early post-discharge period was independently predictive of death during subsequent follow-up. Further study of post-discharge heart rate as a potential therapeutic target in this high-risk population is encouraged.

Interest of NT-proBNP in chronic heart failure follow-up

Reducing readmissions after hospitalisation for acute heart failure is the new challenge of these diseases, approaching 30% within 60 to 90 days of discharge. Congestion related to high ventricular filling pressures, reflected by the high levels of natriuretic peptides, is the main reason for heart failure readmission. Natriuretic peptide levels are a patent prognostic marker of cardiovascular event in chronic heart failure. Treshold values of BNP and NT-proBNP being respectively 125 and 1000 pg/mL. Optimizing treatment of heart failure by monitoring natriuretic peptides, including management of diuretic doses, remains matter of controversies.