B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure
2002; Lippincott Williams & Wilkins; Volume: 105; Issue: 20 Linguagem: Inglês
10.1161/01.cir.0000019121.91548.c2
ISSN1524-4539
Autores Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 105, No. 20B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBB-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart FailureWhat's Next? Alan Maisel, MD Alan MaiselAlan Maisel From the Division of Cardiology and the Department of Medicine, Veteran's Affairs Medical Center and University of California, San Diego. Originally published21 May 2002https://doi.org/10.1161/01.CIR.0000019121.91548.C2Circulation. 2002;105:2328–2331Although major advances in our understanding of the pathophysiology of congestive heart failure (CHF) have resulted in treatments that lead to symptomatic improvement and longer life, CHF still remains a major clinical challenge, especially in the areas of diagnosis, prognosis, and risk stratification. For the first time since the introduction of echocardiography some 20 years ago, a simple blood test appears to offer a significant advance in these areas.See p 2392B-type natriuretic peptide (BNP) is a neurohormone secreted mainly in the cardiac ventricles in response to volume expansion and pressure overload.1,2 Activation of BNP in patients with left ventricular (LV) dysfunction has generated considerable interest in both its diagnostic and prognostic properties. Although data have shown that BNP levels correlate with the severity and prognosis of heart failure,3,4 it was not until the development of a rapid, inexpensive assay that BNP could be used in the active clinical setting. In fact, present data, including the article in this issue of Circulation by Berger et al,5 suggest that BNP has finally cemented its role in these areas.BNP in the Diagnosis of DyspneaFor diagnostic screening tests to be useful in acute care, a test should have a high negative predictive value by itself and, along with clinical findings, should aid in the identification of patients whose dyspnea is a result of CHF. Davis et al,6 who measured the natriuretic hormones atrial natriuretic peptide and BNP in 52 patients presenting with acute dyspnea, found that admission plasma BNP concentrations more accurately reflected the final diagnosis than did ejection fraction or concentration of plasma atrial natriuretic peptide. Dao et al7 used the newly available point-of-care rapid assay for BNP (Triage Assay, Biosite Inc) in 250 patients presenting to the San Diego VA Healthcare Urgent Care Center. Patients diagnosed with CHF (n= 97) had a mean BNP concentration of 1076±138 pg/mL, whereas the non-CHF group (n=139) had a mean BNP concentration of 38±4 pg/mL. BNP at a cut point of 80 pg/mL was found to be highly sensitive and highly specific for the diagnosis of CHF. The negative predictive value of BNP values under 80 pg/mL was 98% for the diagnosis of CHF. Multivariate analysis revealed that after all useful tools for making the diagnosis were taken into account by the emergency department physician, BNP levels continued to provide meaningful diagnostic information not available from other clinical variables.More recently, Morrison et al8 were able to show that rapid testing of BNP could help differentiate between pulmonary and cardiac causes of dyspnea. Some types of pulmonary disease, such as cor pulmonale, lung cancer, and pulmonary embolism, had elevated BNP levels, but these were not usually elevated to the same extent as in patients with acute LV dysfunction.The above studies set the stage for the recently completed multinational Breathing Not Properly (BNP) study.9 In this unique large-scale study, 1586 patients with acute shortness of breath were examined. Not only was BNP able to differentiate CHF from non-CHF causes of dyspnea (area under receiver operating characteristic curve=0.91) with good specificity and high negative predictive values, but a single BNP level was more accurate than both the National Health and Nutrition Examination Score and Framingham, arguably the two criteria most commonly used to diagnose CHF (Figure 1). Download figureDownload PowerPointFigure 1. Accuracy of a single BNP level (>100 pg/mL) in diagnosing CHF compared with established criteria of NHANES and Framingham. Adapted from Maisel et al.9BNP as a Prognostic Marker in CHFSeveral algorithms incorporating various hemodynamic variables or symptomatic indexes have been developed in an attempt to assess an individual heart failure patient's prognosis.10,11 However, most single-variable markers are characterized by unsatisfactory discrimination of patients with and without increased heart failure mortality risk.10BNP has been shown to be a powerful marker for prognosis and risk stratification in the setting of heart failure. In a recent study of 78 patients referred to a heart failure clinic, BNP showed a significant correlation to the heart failure survival score.12 In addition, changes in plasma BNP levels were significantly related to changes in limitations of physical activities and were a powerful predictor of the functional status deterioration. Harrison et al13 monitored 325 patients for 6 months after an index visit to the emergency department for dyspnea. Higher BNP levels were associated with progressively worse prognoses (Figure 2). The relative risk of 6-month CHF death in patients with BNP levels >230 pg/mL was 24. Download figureDownload PowerPointFigure 2. Reverse Kaplan-Meir plot showing cumulative risk of any hospitalization or death from CHF, stratified by BNP levels at the time of initial visit to the emergency department. Higher BNP levels are associated with progressively worse prognosis. Patients with BNP levels >480 pg/mL had a 6-month cumulative probability of CHF admission or death of 42%. Patients with BNP levels <230 pg/mL only had a 2% chance of such an event.Risk stratification of CHF is confounded by the fact that CHF is a multi-system disease involving altered regulation of neurohormonal systems and altered function of other systems, such as renal and skeletal muscle.14 Yet CHF trials have suggested that up to 50% of deaths may be due to an arrhythmia rather than deterioration of pump function. Although other markers of hemodynamic status might help assess severity of disease, BNP may be the first marker that also reflects the physiological attempt to compensate for the pathophysiological alterations and restore circulatory homeostasis.15 Hence, BNP might be expected to influence both mechanical dysfunction and arrhythmic instability as the mechanisms most commonly involved in heart failure mortality. Berger and his colleagues have done a commendable job in cementing the role of BNP as a prognostic marker for sudden, presumably arrhythmic death in CHF. Following 452 patients with ejection fractions 400 pg/mL. Thus, in patients presenting with levels between 100 and 400 pg/mL, one needs to exclude baseline LV dysfunction without exacerbation, pulmonary embolism, and cor pulmonale.The future for BNP testing looks promising. We must continue to help it find its identity for patients with heart failure.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.FootnotesCorrespondence to Alan Maisel, MD, VAMC Cardiology 111-A, 3350 La Jolla Village Dr, San Diego, CA 92161. E-mail [email protected] References 1 Tsutamoto T, Wada A, Maeda K, et al. Attenuation of compensation of endogenous cardiac natriuretic peptide system in chronic heart failure: prognostic role of plasma brain natriuretic peptide concentration in patients with chronic symptomatic left ventricular dysfunction. Circulation. 1997; 96: 509–516.CrossrefMedlineGoogle Scholar2 Chen HH, Burnett JC. Natriuretic peptides in the pathophysiology of congestive heart failure. Curr Cardiol Rep. 2000; 2: 198–205.CrossrefMedlineGoogle Scholar3 Wallen T, Landahl S, Hedner T, et al. Brain natriuretic peptide predicts mortality in the elderly. Heart. 1997; 77: 264–267.CrossrefMedlineGoogle Scholar4 Yasue H, Yoshimura M, Sumida H, et al. Localization and mechanism of secretion of B-type natriuretic peptide in comparison with those of A-type natriuretic peptide in normal subjects and patients with heart failure. Circulation. 1994; 90: 195–203.CrossrefMedlineGoogle Scholar5 Berger R, Huelsman M, Stecker K, et al. B-type natriuretic peptide predicts sudden death in patients with chronic heart failure. Circulation. 2002; 105: 2391–2396.Google Scholar6 Davis M, Espiner E, Richards G, et al. Plasma brain natriuretic peptide in assessment of acute dyspnea. Lancet. 1994; 343: 440–444.CrossrefMedlineGoogle Scholar7 Dao Q, Krishnaswamy P, Kazanegra R, et al. Utility of B-Type Natriuretic Peptide (BNP) in the Diagnosis of CHF in an Urgent Care Setting. J Am Coll Cardiol. 2001; 37: 379–385.CrossrefMedlineGoogle Scholar8 Morrison KL, Harrison A, Krishnaswamy P, et al. Utility of a rapid B-natriuretic peptide (BNP) assay in differentiating CHF from lung disease in patients presenting with dyspnea. J Am Coll Cardiol. 2002; 39: 202–209.CrossrefMedlineGoogle Scholar9 Maisel AM, Krishnaswamy P, Nowak R, et al. Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure: primary results from the Breathing Not Properly (BNP) Multinational study. Paper presented at: 51st Annual Scientific Session of the American College of Cardiology;March 17–20, 2002; Atlanta, Ga.Google Scholar10 Cohn JN. Prognositc factors in heart failure: P poverty amidst a wealth of variables. J Am Coll Cardiol. 1989; 14: 571–572.CrossrefGoogle Scholar11 Kelly TL, Cremo R, Nieosen C, et al. Prediction of outcome in late-stage cardiomyopathy. Am Heart J. 1990; 119: 1111–1121.CrossrefMedlineGoogle Scholar12 Koglin J, Pehlivanli S, Schwaiblamir M, et al. Role of brain natriuretic peptide in risk stratification of patients with congestive heart failure. J Am Coll Cardiol. 2001; 38: 1934–1941.CrossrefMedlineGoogle Scholar13 Harrison A, Morrison LK, Krishnaswamy P, et al. B-type natriuretic peptide (BNP) predicts future cardiac events in patients presenting to the emergency department with dyspnea. Ann of Emerg Med. 2002; 39: 131–138.CrossrefMedlineGoogle Scholar14 Schrier RW, Abraham WT. Hormones and hemodynamics in heart failure. N Engl J Med. 1999; 341: 577–585.CrossrefMedlineGoogle Scholar15 Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med. 1998; 339: 321–328.CrossrefMedlineGoogle Scholar16 Connolly SJ, Hallstrom AP, Cappato R, et al. Meta analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH, CIDS studies. Eur Heart J. 2000; 21: 2071–2078.CrossrefMedlineGoogle Scholar17 Krumholz HM, Parent EM, Tu N, et al. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med. 1997; 157: 99–104.CrossrefMedlineGoogle Scholar18 Konstam MA, Kimmelstiel CD. Economics of heart failure.In: Balady GJ, Pina IL, eds. Exercise and Heart Failure. Armonk, NY: Futura; 1997:19–28.Google Scholar19 Cheng VL, Krishnaswamy P, Kazanegra R, et al. A rapid bedside test for b-type natriuretic peptide predicts treatment outcomes in patients admitted with decompensated heart failure. J Am Coll Cardiol. 2001; 37: 386–391.CrossrefMedlineGoogle Scholar20 Kazanagra R, Chen V, Garcia A, et al. A rapid test for b-type natriuretic peptide (BNP) correlates with falling wedge pressures in patients treated for decompensated heart failure: a pilot study. J Card Failure. 2001; 7: 21–29.CrossrefMedlineGoogle Scholar21 Richardson AM, Doughty R, Nicholls MG, et al. Neurohumoral predictors of benefit from carvedilol in ischemic left ventricular dysfunction. Circulation. 1999; 99: 786–797.CrossrefMedlineGoogle Scholar22 Troughton RW, Frampton CM, Yandle TG, et al. Treatment of heart failure guided by plasma amino terminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000; 355: 1126–1130.CrossrefMedlineGoogle Scholar23 Sodian R, Loebe M, Schmitt C, et al. Decreased plasma concentrations of brain natriuretic peptide as a potential indicator of cardiac recovery in patients supported by mechanical circulatory assist systems. J Am Coll Cardiology. 2001; 38: 1942–1949.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bridwell R, Koyfman A and Long B (2022) High risk and low prevalence diseases: Adult epiglottitis, The American Journal of Emergency Medicine, 10.1016/j.ajem.2022.04.018, 57, (14-20), Online publication date: 1-Jul-2022. 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