pro-BNP Levels Research Articles

Abstract 4120990: Classification of Echocardiography Videos Using TimeSformer for Detecting Incipient Heart Failure in Asymptomatic Patients with Normal Ejection Fraction and Patients with Heart Failure

Background: Recent advancements have seen deep learning models help differentiate echocardiography images of patients with heart failure with preserved ejection fraction (HFpEF) from normal controls. Our aim was to develop a model capable of detecting early signs of heart failure in asymptomatic patients with a normal ejection fraction. Methods: We employed the TimeSformer, a video transformer model that classifies video data using a novel attention-based mechanism. This self-attention mechanism that diverges from traditional convolutional neural networks (CNNs). It focuses on relevant parts of the video across both space and time, split into spatial attention, which processes each frame individually, and temporal attention, which integrates information across different frames. The training and validation of the TimeSformer model were conducted on the same dataset of echocardiography videos from 50 normal controls and 50 patients diagnosed with HFpEF, employing 5-fold cross-validation to ensure robust performance evaluation. Results: The TimeSformer model effectively identified HFpEF in patients, as all diagnosed with HFpEF were flagged as abnormal. The echocardiography assessment, along with NT pro BNP levels, supported the diagnoses, with patients showing NT pro BNP levels of 1016±32 pg/ml. Conversely, 46 out of 50 normal controls were correctly identified, with their NT pro BNP levels averaging 52±12 pg/ml. These controls remained asymptomatic. Conclusions: The TimeSformer model demonstrated capability in identifying subtle deviations indicative of incipient heart failure in videos of normal controls, despite normal NT pro BNP levels. This suggests potential for early detection of heart failure in asymptomatic individuals. Further longitudinal studies are necessary to determine whether individuals identified as abnormal develop heart failure symptoms subsequently.

Predictive Value of NT-proBNP, FGF21, Galectin-3 and Copeptin in Advanced Heart Failure in Patients with Preserved and Mildly Reduced Ejection Fraction and Type 2 Diabetes Mellitus

Background and Objectives: Heart failure (HF) is one of the most common initial presentations of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM). There are different cardiac biomarkers related to the pathophysiological mechanisms of HF in T2DM. The current research aims to identify additional biomarkers that could improve the diagnosis and prognosis of HFpEF, which is currently assessed using NT pro-BNP levels. NT pro-BNP is a valuable tool for diagnosing heart failure but may not always correlate with clinical symptom severity or can present normal levels in certain cases, such as obesity. Biomarkers like FGF-21 and galectin-3 could provide greater insight into heart failure severity, especially in diabetic patients. The main objective of the current study is to assess the performance of NT-proBNP, FGF21, Galectin-3 and Copeptin to discriminate between advanced and mild HF. Materials and Methods: A total of 117 patients were enrolled in this study and divided into two groups: 67 patients in NYHA functional class I-II (mild HF) and 50 patients in NYHA III-IV (advanced HF). NT-pro BNP, FGF21, Galectin 3 and Copeptin serum levels were determined with the ELISA method. Receiver operating characteristic (ROC) analysis and binomial logistic regression analysis were used to measure the ability of the studied biomarkers to distinguish between advanced and mild HF patients. Results: In patients with T2DM with advanced HF, serum FGF21 level was significantly positively correlated with eGFR (ρ = 0.35, p = 0.0125) and triglycerides (ρ = 0.28, p = 0.0465) and significantly negatively correlated with serum levels of HDL cholesterol (ρ = −0.29, p = 0.0386) and with RV-RA gradient (ρ = −0.30, p = 0.0358). In patients with mild HF, serum FGF21 level was significantly negatively correlated with NT-proBNP levels (ρ = −0.37, p = 0.0022), E/e’ ratio (ρ = −0.29, p = 0.0182), TR velocity (ρ = −0.24, p = 0.0470) and RV-RA gradient (ρ = −0.24, p = 0.0472). FGF21 (AUC = 0.70, 95% CI: 0.60−0.79) and NT-proBNP (AUC = 0.73, 95% CI: 0.63–0.82) demonstrated significant predictive value to discriminate T2DM patients with advanced HF from those with mild HF. Elevated values for FGF21 (≥377.50 ng/mL) or NTproBNP (≥2379 pg/mL) were significantly associated with increased odds of advanced HF after adjusting for demographic and clinical covariates. Conclusions: NTpro-BNP and FGF21 have a similar ability to discriminate T2DM patients with advanced HF from those with mild HF. Univariable and multivariable logistic models showed that, FGF21 and NTproBNP were independent predictors for advanced HF in patients with preserved and mildly reduced ejection fraction and T2DM.

Acute echocardiographic assessment of patients with ST-elevation myocardial infarction in detecting clinically hidden hemodynamic deterioration

Abstract Background Transthoracic echocardiography (TTE) offers an immediate non-invasive assessment of cardiac morphology and function that can be performed bedside. Acute TTE in the catheterization laboratory (cath.lab.) may be helpful to identify markers of subsequent development of cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) in addition to the previously validated ORBI risk score. This relationship has not been investigated thoroughly previously. Purpose To investigate the association between acute TTE estimates of left ventricular (LV) function prior to primary percutaneous coronary intervention (pPCI) in STEMI patients and pro-B-type natriuretic peptide (proBNP) as a proxy associated with of CS development. Method From September 2023 all non-CS STEMI patients at one tertiary heart center underwent acute bedside TTE in the cath.lab. and ORBI risk score assessing the risk of CS development aiming for inclusion of 500 patients. The 5 minutes TTE-protocol consisted of LV ejection fraction (EF), LV outflow tract velocity time integral (LVOT VTI), mitral inflow (E and E/A), mitral deceleration time, and mitral annular early diastolic velocity é lateral. The primary endpoint was proBNP measured 24 hours (h) after pPCI (12-36h) stratified in quartiles (Q4 vs. Q1-3). The correlation between proBNP and TTE measurements and proBNP and ORBI risk score was examined using univariate linear regression models. Results Until now 153 STEMI patients (mean age 64 years, 25% female) were studied. Anterior STEMI was present in 36%, and median time from cath. lab. arrival to first wire over the culprit lesion was 28 minutes (IQR 24; 37). Patients with high proBNP level (Q4 vs. Q1-3) had significantly higher heart rate (median 84 bpm vs. 72 bpm) and Killip Class>1 (16% vs. 0%) at admission, but similar lactate levels (1.8mM vs. 1.5mM), systolic blood pressure (130 mmHg vs. 137 mmHg), and out-of-hospital cardiac arrest (11% vs. 12%). Patients with high proBNP levels (Q4 vs. Q1-3) had significantly lower LVEF (35% vs. 50%), higher E/é lateral (median 11.4 vs. 7.9), and higher ORBI risk score (median 8 vs. 4). LVEF, LVOT VTI, E/é lateral, and ORBI risk score were significantly associated with proBNP (Figure 1). Two patients developed CS after the pPCI; one with high proBNP level Q4, and one deceased prior to proBNP measurement. Conclusion Acute TTE is an easy tool for assessment of the acute hemodynamic status in STEMI patients bedside in the cath.lab., and it can be without delaying time to revascularization. LVEF, LVOT VTI, E/é lateral, and ORBI were all parameters associated with increased levels of the hemodynamic biomarker proBNP, and may together with the ORBI risk score improve the assessment and risk stratification of STEMI-patients at risk of CS-development.Figure 1.

Low levels of apolipoprotein M are associated with increased risk of ventricular arrhythmias

Abstract Background Ventricular arrhythmia (VA) is a frequent cause of sudden cardiac death (SCD). Treatment to prevent SCD includes device therapy with implantable cardioverter defibrillator (ICD). Although the electrophysiology underlying VA have been described, the molecular understanding of VA risk remains unclear. Purpose To identify proteins that are associated with higher and lower risk of VA. Methods SMASH 1 Study was a prospective observational study of 490 patients treated with ICD. The plasma proteome was analyzed with the Olink Explore 384 Cardiometabolic platform at study inclusion, and patients were followed for mean 3.1± 0.7 years. VA events were defined as adjudicated ventricular fibrillation or sustained ventricular tachycardia registered from ICD recordings and clinical events were recorded from electronic health records. Protein concentrations were quantified relatively as normalized protein expression on a log2-transformed concentrations where a large number represents higher protein level in the sample. Results The mean age was 66±12 years, 83% were male and 51% had a primary prevention ICD-indication. Episode(s) of VA occurred in 137 patients (28%) during follow-up. In total, 353 distinct proteins were successfully analyzed in all patients. Among these, high B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels were associated with a higher risk of VA, while Apolipoprotein M (APOM) was the only protein significantly associated with a lower risk of VA after multiple testing using Benjamini-Hochberg correction (Figure, Panel A). After adjusting for age, sex, body mass index, coronary artery disease, heart failure, renal function, left ventricular ejection fraction and antiarrhythmic medication, only low APOM levels remained significantly associated with VA: HR 0.51 (95%CI 0.32-0.79] per log unit increase, p=0.003. Patients in the lowest quartile of APOM had a particularly high risk of incident VA: HR 2.26 (95%CI 1.60-3.19), p=3.61x10-6, compared to quartile 2-4 (Figure, Panel B). High APOM levels were also associated with a lower risk of HF hospitalizations (HR 0.25 [95%CI 0.16-0.40], p<0.001) and all-cause mortality (HR 0.36 [95%CI 0.22-0.60], p<0.001), and these associations remained significant in adjusted models. Conclusions Low levels of APOM are associated with a greater risk of incident VA, independently of established risk factors. Low APOM also predicted risk of HF hospitalizations and mortality in our cohort, which suggest protective cardiovascular effects of APOM. Figure: Association of individual proteomic measures with risk of ventricular arrhythmias (VA).A:Volcano plots of the associations of individual plasma proteins with incident VA. The dotted line represents the significance level at false discovery rate <0.05 and the red dots are significant proteins after multiple testing using Benjamini-Hochberg correction.B: Risk of VA by quartile of Apolipoprotein M.

Early increase and subsequent decrease in mature BNP and early decrease and continued decrease in proBNP after sacubitril/valsartan may relate to left ventricular reverse remodeling in heart failure

Abstract Background Current BNP assays measure not only mature BNP (BNP1-32) but also precursor proBNP. Previous studies have shown that the change in BNP after sacubitril/valsartan (Sac/Val) treatment is not consistent. The reason for this may be due to the fact that the immunoreactivity of BNP consists of mature BNP and proBNP and neprilysin degrades only mature BNP but not proBNP. Purpose This study assessed changes in mature BNP, proBNP, total BNP (= mature BNP + proBNP) before and 2 and 12 weeks after administration of Sac/Val in heart failure (HF). Methods We measured mature BNP, proBNP, and total BNP levels by our developed immunoassay, NT-proBNP and ANP by conventional assay and left ventricular (LV) remodeling indices by echocargdioraphy in 34 HF patients before, 2, and 12 weeks (wk) after Sac/Val treatment. 34 HF patients were divided into two groups. Group D (n=20) was defined as the group whose mature BNP at 12wk was lower than the baseline. Whereas Group I (n=14) was defined as the group whose mature BNP at 12wk was higher than the baseline. Results In all patients, total BNP did not change after 2wk or 12wk compared to baseline. ProBNP decreased after 2wk and tended to decrease after 12wk (p=0.07). Whereas there was no change inmature BNP after 2wk or 12wk (Table 1). In group D, total BNP did not change at 2wk, but decreased after 12wk. Mature BNP did not change at 2wk, but decreased after 12wk. ProBNP decreased at 2wk and further decreased at 12wk. In contrast, in group I total BNP did not change at 2wk, but increased at 12wk. ProBNP did not change after 2wk or 12wk compared to baseline. Mature BNP increased after 2wk and further increased after 12wk. Thus, a decrease in both proBNP and mature BNP contributed to the decrease in total BNP in group D, while the increase in total BNP in group I was mainly due to the increase in mature BNP. Correlation coefficient and p value between total BNP, proBNP, mature BNP, NT-proBNP and ANP at baseline, 2wk and 12wk are shown in Table 2. A close correlation was observed between BNP molecular forms. NT-proBNP decreased and ANP increased after Sac/Val administration; however, there was a modest correlation between the two peptides. There were no significant differences in LV ejection fraction (LVEF: %), end-diastolic volume index (LVEDVI: ml/m²) or end-systolic volume index (LVESVI: ml/m²) between two groups at baseline or at 12 wk; however, the delta (at 12 wk – pretreatment) LVEDVI, and LVESVI significantly improved in group D compared with group I (-9.3±11.3 vs. 3.7±10.1, p<0.01; -8.2±13.5 vs. 2.7±8.9, p<0.01, respectively). Conclusion These results suggest that total BNP appears to be unchanged after Sac/Val administration, but its components, proBNP and mature BNP, are altered; reverse cardiac remodeling may relate to decrease of mature BNP and proBNP; and the closely correlated natriuretic peptide molecules, regardless of the degradation by neprilysin, may be regulated in the same direction.

Prevalence of transthyretin amyloid cardiomyopathy in patients hospitalised for heart failure with preserved ejection fraction in an LATAM center

Abstract Introduction Transthyretin Amyloid cardiomyopathy (ATTR-CM) usually presents as heart failure with preserved ejection fraction (HFpEF). Its diagnosis has a significant clinical impact, as specific treatment is currently available. Purpose To assess the prevalence of ATTR-CM in patients hospitalised for HFpEF and increased septal thickness in our institution of general community hospital in Latin America (LATAM). Methods Cross-sectional study. Patients hospitalised for HFpEF (>50%) and septal thickness ≥ 12 mm during the period from 8/2019 to 1/2023 were prospectively included. Patients with pacemaker, significant left valve disease and end-stage renal failure (creatinine clearance < 30 ml/min/BSA) were excluded. A pyrophosphate bone scintigraphy (PYP) was planned to be performed in order to assess ATTR-CM. The prevalence of ATTR-CM and its 95% confidence interval were calculated. Results A PYP was performed in 59/82 patients hospitalised for HFpEF. Median age was 85 [IQR 78-88] years, and 54% were women. At admission, 61% (n=36) had atrial fibrillation and the median NT Pro-Bnp was 3536 [1700-7748] pg/mL. The mean left ventricle ejection fraction was 57% (+/- 5%). The prevalence of ATTR-CM diagnosed by PYP was 19% (95% CI 9.7-30.1, n=11). There were no significant clinical differences between patients who performed a PYP and did not. Patients with ATTR-CM had lower blood pressure and higher septal thickness, NT Pro-Bnp and troponin levels compared to patients without ATTR-CM (TABLE). Conclusion In patients admitted for HFpEF and increased septal thickness, the diagnosis of ATTR-CM was relatively common (one of five had ATTR-CM) in our region (LATAM). We believe that systemic assessment with PYP should be performed in patients hospitalised with HFpEF and increased wall thickness.

Metoprolol therapy in patients with Eisenmenger syndrome (MINES) study. A single-centre, double-blinded, randomised, placebo-controlled trial

Abstract Background Prevalence of Eisenmenger syndrome is still common in developing countries where early neonatal screening and referral for surgery is seldom possible. Limited number of drugs are available for treatment of this condition. Beta-blockers may improve functional status in these patients. Observational study has shown beta blockers to be safe and effective in improving effort intolerance in patients with Eisenmenger syndrome. Purpose To study the safety and efficacy of metoprolol succinate therapy in patients with Eisenmenger syndrome. Methods In this double-blind, placebo-controlled study, we randomly assigned 60 patients with Eisenmenger syndrome to receive placebo or to receive 25 mg of metoprolol succinate once daily for 2 weeks followed by 25 mg twice daily for 14 weeks (total of 16 weeks). The primary outcome was mean difference in 6-minute walk test (6MWT) distance. Secondary outcomes were clinical composite outcome (all-cause death, heart failure hospitalization, worsening of heart failure, change in WHO functional class, and new onset syncope), change in resting saturation, Tricuspid Annular Plane Systolic Excursion (TAPSE) and NT Pro BNP level at 16 weeks. Results At 16 weeks, the mean difference in 6MWT distance between treatment group and placebo group as per protocol analysis was 6 meters (95% confidence interval, - 7.43 to 19.49; P 0.37), and the mean difference in 6MWT distance as per intention to treat analysis was -1.1 meters (95% confidence interval, - 16.97 to 14.77; P 0.89). Clinical composite outcome occurred more in the treatment group 5(17%) as compared to the placebo group 1(3%) (P 0.197) though it did not reach statistical significance. This was primarily driven by worsening of heart failure in the treatment group. Compared to baseline metoprolol group had 37% increase in NT pro BNP level while placebo group had 13% (-313.69, 88.80) reduction in NT Pro BNP level. There was no difference in TAPSE 0.05 (95% confidence interval -0.62 to 0.72; P 0.88) or resting saturation -0.06 (95% confidence interval -0.88 to 0.75; P 0.87) between the two groups at 16 weeks Conclusion Metoprolol succinate therapy did not improve 6-minute walk distance at 16 weeks among patients with Eisenmenger syndrome compared to placebo. Metoprolol succinate therapy was associated with increased clinical composite outcomes, primarily driven by worsening of heart failure.Graphic Abstract of MINES study

Sex differences in clinical data and long-term outcomes of elderly patients with acute myocardial infarction presenting with cardiogenic shock undergoing percutaneous coronary intervention

Abstract Background Data on contemporary clinical practice and long-term outcomes for sex differences in elderly patients with acute myocardial infarction (MI) who have undergone percutaneous coronary intervention (PCI) presenting with cardiogenic shock (CS) is limited. Purpose This study aimed to investigate contemporary clinical data and long-term clinical outcomes according to sex differences in elderly patients undergoing PCI for acute MI complicated by CS. Methods We analyzed data from a nationwide, prospective, and real-world registry comprising elderly patients (≥65 years) with acute MI who have undergone PCI and presented with CS. Of the 540 patients included, 228 were women, and 312 were men. We compared major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, heart failure [HF] readmission, or definite/probable stent thrombosis [ST]) and the components of MACE between the groups using multivariable Cox regression, propensity score (PS) matching, and PS-adjusted analyses. Results Compared to men, women were younger and had higher incidences of hypertension and elevated pro-BNP levels. No significant differences were observed in other cardiovascular risk factors, left ventricular systolic function levels, or adherence to guideline-directed medical therapy between the groups. Over a median follow-up of 1035 days, MACE, all-cause death, and cardiac death occurred in 257 (47.6%), 212 (39.3%), and 170 (31.5%) patients, respectively. Women exhibited significantly increased risks of MACE (overall: 53.5% vs. 43.3%, hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.59-0.97, p=0.023; PS-matched: n=368, 52.3% vs. 41.8%, HR 0.73, 95% CI 0.53-0.94, p=0.033), all-cause death (overall: 44.7% vs. 35.3%, HR 0.77, 95% CI 0.58-0.97, p=0.032; PS-matched: 42.8% vs. 33.4%, HR 0.71, 95% CI 0.54-0.95, p=0.041), cardiac death (overall: 35.1% vs. 28.8%, HR 0.81, 95% CI 0.60-0.97, p=0.048; PS-matched: 34.4% vs. 26.9%, HR 0.78, 95% CI 0.54-0.95, p=0.043) compared to men. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, HF readmission, and definite/probable ST between the groups. Conclusions In this nationwide registry, women compared to men exhibited increased risks of long-term clinical outcomes in elderly patients with acute MI who have undergone PCI presenting with CS.

Comparing the anti-remodeling effect of sacubitril/valsartan and angiotensin-converting enzyme inhibition on myocardial samples of advanced heart failure patients undergoing heart transplantation

Abstract Background In decreasing heart failure (HF) hospitalization and cardiovascular death in HF patients with reduced ejection fraction, Sacubitril/Valsartan (SAC/VAL) treatment was proved to be superior to angiotensin-converting enzyme inhibition (ACEi). According to recent experimental results and clinical data based on echocardiography and circulating biomarkers, this benefit might be at least partially attributed to a greater anti-remodeling effect. However, there is a lack of direct evidence from human myocardial samples for this assumption. Purpose Therefore, we aimed to compare the anti-remodeling effect of SAC/VAL treatment to ACEi on myocardial samples of HF patients undergoing heart transplantation (HTX). Methods We studied left ventricular (LV) samples of seventy advanced HF patients who underwent HTX and received either SAC/VAL (SAC/VAL group, N=32) or ACEi treatment (ACEi group, N=38) for at least three months prior to HTX. Furthermore, all patients received beta-blockers and mineralocorticoid receptor antagonists titrated to maximally tolerated or target dose. Our groups were matched for age, sex, ejection fraction and other clinical parameters. Patients with liver or kidney failure, mechanical circulatory support, systemic inflammatory/fibrotic diseases or positive inotrope treatment were excluded. Myocardial mRNA expression of fibrotic markers and B-type natriuretic peptide (BNP) were measured with qRT-PCR and normalized to glyceraldehyde 3-phosphate dehydrogenase expression. Interstitial fibrosis area was assessed histologically. Results Preoperative plasma N-terminal pro-BNP levels were similar in the two groups (SAC/VAL: 4363±752 pg/mL vs. ACEi: 4616±1020 pg/mL; p=0.911). In contrast, the mRNA level of BNP in the myocardium was lower in patients treated with SAC/VAL (SAC/VAL: 2.2±1.05 vs. ACEi: 5.2±1.74; p=0.006). TIMP metallopeptidase inhibitor 1 (SAC/VAL: 0.07±0.01 vs. ACEi: 0.13±0.02; p=0.011), TIMP metallopeptidase inhibitor 2 (SAC/VAL: 0.06±0.01 vs. ACEi: 0.11±0.01; p<0.001), collagen type I alpha 1 chain (SAC/VAL: 0.02±0.00 vs. ACEi: 0.08±0.02; p<0.001) and collagen type III alpha 1 chain (SAC/VAL: 0.12±0.02 vs. ACEi: 0.27±0.04; p<0.001) relative gene expressions were also decreased in the LV of SAC/VAL-treated patients. Histology analysis confirmed reduced interstitial myocardial fibrosis area in the SAC/VAL group as well (SAC/VAL: 7.2±0.4% vs. ACEi: 8.6±0.5%; p=0.031). Conclusions SAC/VAL treatment decreased the myocardial expression of BNP and fibrosis-related genes to a greater extent compared with ACEi in LV samples of patients undergoing HTX. Histological analysis also verified the differences in fibrosis. Thus, the anti-remodeling effect of SAC/VAL might be superior to ACEi even in advanced HF.

Health-related quality of life and prognosis in cardiac sarcoidosis

Abstract Background Cardiac sarcoidosis (CS) is characterized by inflammatory myocardial disease, often leading to conduction disturbances, ventricular tachycardias, and heart failure. While factors like initial symptoms, LVEF, and troponin levels are known prognostic indicators, the impact of CS on health-related quality of life (HRQoL) is not well-understood. Additionally, limited data exists on the predictive value of FDG-PET in CS. Purpose This study aimed to assess HRQoL in CS patients and investigate its prognostic relevance concerning cardiac events. Methods Patients diagnosed with CS completed the RAND-36 general health-related questionnaire, covering eight dimensions. Clinical data were obtained from the Finnish myocardial inflammatory diseases registry. Follow-up data on cardiac events, including life-threatening ventricular tachyarrhythmias (VT/VF), heart transplant, left ventricular assist device (LVAD) implantation, pericardial tamponade, or death, were collected over 36 months. Results Of the 240 CS patients surveyed, 179 (75%) were female, with a median age of 56 [IQR 48 – 64]. CS patients reported significantly lower RAND-36 scores across all dimensions compared to the general Finnish population. Over the 3-year follow-up, 38 (16%) patients experienced cardiac-related adverse events, including VT/VF (26 cases), deaths (8 cases), heart transplants (2 cases), LVAD implantation (1 case), and pericardial tamponade (1 case). We divided CS patients into those without adverse event (N=202) and with adverse events (N=38). Interestingly, in four dimensions of PF 70.0 [50.0-90.0] vs 60.0 [33.8-80.0], p=0.019, RP 50.0 [0.0-100.0] vs 0.00 [0-56.3], p=0.002, MH 76.0 [59.0-88.0] vs 66.0 [51.0-84.0], p=0.036, and SF 75.0 [50-100] vs 62.5 [37.5-78.1], p=0.037 were significantly lower scores in the event group. Univariate Cox regression analysis (Table 1) revealed that physical functioning (PF) and role-physical (RP) dimensions, along with certain clinical factors, such as younger age, higher NYHA classification, elevated proBNP levels, lower hemoglobin levels, and the main manifestation of the disease as ventricular tachyarrhythmia, independently predicted adverse cardiac events. In the multivariate analysis, lower role-physical scores and younger age remained independent prognostic factors for adverse cardiac events. Conclusions Patients with CS demonstrated lower HRQoL compared to the general Finnish population. This study enhances our understanding of prognosis in CS and underscores the predictive value of HRQoL in identifying future adverse cardiac events, highlighting its relevance in the clinical management of these patients.

Evaluation of Bedside Lung Ultrasonography in Diagnosis of Acute Pulmonary Oedema

Background: Pulmonary oedema is one of the major causes of mortality and morbidity. Acute heart failure is the major cause of pulmonary oedema. NT-pro B-type natriuretic peptide has been found to be effective in distinguishing acute pulmonary oedema from other causes of dyspnea in the emergency care setting. But it is costly and time consuming. Bedside lung ultrasonography (LUS) is being considered as noninvasive, radiation-free and easy to perform tool to diagnosis pulmonary oedema. Objective: To determine the role of bedside LUS in diagnosis of patients with acute pulmonary oedema. Methods: This observational cross-sectional study was carried out in ICU, Department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka from August 2018 to October 2019. Ethical approval was sought before conduction of the study. One hundred critically-ill patients with pulmonary oedema, detected by clinical examination & chest X-ray, due to heart failure were included in the study. Routine labs including NT-pro B-type natriuretic peptide level were sent. Bedside LUS was done with a portable ultrasound machine. Data was collected by using a semi-structured data sheet. Observation and Results: The median age was 42 years (IQR 18-66). Among them, 67.71% were male. 90.0% of patients diagnosed as acute pulmonary oedema by NT-pro B-type natriuretic peptide levels findings and 88.5% of patients were diagnosed as acute pulmonary oedema by bedside lung ultrasonography. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of lung ultrasonography findings alone statistically significant as 94.2%, 66.7%, 96.4% & 54.5% and 91.66% respectively in detection of pulmonary oedema. Conclusions: Bed side lung ultrasonography can be an effective adjunct tool for rapid and high diagnostic accuracy for diagnosis of acute pulmonary oedema along with NT pro BNP level in ICU. Bangladesh Crit Care J September 2024; 12 (2): 113-117

Minimizing unnecessary proBNP blood tests: an evaluation of a pop-up form implementation in general practice

Objective To evaluate the impact of a compulsory pop-up form on the ordering pattern of proBNP blood tests by general practitioners in the Capital Region of Denmark. Design A follow-up study comparing the average number of proBNP tests ordered before and after the implementation of an intervention. Setting and subjects From 2016 to 2021, the average number of proBNP tests increased by over 300%. In March 2022, a compulsory pop-up form was introduced in the electronic request system (WebReq), requiring general practitioners to select one of three indications for ordering proBNP, as recommended by the Danish Society of Cardiology. The study included 528 general practitioners in the Capital Region of Denmark, with data available from January 2020 to 2023, encompassing 83,576 proBNP results from 56,645 patients. Main outcome measure The average number of proBNP tests ordered per month and the median level of proBNP before and after the intervention. Results Following the intervention, the average number of proBNP tests per month decreased by 60% over a 22-month follow-up period. The highest reduction was seen among general practitioners who previously ordered the most tests (≥3 per 1000 biochemical tests). In this group, the median proBNP level increased from 12.1 pmol/L before the intervention to 13.5 pmol/L after the intervention (p < 0.0001). Conclusions This study demonstrates a significant decrease in the number of proBNP requests from general practitioners in the Capital Region of Denmark after the introduction of a pop-up form in the requisition system containing the current guidelines.

Atrial refractoriness early after transcatheter aortic valve implantation TAVI in patients with severe aortic stenosis and sinus rhythm.

Aortic valve stenosis (AS) is a common valvular heart disease, especially in the elderly, and is associated with a high prevalence of atrial fibrillation. Although the risk of atrial fibrillation is expected to decrease after the intervention, atrial fibrillation develops in many patients undergoing surgical or percutaneous transaortic valve implantation. We aimed to evaluate atrial refractoriness since it may play a key role in the occurrence of atrial fibrillation after transaortic valve implantation. Seventy-nine consecutive patients who underwent TAVI between October 2021 and May 2023 were enrolled in this trial. Sixty-seven patients underwent electrophysiology study before and after TAVI. We evaluated the changes in PA and AH intervals, as well as atrial effective refractory periods. Besides the hemodynamic changes, atrial effective refractory periods increased, and atrial effective refractory period dispersion (39.8±21.6 vs. 31.1±18.0) decreased significantly after TAVI. The change in atrial effective refractory period dispersion after TAVI was correlated only with the changes in left ventricular end-diastolic pressure (r=0.77, P=0.001) and the changes in aortic gradient (r=0.4, P=0.001). The independent variables affecting the changes in atrial effective refractory period dispersion were basal pro-BNP levels, besides the changes in left ventricular end-diastolic pressure and aortic gradient after transaortic valve implantation. Our results show an acute improvement in atrial refractoriness after TAVI, though high atrial fibrillation rates are reported in the literature. The timing of aortic valve replacement is important, as irreversible maladaptive changes might have already developed by the time of intervention.

Correlation of Pseudocholinesterase Level with Clinical, Biochemical Parameters Including Cardiac Profile and the Outcome in Organophosphorus Poisoning.

Poisoning is a significant health hazard and a leading cause of morbidity and mortality worldwide. India, being a predominantly agrarian country, routinely employs organophosphate (OP) pesticides in farming, and they are readily available "over the counter." OPs exert their toxicity by interfering with the normal function of acetylcholine, an essential neurotransmitter throughout the autonomic and central nervous systems. Due to the limited availability of facilities and resources in health-care systems, and economically restraining patients, it is necessary to rely more on clinical features to assess the severity of poisoning and manage the condition properly. It was a hospital-based prospective observational study that included patients aged >13 years in a tertiary care hospital. All patients were clinically evaluated based on their history and examination. The diagnosis was made based on characteristic clinical manifestations or evidence of exposure to organophosphorus compounds (corroborative evidence such as empty containers and the odor of gastric aspirates). Clinical severity was assessed and categorized according to the Peradeniya Organophosphorus Poisoning Scale (POP scale). A score of 0-3 is considered mild poisoning, 4-7 as moderate poisoning, and 8-11 as severe poisoning. Out of the 50 patients enrolled in the study, 17 (34.00%) were aged <20 years, 19 (38%) were in the 20-30 years age group, and 14 (28%) were aged >30 years. Ingestion is the only mode of exposure to poisoning. None of the patients had history of contact or inhalational exposure. Of the 50 cases, 12 (24.0%) were in the mild category, 26 (52.0%) in the moderate category, and 12 (24%) in the severe category on the POP grading. A comparison of the mean serum pseudocholinesterase, troponin-T, and pro-BNP levels with severity was performed. In mild OP poisoning, the mean serum PChE level was 2766.58 ± 1120.44; in moderate, it was 1969.35 ± 1330.07, and in severe, it was 701.83 ± 961.17. Pseudocholinesterase levels decreased progressively with increasing clinical severity from mild-to-severe cases, and this association was statistically significant (P < 0.001). Two-dimensional echocardiography screening done in all patients did not show any significant abnormalities. This study shows that serum PCE is reduced in OP poisoning and correlates with the clinical severity grading done by the POP scale and is also associated with an increase in the duration of intensive care unit stay. No significant evidence of direct cardiac injury was observed in this study. A low Glasgow Coma Scale score and an increased respiratory rate at presentation are associated with poor outcomes.

Mitigating Doxorubicin-Induced Cardiotoxicity through Quercetin Intervention: An Experimental Study in Rats.

Doxorubicin (DOX) is an effective anticancer drug, but its use is limited by dose-dependent heart toxicity. Quercetin is a natural antioxidant frequently studied for its beneficial properties. Moreover, a wide range of dietary supplements are available for human use. This in vivo study aimed to explore the potential cardioprotective effects of quercetin in chronic DOX treatment. A total of 32 Wistar rats were randomly divided into four groups: control, DOX, DOX/Q-50, and DOX/Q-100, treated with saline, 2.5 mg/kg body-weight DOX, 2.5 mg/kg body-weight DOX + 50 mg quercetin, and 2.5 mg/kg body-weight DOX + 100 mg quercetin, respectively, for two weeks. Rats were monitored using cardiac ultrasound (US) and markers for cardiac injury. Oxidative damage and ultrastructural changes in the heart were investigated. Chronic DOX treatment led to a decline in cardiac function and elevated values of NT pro-BNP, troponin I, and CK-MB. Quercetin treatment slightly improved certain US parameters, and normalized serum NT pro-BNP levels. Furthermore, DOX-induced SOD1 depletion with consequent Nrf2 activation and DNA damage as shown by an increase in γH2AX and 8HOdG. Quercetin treatment alleviated these alterations. Oral administration of quercetin alleviated serum markers associated with DOX-induced cardiotoxicity. Furthermore, it exhibited a favorable impact on the cardiac US parameters. This suggests that quercetin may have potential cardioprotective properties.

Comprehensive analysis of recurrence factors in cryoballoon AF ablation: integrating clinical, biomarkers, and echocardiographic parameters.

Atrial fibrillation (AF) poses substantial challenges in cardiovascular diseases, impacting patient health and economic burdens. Understanding the mechanical effects of AF on the left atrium (LA) and assessing the influence of treatment modalities on LA functions are critical. This study aims to assess the efficacy of echocardiographic and biochemical parameters in predicting AF recurrence following second generation cryoballoon ablation (CB-2). Ninety-two patients with symptomatic AF, treated with CB-2 at Istanbul University-Cerrahpaşa, Faculty of Medicine, Department of Cardiology, were prospectively examined from January 2021 to July 2023. The study endeavors to develop a predictive model for AF recurrence, investigating the relationship between echocardiographic measurements and serum biomarkers with recurrence. The follow-up duration for echocardiographic assessments and biochemical analyses was systematically documented. The study revealed a significant enhancement in LA mechanical functions during echocardiographic follow-ups three months post-procedure. Specifically, LA strain parameters emerged as significant predictors of recurrence (LAsr: 95%CI 1.004-1.246, p = 0.047; LAsct: 95%CI 1.040-1.750, p = 0.024). Biochemical analyses demonstrated a correlation between elevated PRO-BNP levels and an increased risk of recurrence (95%CI 1.000-1.003, p = 0.012). Moreover, specific biomarkers such as MYBPHL, which demonstrated increased levels post-procedure, were deemed indicative of atrial damage, suggesting potential additional atrial substrate modification beyond PVI. Consequently, improvements in LA function post-cryoballoon ablation and biochemical markers have surfaced as potential indicators for predicting AF recurrence. This study elucidates the effectiveness of CB-2 in treating AF and its impact on LA functions. Notably, LA strain measurements and PRO-BNP levels have emerged as reliable indicators for predicting recurrence. Beyond clinical implications, our research establishes a foundation for a deeper understanding of the role of CB-2 in AF management and factors associated with recurrence.

A prospective analysis of the correlation between ultrasonic B-lines, cardiac tissue doppler signals and left ventricular end-diastolic pressure in patients with severe aortic stenosis

BackgroundThe development of heart failure is a turning point in the natural course of aortic stenosis (AS). Pulmonary oedema and elevated left ventricular pressure (LVP) are cardinal features of heart failure. Evaluating pulmonary oedema by lung ultrasound involves taking the upper hand with a bedside noninvasive tool that may reflect LVP.AimWe sought to assess the correlation between sonographic pulmonary congestion, invasive LV pre-A pressure, and echocardiographic LV end-diastolic pressure (LVEDP) in symptomatic AS patients receiving transcatheter aortic valve replacement.MethodsForty-eight consecutive patients with severe AS and planned transcatheter aortic valve implantation (TAVI) were enrolled. LVEDP was estimated to be normal or elevated using the ASE/EACVI algorithm and transmitral Doppler indices, the E/A ratio, the E/e′, and the left atrial volume index. Invasive LV pre-A pressure was used as a reference, with > 12 mm Hg defined as elevated.ResultsForty-eight patients (25 women (52%), mean age 75 years, standard deviation (SD) ± 7.7 years) were enrolled in the study. We detected severe B-lines (≥ 30) in 13 (27%) patients and moderate B-lines (15–30) in 33 (68.6%) patients. The number of B-lines increased significantly with the severity of New York Heart Association (NYHA) functional classes (Fig. 1). The B-line count was 14 ± 13 in NYHA class I patients, 20 ± 20 in class II patients, and 44 ± 35 in class III patients (p < 0.05, rho = 0.384). The number of B-lines was correlated with the E/E’ ratio (R = 0.664, p < 0.0001) and the proBNP level (R = 0. 882, p < 0.008). We found no significant correlation with the LVEDP or LVEF. The LVEDP correlated well with the E/E’ ratio (R = 0.491, p < 0.001) but not at all with E/A, DT, or LAVI. All patients had an elevated LVEDP > 12, with a mean pressure of 26 mmHg, a minimum of 13 mmHg, and a maximum of 45 mmHg, with an SD of 7.85.ConclusionAssessing lung ultrasonic B-lines is a straightforward and practical approach to identifying pulmonary oedema in AS patients. The number of B-lines correlated with the E/E’ ratio and the functional status of patients but did not correlate with invasive LVEDP or LVEF. All patients had elevated LVEDP that correlated with E/E’.

Outcomes of extracorporeal membrane oxygenation cannulation strategy in lung transplantation: A retrospective cohort study

ObjectivesExtracorporeal membrane oxygenation (ECMO) with different cannulation strategies is determined according to surgical position and patient condition. However, no cannulation guidelines have been proposed. This retrospective study assessed the outcomes of diverse ECMO cannulation strategies in patients undergoing lung transplantation (LTx). MethodsData of patients undergoing intraoperative veno-arterial ECMO-assisted LTx were retrospectively collected from December 1st, 2015 to October 31st, 2021. Patients were classified into three groups based on the different cannulation strategies: femoral artery-femoral vein (F–F)-ECMO, axillary artery-femoral vein (A-F)-ECMO, and ascending aorta-femoral vein (AAO-F)-ECMO. The F-F-ECMO, A-F-ECMO, and AAO-F-ECMO groups comprised 34, 44, and 30 patients, respectively. Main resultsThe AAO-F-ECMO group exhibited a significantly shorter duration of postoperative ECMO therapy (3 vs. 2 vs. 0 days, P < 0.01).the level of postoperative proBNP was lower on the third and seventh days (P < 0.001). AAO-F-ECMO patients had a significantly lower incidence of postoperative infections, heart failure, and bleeding (P < 0.05). Similar outcomes were observed in postoperative survival rates among the three groups (P > 0.05). ConclusionsAscending aorta-femoral vein ECMO can provide sufficient and effective aerobic blood to perfuse organs with fewer side effects than cannulation in the femoral artery-femoral vein or axillary artery-femoral vein.

Who Can Receive Clinical Benefit from Mid-Term Vericiguat Add-on Therapy Among Patients with Systolic Heart Failure Receiving Quadruple Medical Therapy?

Vericiguat, a soluble guanylate cyclase stimulator known for augmenting cyclic guanosine monophosphate production, has garnered substantial clinical attention in patients with systolic heart failure. Despite its proven efficacy, discerning the specific subset of individuals who can enjoy clinical advantages from vericiguat therapy in contemporary real-world clinical practice, particularly among the individuals undergoing "quadruple medical therapy" comprising administration of a beta-blocker, angiotensin receptor neprilysin inhibitor, mineralocorticoid receptor antagonist, and sodium-glucose co-transporter 2 inhibitor, remains an unresolved query. This study involved patients undergoing 3-month vericiguat therapy alongside complete quadruple medical therapy in a contemporary real-world clinical practice. Baseline characteristics associated with the primary outcome, defined as a reduction in serum NT pro-B-type natriuretic peptide (BNP) levels over the 3-month therapeutic duration, were scrutinized. A cohort of 24 patients (median age: 66 years; 20 males) were included. All participants diligently adhered to the 3-month vericiguat therapy in conjunction with the quadruple medical regimen. A higher baseline systolic blood pressure emerged as an independent factor linked to the primary outcome, yielding an adjusted odds ratio of 1.31 (95% confidence interval: 1.03-1.65, P = 0.026) at a threshold of 105 mmHg. This threshold notably stratified the trajectories of serum NT pro-BNP levels during the 3-month vericiguat therapy. In conclusion, preservation of baseline systolic blood pressure emerged as a pivotal determinant for reaping the clinical benefits from mid-term vericiguat therapy among patients with systolic heart failure receiving quadruple medical therapy.

Correlation of Left Atrial Volume Index with Pro-BNP in Heart Failure with Preserved Ejection Fraction

Objective: To determine the correlation between left atrial (LA) volume index and Pro- BNP in heart failure patients with preserved ejection fraction. Methodology: This descriptive Cross-Sectional Study was conducted at Department of Cardiology, Liaquat University of Medical &amp; Health Sciences (LUMHS), Jamshoro, Pakistan, during Six months after the approval of synopsis from March 26, 2021 to September 25, 2021. All patients who fulfilled the inclusion criteria and visited to LUMHS, Jamshoro were included in the study. Informed consent was taken after explaining the procedure, risks and benefits of the study. Peripheral venous blood samples were obtained for assessment of pro- BNP level. A detailed comprehensive echocardiography was performed in all patients. All the collected data were entered into the proforma attached at the end and used electronically for research purpose. Results: The age of the patients ranged from 19 to 59 years with a median of 58 with interquartile range 12. In distribution of gender, 20 (60.5%) patients were male while 13 (39.4%) were female. Pearson’s correlation coefficient showed weak and non-significantly linear correlation between left atrial volume index and Pro-BNP levels i.e. (r= 0.134) in the region P &lt; 0.05. Conclusion: It is to be concluded that there was a weak correlation between left atrial volume index and Pro-BNP levels. More studies are necessary to evaluate the statistical association with a larger sample size and with more parameters in multiple study centers in Pakistan are needed to validate the findings of the present study.