N-terminal pro-B-type Natriuretic Peptide Testing Research Articles

N-terminal pro-B-type natriuretic peptide concentrations, testing and associations with worsening heart failure events.

In patients with heart failure (HF), we aimed to assess (i) the time trends in N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing; (ii) patient characteristics associated with NT-proBNP testing; (iii) distribution of NT-proBNP levels, focusing on the subgroups with (WHFE) vs. without (NWHFE) a worsening HF event, defined as an HF hospitalization; and (iv) changes of NT-proBNP levels over time. NT-proBNP testing and levels were investigated in HF patients enrolled in the Swedish Heart Failure Registry (SwedeHF) linked with the Stockholm CREAtinine Measurements project from January 2011 to December 2018. Index date was the first registration in SwedeHF. Patterns of change in NT-proBNP levels before (in the previous 6±3months) and after (in the following 6±3months) the index date were categorized as follows: (i) <3000ng/L at both measurements=stable low; (ii) <3000ng/L at the first measurement and ≥3000ng/L at the second measurement=increased; (iii) ≥3000ng/L at the first measurement and <3000ng/L at the second measurement=decreased; and (iv) ≥3000ng/L at both measurements=stable high. Univariable and multivariable logistic regression models, expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs), were performed to assess the associations between (i) clinical characteristics and NT-proBNP testing and (ii) changes in NT-proBNP from 6months prior to the index date and the index date and a WHFE. Consistency analyses were performed in HF with reduced ejection fraction (HFrEF) alone. A total of 4424 HF patients were included (median age 74years, women 34%, HFrEF 53%), 33% with a WHFE. NT-proBNP testing increased over time, up to 55% in 2018, and was almost two-fold as frequent, and time to testing was less than half, in patients with WHFE vs. NWHFE. Independent predictors of testing were WHFE, higher heart rate, diuretic use, and preserved ejection fraction. Median NT-proBNP was 3070ng/L (Q1-Q3: 1220-7395), approximately three-fold higher in WHFE vs. NWHFE. Compared with stable low NT-proBNP levels, increased (OR 4.27, 95% CI 2.47-7.37) and stable high levels (OR 2.48, 95% CI 1.58-3.88) were independently associated with a higher risk of WHFE. Results were consistent in the HFrEF population. NT-proBNP testing increased over time but still was only performed in half of the patients. Testing was associated with a WHFE, with features of more severe HF and for differential diagnosis purposes. Increased and stable high levels were associated with a WHFE. Overall, our data highlight the potential benefits of carrying further implementation of NT-proBNP testing in clinical practice.

Abstract 16789: Modeling the Optimal Strategy of Natriuretic Peptide Testing for Heart Failure Prevention in Diabetes: A Pooled Cohort Analysis

Introduction: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is associated with heart failure (HF) risk and measurement is recommended in diabetes. Incorporation of NT-proBNP with WATCH-DM, a HF risk score validated in diabetes, improved HF risk prediction in low-risk individuals (score &lt;13). Whether WATCH-DM can improve the yield of NT-proBNP testing and inform allocation of SGLT2 inhibitors is unknown. Methods: Adults with diabetes and free of HF at baseline from ARIC, CHS, CRIC, DHS, FOS, and MESA cohorts were included. Participants without cardiovascular disease (CVD) were stratified into high- vs. low-risk categories based on 4 approaches: 1) WATCH-DM (score ≥ vs. &lt;13); 2) NT-proBNP (≥ vs. &lt;125 pg/mL); 3) WATCH-DM plus NT-proBNP (both high vs. not); 4) WATCH-DM-based NT-proBNP (if score &lt;13, measure NT-proBNP) (either high vs. not). Five-year cumulative incidence rates of HF, number needed to treat (NNT 5 ) and number needed to screen (NNS 5 ) were estimated based on pooled treatment effects of SGLT2 inhibitors. Results: The study included 6,410 participants (47.5% women, 35.1% Black, 20.5% with CVD) with 428 (6.7%) incident HF events over 5-year follow-up. The 5-year risk of HF was 12.3% among participants with CVD and comparable to those without CVD identified as high-risk based on all 4 approaches ( Figure ). Among participants without CVD, WATCH-DM-based NT-proBNP identified 46% of participants as high-risk and accounted for 80% of HF events. The NNT 5 with an SGLT2 inhibitor to prevent 1 HF event in participants with CVD was 25 and similar to the primary prevention population identified as high-risk ( Figure ). The NNS 5 was lowest in the WATCH-DM-based NT-proBNP strategy ( Figure ). Conclusions: Selective NT-proBNP assessment based on a validated clinical risk score for HF improved the yield of testing and may represent an efficient approach to risk stratification and allocation of therapies among individuals with diabetes.

Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital....

A-058 Frequency of Biochemical Assessment of Risk for Heart Failure among Diabetic Population

Abstract Background Diabetes remains a prevalent chronic health condition. Patients with diabetes have nearly twice the risk of developing heart failure as the general population and the American Diabetes Association recommends annual assessment by measuring N-terminal pro-B-type natriuretic peptide (NT-proBNP) or BNP among diabetic patients. We evaluated the frequency of biomarker assessment among our diabetic population. Methods Retrospective analysis of glycated hemoglobin (A1c) and NT-proBNP measured over a period of 21 months were performed. The frequency of NTproBNP assessment among patients with diagnostic A1c values were determined. Statical analysis were performed using Microsoft® Excel and NCSS® statistical software. Results A total of 74 973 A1c and 23 540 NT-proBNP measurements were performed during the study period. Among diabetics, 16% of patients received NT-proBNP testing with about 38% exhibiting elevated values. Conclusion This preliminary and retrospective study indicated that diabetic patients are receiving biochemical assessment for heart failure and that a significant number are of diagnostic value. It is not clear if other clinical modalities for heart failure assessment are in effect and if increased utility of biochemical assessment is required. Further studies are required to assess the utility among our patient’s population and on the best protocol to apply.

Cardiovascular complications among hematopoietic cell transplantation survivors - the role of cardiomarkers.

Allogeneic hematopoietic stem cell transplantation (HSCT) offers potentially curative therapy for numerous malignant and nonmalignant diseases. The number of survivors and length of follow-up after successful HSCT is continually increasing. HSCT can induce damage of various organs and tissues - from minimal potentially progressive subclinical changes to life-threatening conditions. The aim of this thesis was to assess the prognostic value of high sensitive cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing and early identification of patients at high risk of a cardiac event after allogeneic HSCT. Sixty-three patients with the median age of 37 years at the time of allogeneic HSCT for hematologic diseases were studied. Cardiac bio-markers were serially measured before conditioning regimen and at days 1, 14 and 30 after HSCT. Cardiac systolic and diastolic functions were assessed before the conditioning regimen and 1 month after HSCT by echocardiography. The differences in plasma NT-proBNP and hs-cTnT concentrations during the 30 days following HSCT were statistically significant (P &lt; 0.001 vs. P = 0.02). Seven of 63 patients (11.1 %) developed a cardiac event defined as cardiovascular dys-rhythmias, pericarditis with cardiac tamponade and heart failure. By multivariate analysis, the strongest prognostic factor of cardiac event was an increased level of hs-cTnT and NT-proBNP persisted for a period of 14 days after HSCT (P &lt; 0.0001). The area under the curve from hs-cTnT testing plus NT-proBNP testing together (AUC = 0.95) was superior to each dia-gnostic modality alone. Measurements of plasma NT-proBNP and hs-cTnT concentrations might be a useful tool for identification of high-risk patients requiring further cardiological follow up. Measurement of hs-cTnT plus NT-proBNP together was superior to hs-cTnT and NT-proBNP measurements alone.

Analytical and clinical performance of a rapid magnetic immunochromatographic assay for N-terminal pro-B-type natriuretic peptide detection

ObjectiveGoldMag® immunochromatography is a novel point-of-care immunoassay platform utilizing quantitative determination of magnetic signals. A N-terminal pro-B-type natriuretic peptide (NT-proBNP) assay has been developed on this system. The objective of this study was to determine whether GoldMag® immunochromatography for NT-proBNP test fulfils the basic requirements of analytical and clinical performance so as to be used as a point-of-care test. MethodsAnalytical performance was performed for the linearity, sensitivity, precision, interference and recovery by Clinical and Laboratory Standards Institute guidelines (CLSI). Clinical evaluation was performed by testing 206 residual serum samples and comparing with Elecsys® proBNP assay (Roche Diagnostics GmbH, Mannheim, Germany). ResultsGoldMag® immunochromatography was able to differentiate concentrations of NT-proBNP from 0.000 to 8,000 pg/mL with a correlation coefficient R2 = 0.9914 and a limit of detection (LOD) of 43 pg/mL. According to statistics, this system exhibited high precision, high recovery, and no interference with lipemia, bilirubinemia, and hemolysis. Correlation analysis showed that the two assays yielded a good correlation with R2 of 0.9860. Bland-Altmananalysis showed a bias offset of 28.98 pg/mL with 95% confidence interval from 6.056 to 72.74 pg/mL for NT-proBNP. ConclusionGoldMag® immunochromatography system for NT-proBNP detection provides high accuracy, reliability, and easy operation. It can be used as a point-of-care test with a great application value in clinical management of chronic and acute heart failure patients.

Comparison between BNP and NT-proBNP in pediatric populations

BackgroundB-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are essential biomarkers for the evaluation of cardiac pathologies. However, pediatric reference intervals for BNP and NT-proBNP are not well defined and concordance between them in the evaluation of pediatric patients has been poorly described. MethodsPaired BNP and NT-proBNP testing was performed on 311 specimens representing 175 pediatric patients. Pediatric BNP and NT-proBNP reference intervals derived from the literature were used to evaluate concordance of results based on age group and cardiac pathology. ResultsDeming regression analysis of BNP and NT-proBNP results revealed a slope of 13.63 (95% CI, 10.35–16.92) and y-intercept of −977.8 (-2063–107.2) with a positive Spearman correlation (r = 0.91). By age group, concordance kappa between BNP and NT-proBNP was 1.0 for 0–10 days, 0.23 (0–0.62) for 11–30 days, 0.82 (0.67–0.97) for 31 days–1 year, 0.81 (0.57–1.0) for 1–2 years and 0.73 (0.64–0.86) for 2–18 years. The ratio of NT-proBNP to BNP was lowest in heart transplant patients (ratio, 6.5 [95% CI, 5.1–8.1]) relative to those with heart disease (10.5 [8.8–13.7]) and pulmonary hypertension (14.2 [11.3–16.0]) but no differences in concordance were observed. For serial specimens, 21% displayed inverse, discordant changes in BNP and NT-proBNP results. Review of discordant serial results revealed that kinetics of changes was comparable and unlikely to be clinically significant. ConclusionsThere is positive correlation and moderate concordance between BNP and NT-proBNP in the pediatric population studied.

Periprocedural changes in natriuretic peptide levels and clinical outcome after transcatheter mitral valve repair.

AimsThis multicentre study investigated the association of periprocedural changes in the levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) with clinical outcomes after transcatheter edge‐to‐edge mitral valve repair (TMVR).Methods and resultsPatients were retrospectively analysed who underwent TMVR with the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) and had available sequential NT‐proBNP testing at baseline and 2 months after TMVR. Periprocedural changes in NT‐proBNP following TMVR were assessed as the percent change in NT‐proBNP between baseline and the 2 month follow‐up, and the significant reduction in NT‐proBNP was defined as a decrease of >30% in the follow‐up NT‐proBNP compared with the pre‐procedural NT‐proBNP level. Primary outcome was defined as a composite outcome consisting of all‐cause mortality and hospitalization due to heart failure from 2 months to 2 years after TMVR. Additionally, we identified the cut‐off value of pre‐procedural NT‐proBNP to predict the composite outcome using a receiver operating characteristic analysis (cut‐off: 2485 pg/mL). Of 485 patients undergoing TMVR (age: 76.2 ± 9.2 years, female: 42.1%, secondary mitral regurgitation: 67.2%), 150 patients (30.9%) had the significant reduction in NT‐proBNP (>30%) following the procedure. Patients with the NT‐proBNP reduction had a lower incidence of the composite outcome, compared with those without the reduction in NT‐proBNP (31.4% vs. 40.2%; log‐rank P = 0.03). The significant reduction in NT‐proBNP was also associated with a lower risk of the composite outcome [adjusted hazard ratio (HR): 0.67; 95% confidence interval (CI): 0.45–0.97; P = 0.04], independently of pre‐procedural NT‐proBNP levels and other clinical parameters. The percent change in NT‐proBNP was associated with a linear trend of the incidence of the composite outcome (adjusted HR per 10% decrease: 0.96; 95% CI: 0.94–0.98; P < 0.001). A stratified analysis revealed that the prognostic impact of the significant reduction in NT‐proBNP was consistent among clinical subgroups, including aetiology of mitral regurgitation (P for interaction = 0.99). Higher pre‐procedural NT‐proBNP level (>2485 pg/mL) was associated with the increased risk of the composite outcome (adjusted HR: 1.50; 95% CI: 1.03–2.17; P = 0.03); however, patients with a higher pre‐procedural NT‐proBNP who achieved the significant reduction in NT‐proBNP had a similar risk of the composite outcome to those with a lower pre‐procedural NT‐proBNP.ConclusionsChanges in sequential NT‐proBNP measurements were associated with clinical outcomes within 2 years after TMVR. The assessment of NT‐proBNP dynamics may be valuable to assess the residual risk for patients undergoing TMVR and could assist with post‐procedural management after TMVR.

Comparison of Nt-proBNP Concentrations When in or out of Heartlogic Alerts

Background N-terminal pro-B-type natriuretic peptide (NT-proBNP), a non-active fragment of the prohormone proBNP, is produced by the heart and released in response to volume or pressure overload. NT-proBNP has proven to be a valuable biomarker in the diagnosis and prognosis of heart failure (HF), and NT-proBNP concentrations rise with worsening HF. HeartLogic, a multi-sensor composite index and alert algorithm, aggregates multiple physiologic trends associated with HF status, and proactively provides alerts for worsening HF with high sensitivity and low alert burden. Objective To compare NT-proBNP concentrations during periods IN or OUT of an active HeartLogic alert. Methods The MultiSENSE study enrolled 900 HF patients with an implanted COGNIS CRT-D, and followed them up to 1 year. Device software was modified to permit collection of chronic trends HeartLogic leveraged (heart sounds, heart rate, thoracic impedance, respiration and activity). Clinicians were blinded to individual sensors and results of HeartLogic during the study. Optional NT-proBNP tests were conducted when clinically needed (e.g., patients hospitalized with HF symptoms). HeartLogic index of the day before each of the NT-proBNP test dates was extracted. Based on HeartLogic alert state (i.e., IN alert vs OUT of alert), NT-proBNP concentrations were divided into two groups and compared using a one-way ANOVA. Results Of a total of 855 valid NT-proBNP tests in 741 patients with valid associated HeartLogic index, 180 NT-proBNP concentrations were measured in 150 patients while the HeartLogic alert state was IN alert, and 675 were measured in 616 patients while HeartLogic was OUT of alert. Figure 1 shows when HeartLogic was IN alert, the NT-proBNP concentrations (6957.9±10398.0 pg/ml) were significantly higher than those when HeartLogic was OUT of alert (1675.5±4403.1 pg/ml) (p Conclusion HF patients’ NT-proBNP concentrations were significantly elevated when HeartLogic was IN alert status, consistent with the HeartLogic algorithm capturing clinical worsening of HF status.

P2631Improved attitudes of non-cardiologists towards decreased left ventricular ejection fraction after marking “warning on echocardiography report”

Abstract Background Echocardiography (echo) has become a well-accepted noninvasive examination for patients with confirmed or suspected cardiac structural and/or functional abnormalities, by not only heart doctors but also non-heart doctors. Left ventricular ejection fraction (LVEF) as the most important parameter of cardiac systolic function must be listed on every echo report. A LVEF of &lt;50% has been regarded as LV systolic dysfunction with reduced ejection fraction. Purpose This study aimed to test whether a warning label as “reduced LVEF” on echo report would change the attitude or practice with regard to heart failure (HF) diagnosis and treatment in non-heart doctors. Methods From January to June, 2018, the program was conducted by adding a warning label as “reduced LVEF” next to the LVEF reading on echo report if it was &lt;50%. The patients with a reported LVEF &lt;50% and an echo request from non-heart doctors (cardiologists or cardiac surgeons) were selected (labeled group, n=359) for analysis, and a similar group of patients from January to June, 2017 were served as controls (unlabeled group, n=367). The rates of HF diagnosis, N-terminal-pro-B-type natriuretic peptide (NT-proBNP) test, cardiologist consultation and anti-HF medical therapy at discharge were compared between the 2 groups. Results There were no major differences in baseline characteristics between the 2 groups. The labeled group received more opportunities of cardiologist consultation (53.2% vs. 44.7%, p=0.02) and referral to cardiology outpatient clinic (57.9% vs. 50.1%, p=0.04) when compared with the unlabeled group. However, the difference was mainly found in patients with a LVEF of 40–49% (n=448, 53.2% of the labeled group vs. 44.7% of the unlabeled group, p=0.02). By pooling the data from the labeled and unlabeled groups, the patients who received cardiologist consultation (n=355) had a significant improvement in HF diagnosis and management than those who did not have a chance of cardiologist consultation (n=371), in terms of higher rates of NT-proBNP test (59.6% vs. 80.8%, p&lt;0.01) and standardized anti-HF medication (Renin-anigotensin system inhibitors: 23.7% vs. 37.2%, p&lt;0.01; β blockers: 22.1% vs. 33.8%, p&lt;0.01; mineralocorticoid Receptor Antagonists: 27.5% vs. 35.5%, p&lt;0.01). Conclusions An added warning label as “reduced LVEF” on echo report beside the LVEF reading would enhance the awareness of systolic HF and the appropriate management in non-heart doctors, in particular for patients with a LVEF of 40∼49%. Acknowledgement/Funding The study was supported by a research grant from the Science and Technology Department of Sichuan Province (project number: 2017SZ0059)

Plasma NT-proBNP levels associated with cardiac structural abnormalities in asymptomatic health examinees with preserved ejection fraction: a retrospective cross-sectional study

ObjectivesStage B heart failure (HF) is defined as an asymptomatic abnormality of the heart structure or function. The circulating level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in symptomatic...

Effects of Repetitive Transendocardial CD34+ Cell Transplantation in Patients With Nonischemic Dilated Cardiomyopathy.

Preclinical data in heart failure models suggest that repetitive stem cell therapy may be superior to single-dose cell administration. We investigated whether repetitive administration of CD34+ cells is superior to single-dose administration in patients with nonischemic dilated cardiomyopathy. Of 66 patients with dilated cardiomyopathy, New York Heart Association functional class III, and left ventricular ejection fraction (LVEF) <40% enrolled in the study, 60 were randomly allocated to repetitive cell therapy (group A, n=30) or single-cell therapy (group B, n=30). Patients received G-CSF (granulocyte colony-stimulating factor) for 5 days, and 80 million CD34+ cells were collected by apheresis and injected transendocardially. In group A, cell therapy was repeated at 6 months. All patients were followed for 1 year, and the primary end point was the difference in change in LVEF between the groups. At baseline, the groups did not differ in age, sex, LVEF, NT-proBNP (N-terminal pro-B-type natriuretic peptide), or 6-minute walk test distance. When directly comparing groups A and B at 1 year, there was no significant difference in change in LVEF (from 32.2±9.3% to 41.2±6.5% in group A and from 30.0±7.0% to 37.9±5.3% in group B, P=0.40). From baseline to 6 months, both groups improved in LVEF (+6.9±3.3% in group A, P=0.001 and +7.1±3.5% in group B, P=0.001), NT-proBNP (-578±211 pg/mL, P=0.02 and -633±305 pg/mL, P=0.01), and 6-minute walk test (+87±21 m, P=0.03 and +92±25 m, P=0.02). In contrast, we observed no significant changes between 6 months and 1 year (LVEF: +2.1±2.3% in group A, P=0.19 and +0.8±3.1% in group B, P=0.56; NT-proBNP: -215±125 pg/mL, P=0.26 and -33±205 pg/mL, P=0.77; 6-minute walk test: +27±11 m, P=0.2 and +12±18 m, P=0.42). In patients with dilated cardiomyopathy, repetitive CD34+ cell administration does not seem to be associated with superior improvements in LVEF, NT-proBNP, or 6-minute walk test when compared with single-dose cell therapy. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02248532.

N-terminal pro-B-type natriuretic peptide variability in stable dialysis patients.

Monitoring N-terminal pro-B-type natriuretic peptide (NT-proBNP) may be useful for assessing cardiovascular risk in dialysis patients. However, its biologic variation is unknown, hindering the accurate interpretation of serial concentrations. The aims of this prospective cohort study were to estimate the within- and between-person coefficients of variation of NT-proBNP in stable dialysis patients, and derive the critical difference between measurements needed to exclude biologic and analytic variation. Fifty-five prevalent hemodialysis and peritoneal dialysis patients attending two hospitals were assessed weekly for 5 weeks and then monthly for 4 months between October 2010 and April 2012. Assessments were conducted at the same time in the dialysis cycle and entailed NT-proBNP testing, clinical review, electrocardiography, and bioimpedance spectroscopy. Patients were excluded if they became unstable. This study analyzed 136 weekly and 113 monthly NT-proBNP measurements from 40 and 41 stable patients, respectively. Results showed that 22% had ischemic heart disease; 9% and 87% had left ventricular systolic and diastolic dysfunction, respectively. Respective between- and within-person coefficients of variation were 153% and 27% for weekly measurements, and 148% and 35% for monthly measurements. Within-person variation was unaffected by dialysis modality, hydration status, inflammation, or cardiac comorbidity. NT-proBNP concentrations measured at weekly intervals needed to increase by at least 46% or decrease by 84% to exclude change due to biologic and analytic variation alone with 90% certainty, whereas monthly measurements needed to increase by at least 119% or decrease by 54%. The between-person variation of NT-proBNP was large and markedly greater than within-person variation, indicating that NT-proBNP testing might better be applied in the dialysis population using a relative-change strategy. Serial NT-proBNP concentrations need to double or halve to confidently exclude change due to analytic and biologic variation alone.

Head-to-Head Comparison of Serial Soluble ST2, Growth Differentiation Factor-15, and Highly-Sensitive Troponin T Measurements in Patients With Chronic Heart Failure

This analysis aimed to perform a head-to-head comparison of 3 of the promising biomarkers of cardiovascular (CV) outcomes in heart failure (HF)-soluble ST2 (sST2), growth differentiation factor (GDF)-15, and highly-sensitive troponin T (hsTnT)-and to evaluate the role of serial measurement of these biomarkers in patients with chronic HF. sST2, GDF-15, and hsTnT are strongly associated with CV outcomes in HF. This post-hoc analysis used data from a study in which 151 patients with chronic HF due to left ventricular systolic dysfunction were followed up over 10 months. At each visit, N-terminal pro-B-type natriuretic peptide (NT-proBNP), sST2, GDF-15, and hsTnT were measured and any major CV events were recorded. Baseline values of all 3 novel biomarkers independently predicted total CV events even after adjusting for clinical and biochemical characteristics, including NT-proBNP, with the best model including all 3 biomarkers (p < 0.001). Adding serial measurement to the base model appeared to improve the model's predictive ability (with sST2 showing the most promise), but it is not clear whether this addition is a unique contribution. However, when time-dependent factors were included, only sST2 serial measurement independently added to the risk model (odds ratio: 3.64; 95% confidence interval: 1.37 to 9.67; p = 0.009) and predicted reverse myocardial remodeling (odds ratio: 1.22; 95% confidence interval: 1.04 to 1.43; p = 0.01). In patients with chronic HF, baseline measurement of novel biomarkers added independent prognostic information to clinical variables and NT-proBNP. Only serial measurement of sST2 appeared to add prognostic information to baseline concentrations and predicted change in left ventricular function. (Use of NT-proBNP Testing to Guide Heart Failure Therapy in the Outpatient Setting (PROTECT)]; NCT00351390).

Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure

ObjectiveThe main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. MethodsNT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. ResultsThe mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). ConclusionElevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.

N-terminal proB-type natriuretic peptide testing: practical diagnostic value in a emergency department

Purpose: N-terminal proBNP (NT-proBNP) testing has been proposed as a part of the evaluation of patients with dyspnea in Emergency Department (ED). Observational studies demonstrated that NT-proBNP improved diagnosis and reduced costs. Nevertheless, recent randomized studies failed to confirm the utility of this laboratory test in ED. We sought to evaluate the diagnostic impact of NT-proBNP measurement in patients presenting with acute dyspnea in ED, taking into account clinical and chest x-ray results routinely obtained. Methods: We enrolled 498 consecutive patients presented at our ED for dyspnea (male/female 248/250; mean±SD age 77.3±12) with a single NT-proBNP determination (Elecsys Roche Diagnostics, cutoff: 450 ng/L) at admission. For each patient enrolled, a score was calculated by evaluating the presence or absence of six clinical and radiological findings, such as: 1) history of heart failure; 2) history of ischemic cardiomyopathy; 3) pulmonary rales; 4) leg edema; 5) chest x-ray cardiac enlargement; 6) chest x-ray pulmonary congestion. According to the clinical and radiological score, the patients were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. On a second time two cardiologists, rather than knowledge of the results of NT-proBNP, reviewed all other clinical data and made the final diagnosis. Results: NT-proBNP mediane value was 2445 ng/L (lower quartile 631 and upper quartile 5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score, and 0.936 for the two in combination (logistic model). The likelihood ratio positive (LR+) was not determinable in the group A, 1.63 in the group B and 1.22 in the group C. The LR- was 1.26 in the group A, 0.16 in the group B and 0.05 in the group C In the B- group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions: NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. In patients presenting to an ED with acute dyspnea classifiable in the low or high probability groups this marker keeps its strong discriminating power, but gives poor additional information to clinical standard evaluation. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

Predictive cutoff point of admission N-terminal pro–B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure

ObjectiveThe main objective of this study was to determine a cutoff level of plasma N-terminal pro–B-type natriuretic peptide (NT-proBNP) that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the emergency department. The results of our study are presented in context with previously published literature. We believe that the present study will be useful and salutary for the progress of literature. MethodsN-terminal pro–B-type natriuretic peptide plasma levels were obtained from 100 patients with shortness of breath and left ventricular dysfunction upon admission to the emergency department. All patients underwent follow-up evaluations 30 days and 1 year after admission. The end point was defined as all-cause mortality. ResultsThe mean age of the patients in this study was 70.8 ± 11.6 years, and 51% were female. All-cause mortality at the 30-day and 1-year follow-up evaluations was 21.2% and 53.5%, respectively. We determined that the optimal NT-proBNP cutoff point for predicting 30-day mortality at the time of admission was 9152.4 pg/mL, with a 71.4% sensitivity and an 81.3% specificity (95% confidence interval, area under the curve: 0.726; P = .002). The optimal NT-proBNP cutoff point for predicting 1-year mortality at the time of admission was 3630.5 pg/mL, with an 83.0% sensitivity and a 52.2% specificity (95% confidence interval, area under the curve: 0.644; P = .014). ConclusionElevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute heart failure at 30 days and 1 year after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 30-day and 1-year mortality had high sensitivity.

Diagnostic value of N-terminal ProB-Type Natriuretic Peptide in Emergency Department: Analysis by subgroups

Objectives. Our aim was to evaluate the diagnostic impact of N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement in patients presenting with acute dyspnea in Emergency Department (ED), taking into account clinical and chest x-ray results routinely obtained. Methods. This was a prospective observational study. Four hundred eighty-eight consecutive subjects evaluated for dyspnea in a metropolitan 600 beds hospital ED, entered into the final data analysis. According to a clinical and radiological score, the patients enrolled were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. Results. NT-proBNP median value was 2445 ng/L (Inter Quartile Range 631-5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score and 0.936 for the two in combination (logistic model). In the B-group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A- and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions. NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

Dynamic Cardiovascular Risk Assessment in Elderly People: The Role of Repeated N-Terminal Pro–B-Type Natriuretic Peptide Testing

This study sought to determine whether serial measurement of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in community-dwelling elderly people would provide additional prognostic information to that from traditional risk factors.Accurate cardiovascular risk stratification is challenging in elderly people.NT-proBNP was measured at baseline and 2 to 3 years later in 2,975 community-dwelling older adults free of heart failure in the longitudinal CHS (Cardiovascular Health Study). This investigation examined the risk of new-onset heart failure (HF) and death from cardiovascular causes associated with baseline NT-proBNP and changes in NT-proBNP levels, adjusting for potential confounders.NT-proBNP levels in the highest quintile (>267.7 pg/ml) were independently associated with greater risks of HF (hazard ratio [HR]: 3.05; 95% confidence interval [CI]: 2.46 to 3.78) and cardiovascular death (HR: 3.02; 95% CI: 2.36 to 3.86) compared with the lowest quintile (<47.5 pg/ml). The inflection point for elevated risk occurred at NT-proBNP 190 pg/ml. Among participants with initially low NT-proBNP (<190 pg/ml), those who developed a >25% increase on follow-up to >190 pg/ml (21%) were at greater adjusted risk of HF (HR: 2.13; 95% CI: 1.68 to 2.71) and cardiovascular death (HR: 1.91; 95% CI: 1.43 to 2.53) compared with those with sustained low levels. Among participants with initially high NT-proBNP, those who developed a >25% increase (40%) were at higher risk of HF (HR: 2.06; 95% CI: 1.56 to 2.72) and cardiovascular death (HR: 1.88; 95% CI: 1.37 to 2.57), whereas those who developed a >25% decrease to <or=190 pg/ml (15%) were at lower risk of HF (HR: 0.58; 95% CI: 0.36 to 0.93) and cardiovascular death (HR: 0.57; 95% CI: 0.32 to 1.01) compared with those with unchanged high values.NT-proBNP levels independently predict heart failure and cardiovascular death in older adults. NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk.

Ruling out heart failure in primary-care: The cost-benefit of pre-screening using NT-proBNP and QRS width

Background Half of the patients presenting to primary-care with signs and symptoms of heart failure (HF) are found not to have serious heart disease after echocardiographic assessment. This places an unnecessary burden on hospital services. We sought to assess the cost-benefit of screening for left ventricular systolic dysfunction (LVSD) and major structural heart disease (SHD) using N-terminal pro-B-type natriuretic peptide (NT-proBNP) and QRS-width from an electrocardiogram in patients presenting with suspected HF to primary-care physicians (PCP). Methods Patients were recruited from a community-based service pilot. Blood samples for NT-proBNP measurement were obtained in primary-care. All patients were referred irrespective of the NT-proBNP result, with echocardiograms reviewed by a cardiologist blinded to the NT-proBNP result. Results NT-proBNP< 180 pg/ml (21 pmol/l) ‘ruled-out’ major-LVSD avoiding 38% of echoes and 23% of cost compared with direct referral for echocardiography. NT-proBNP< 93 pg/ml (11 pmol/l) ‘ruled-out’ major-SHD, avoiding 20% of echoes and 8% of cost. A QRS< 84 ms ‘ruled-out’ major-LVSD, avoiding 28% of echoes and 17% of cost. A QRS< 82 ms ‘ruled-out’ major-SHD avoiding 20% of echoes and 9% of cost. Intermediate values of NT-proBNP were often associated with equivocal echocardiography and in some scenarios NT-proBNP testing might avoid 61% of echocardiograms and 46% of cost. Conclusion Use of NT-proBNP by PCPs to detect major-LVSD and major-SHD in patients with suspected HF could reduce referrals for specialist HF-assessment, provide cost-avoidance compared to direct referral and improve the efficiency of care. QRS-width is less effective as a diagnostic test and adds little cost-benefit when combined with NT-proBNP.