Amino Terminal B-Type Natriuretic Peptide, Renal Function, and Prognosis in Acute Heart Failure: A Hospital Cohort Study

doi:10.1016/j.cardfail.2007.01.001

Journal of Cardiac Failure

Volume 13, Issue 4, May 2007, Pages 275-280

https://doi.org/10.1016/j.cardfail.2007.01.001 Get rights and content

Abstract

Background

Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a valuable diagnostic and prognostic test in heart failure (HF). Limited information is available concerning its use in patients with renal failure, in whom dependence on renal clearance may negatively affect its performance.

Methods and Results

We evaluated influence of renal function on NT-proBNP levels and on its prognostic value after hospital discharge in 283 acute HF patients. Admission and discharge NT-proBNP levels were higher in patients with decreased estimated glomerular filtration rate (eGFR). In these patients discharge NT-proBNP above median was associated to occurrence of death or readmission at 6 months (hazard ratio [HR] 2.53, 95% confidence interval [CI] 1.27–5.03); in patients with normal eGFR, a trend to this association was found (HR 1.64, CI 0.98–2.76). Decrease in NT-proBNP less than 30% of baseline was associated to outcome in patients with normal eGFR (HR 2.68, CI 1.54–4.68) and decreased eGFR (HR 2.54, CI 1.49–4.33).

Conclusions

Acute HF patients with renal failure have higher NT-proBNP levels than those with normal renal function. Discharge NT-proBNP has long-term prognostic value in HF patients with renal dysfunction. NT-proBNP variations during hospitalization provide additional prognostic information either in patients with normal or reduced eGFR.

Section snippets

Patients

We included patients admitted between October 2002 and April 2004 to our department because of decompensated HF, defined as exacerbation of symptoms in patients with at least 1 New York Heart Association class deterioration. The diagnosis of HF was based on the European Society of Cardiology criteria.¹⁴ Patients with acute coronary syndromes and on hemodialysis were excluded.

Blood samples were collected in EDTA-containing tubes up to 24 hours after admission and before discharge. NT-proBNP was

Results

During the study period, 511 patients were admitted because of decompensated HF, 52 (10.2%) of whom died in the hospital. Among the 419 patients discharged alive, NT-proBNP levels at admission and discharge were available for 287 patients. Of these, 4 were previously or became on dialysis during hospitalization and were excluded. The subsequent analysis refers to the other 283 patients [mean age = 72.8 ± 11.7 years; 147 (51.9%) females]. Table 1 shows demographic, clinical, functional, and

Discussion

We found in a population of acute HF patients that NT-proBNP levels were proportional to renal function impairment. In addition, we observed that discharge NT-proBNP was a useful marker of long-term prognosis in patients with renal dysfunction and also that NT-proBNP variations during hospitalization predicted readmission and death even in patients with mild/moderate renal dysfunction.

The prognostic value of NT-proBNP has been extensively reported. It has been observed in all spectrum of HF

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Cited by (21)

BNP-Response to Acute Heart Failure Treatment Identifies High-Risk Population
2020, Heart Lung and Circulation
Citation Excerpt :
Next, a delta pro-BNP percentage was calculated for each admission based on their change in pro-BNP and their admission pro-BNP. Then, as has been done previously, a threshold of 30% was used to divide admissions into two groups: (1) pro-BNP responsive to treatment and (2) pro-BNP unresponsive to treatment. [14–17] Specifically, the pro-BNP responsive group was defined as a decrease in pro-BNP by at least 30%, and the pro-BNP unresponsive group was defined as a decrease in pro-BNP by less than 30% or an increase in pro-BNP.
Using serial measurements of brain natriuretic peptide (BNP) has been proposed as a method to guide therapy for patients treated for acute decompensated heart failure. However, 20–47% of patients do not achieve the target BNP thresholds despite treatment. We hypothesised that “BNP unresponsive” patients represent a distinct group at high risk for poor outcomes and sought to examine the characteristics and outcomes of this group.
In a retrospective study using electronic health record (EHR) data, we examined the outcomes of patients admitted with acute decompensated heart failure. Patients were divided into two groups based on their pro-BNP response to treatment: (1) pro-BNP responsive to treatment (decrease by at least 30%) and (2) pro-BNP unresponsive to treatment (decrease by less than 30%). The primary outcomes of interest were 180-day mortality and 180-day readmission. Univariate and multivariate Cox proportional hazard models were used to assess the independent association between pro-BNP response to treatment and 180-day mortality and readmission. Adjustment variables included age, gender, Charlson co-morbidity score, admission creatinine, admission haematocrit, ejection fraction, preserved ejection fraction, and LV end-diastolic dimension.
The total study population included 819 patients with 455 (55.6%) in the pro-BNP responsive group and 364 (44.4%) in the pro-BNP unresponsive group. Admissions whose BNP was unresponsive to treatment had significantly increased risk for 180-day mortality, compared with BNP-responsive admissions (26.4% vs. 13.2%, p < 0.001). Brain natriuretic peptide unresponsiveness remained significantly associated with increased 180-day mortality after adjustment for demographic and clinical characteristics (HR_adj = 2.19, 95% CI: 1.52–3.14). BNP-unresponsiveness was not associated with significantly increased 180-day readmission rates (HR_adj = 1.07, 95% CI: 0.92–1.25).
Patients whose pro-BNP did not improve by >30% were at increased risk for 180-day mortality, but not 180-day readmission. Thus, BNP-unresponsiveness provides meaningful prognostic information, and it may define a patient population that would benefit from specific therapies to reduce the risk.
Systemic Sclerosis
2017, The Heart in Rheumatic, Autoimmune and Inflammatory Diseases: Pathophysiology, Clinical Aspects and Therapeutic Approaches
Cardiac involvement in systemic sclerosis (SSc) may be either primary or secondary to the impairment of other organs such as the lungs and kidneys. Primary cardiac involvement, which develops as a direct consequence of the disease, may affect all cardiac tunics, endocardium, myocardium, and pericardium. This may conduct to pericardial effusion, arrhythmias, conduction system defects, myocardial ischemia, myocardial hypertrophy, and heart failure. The prevalence of primary cardiac involvement in SSc varies depending on the sensitivity of the diagnostic tools used, but it is ascertained that overt cardiac manifestations are associated with poor prognosis. Microvascular impairment is a pathognomonic feature of SSc, and together with focal fibrosis may involve all cardiac structures. In contrast, the frequency of atherosclerotic coronary artery disease in SSc seems to be comparable to that of the general population. Because cardiac involvement in SSc can be often clinically obscure, a complete routine evaluation should be adopted in every patient, including standard 12-lead electrocardiogram (ECG) and Doppler echocardiography (especially tissue Doppler imaging), while magnetic resonance imaging and cardiac computed tomography are sensitive techniques for earlier detection of both structural and functional scleroderma-related cardiac pathologies, although they still represent a second level examination, not available everywhere. Additional investigations can be required in suspicion of other manifestations such as conduction and rhythm disorders (24-h Holter monitoring, invasive electrophysiological studies), or myocarditis (cardiac magnetic resonance). Routine screening for subclinical cardiac involvement with more sensitive tools leads to early diagnosis, in order to treat patients in a “window of opportunity” with drugs that may improve myocardial perfusion and function, and possibly limit the progression of the most life-threatening complications.
Novel markers and therapies for patients with acute heart failure and renal dysfunction
2015, American Journal of Medicine
Citation Excerpt :
Table 3 provides a summary of existing and emerging biomarkers that were of interest in our analysis.21-32 Table 4 presents a summary of the results of our literature search in this topic area.1,33-52 Brain natriuretic peptide (BNP) is a bioactive cardiac neurohormone secreted from the myocardium of the ventricles in response to stretching or volume overload, and it is a reliable biomarker used to aid in the diagnosis of acute heart failure.33,42,53
Acute kidney injury complicates decompensated heart failure in ∼33% of cases and is associated with morbidity and mortality; thus, we sought to systematically review this topic in order to summarize novel diagnostic and therapeutic approaches.
Structured PubMed searches on these topics were conducted in February 2014 and relevant literature was identified. The PubMed search identified a total of 192 articles that were individually screened for inclusion in this analysis, and 58 were included.
Acute kidney injury, defined by substantial increases in serum creatinine, is associated consistently with prolonged length of stay, rehospitalization, and mortality. Biomarker studies suggested that natriuretic peptides are prognostic for shorter- and longer-term mortality. Novel proteins indicating kidney damage and albumin in the urine are associated with acute kidney injury. The most promising acute pharmacologic treatment appears to be serelaxin, which has been shown to improve acute heart failure symptoms, hemodynamic parameters, and renal function.
The presence of acute kidney injury results in worse clinical outcomes for patients with acute heart failure. Novel biomarkers and therapies hold the promise of improving both cardiac and renal outcomes in these patients.
Prognostic role of NT-proBNP in emergency department in the elderly with acute heart failure
2013, Revista Espanola de Geriatria y Gerontologia
Determinar la utilidad pronóstica del NT-proBNP en la estratificación del riesgo de mortalidad, y el reingreso a los 30 días en los ancianos atendidos por insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH) españoles, así como analizar aquellos factores que pueden influir a la hora de la interpretación del NT-proBNP.
Estudio de cohorte multipropósito multicéntrico con seguimiento prospectivo que incluyó a todos los pacientes de 65 años o más con ICA atendidos en 12 SUH españoles. Se recogieron variables demográficas, antecedentes personales, datos del episodio de urgencias, y el valor del NT-proBNP a la llegada a urgencias. Las variables resultado fueron la mortalidad y el reingreso a los 30 días. A la hora del análisis se adoptó el punto de corte de NT-proBNP ≥ 5.180 pg/ml. Se utilizó un paquete estadístico SPSS^® 18.0.
Se incluyeron un total de 585 pacientes con una edad media de 80,4 (DE: 6,9) años. El punto de corte de NT-proBNP ≥ 5.180 pg/ml se asoció de forma independiente con el grado severo de filtrado glomerular (< 30 ml/h) (p < 0,001) y la severidad del episodio (NYHA II-IV) (p = 0,012). La curva ROC para el NT-proBNP respecto a la mortalidad a los 30 días presentó un área bajo la curva (ABC) de 0,71 (IC 95%: 0,63-0,77; p < 0,001) y respecto a la revisita a los 30 días un ABC de 0,50 (IC 95%: 0,45-0,56; p = 0,846). Tras realizar una análisis multivarible, se halló que el punto de corte de NT-proBNP ≥ 5.180 pg/ml era un factor asociado independiente de mortalidad a los 30 días en los ancianos con ICA atendidos en los SUH españoles.
Los niveles de NT-proBNP se asocian a la mortalidad a corto plazo en la población anciana atendida por ICA en los SUH, indistintamente de los factores que influyen en su interpretación como son la severidad del episodio agudo o la disminución del filtrado glomerular, y no así con el reingreso a los 30 días.
To determine prognostic role of NT-proBNP as predictor of 30 day-mortality and readmission in the elderly with acute heart failure (AHF) treated in Spanish Emergency Departments (EDs), and to analyse the confounding factors when the NT-proBNP value is interpreted.
A multicentre and multi-purpose cohort study with prospective follow-up was conducted on all patients aged 65 years or older with AHF treated in Spanish EDs. The variables recorded include demographic characteristics, comorbidity, details of episode, and NT-proBNP value. The outcome variables were 30 day-mortality and readmission. An NT-proBNP≥5,180 pg/ml was adopted as the cut-off limit. The statistical package SPSS^® 18.0 was used to analyse the data.
A total of 585 patients were included, with a mean age of 80.4 (SD: 6.9) years old. The cut-off NT-proBNP≥5,180 pg/ml was independently associated with a severely impaired glomerular filtration (<30 ml/h) (P<.001) and severe episode (NYHA II-IV) (P=.012). The NT-proBNP area under curve (AUC) for 30 day-mortality was 0.71 (CI95%: 0.63-0.77; P<.001) and for 30 day-readmission, was 0.50 (CI95%: 0.45-0.56; P=.846). A multivariable analysis showed that the cut-off NT-proBNP ≥5,180 pg/ml was an independent factor associated with 30 day-mortality in the elderly with AHF attended in Spanish EDs.
The NT-proBNP value is associated with short-term mortality in the elderly with AHF attended in the EDs independently of the presence of confounding factors, such as the severity of the episode and glomerular filtration reduction, but not with 30 day-readmission.
Hospitalization epidemic in patients with heart failure: Risk factors, risk prediction, knowledge gaps, and future directions
2011, Journal of Cardiac Failure
Citation Excerpt :
Admission and discharge levels predict readmission in various populations82,91,103–107 including those with systolic dysfunction,27,36 restrictive filling pattern,81 or chronic renal insufficiency.95 Although not consistently seen or universally agreed upon, a reduction in natriuretic peptide levels during hospitalization by >30%-40% has been associated with improved outcomes in some studies.36,76,95,105,108–110 Postdischarge measurement also provides risk stratification.29,111–113
Patients with heart failure (HF) are hospitalized over a million times annually in the United States. Hospitalization marks a fundamental change in the natural history of HF, leading to frequent subsequent rehospitalizations and a significantly higher mortality compared with nonhospitalized patients. Three-fourths of all HF hospitalizations are due to exacerbation of symptoms in patients with known HF. One-half of hospitalized HF patients experience readmission within 6 months. Preventing HF hospitalization and rehospitalization is important to improve patient outcomes and curb health care costs. To implement cost-effective strategies to contain the HF hospitalization epidemic, optimal schemes to identify high-risk individuals are needed. In this review, we describe the risk factors that have been associated with hospitalization risk in HF and the various multimarker risk prediction schemes developed to predict HF rehospitalization. We comment on areas that represent gaps in our knowledge or difficulties in interpretation of the current literature, representing opportunities for future research. We also discuss issues with using HF readmission rate as a quality indicator.
Usefulness of brain natriuretic peptide and N-terminal pro-brain natriuretic peptide in the elderly
2009, Revue de Medecine Interne
Le peptide natriurétique B (BNP) et le N-terminal–proBNP sont deux biomarqueurs sécrétés en réponse à l’étirement cardiomyocytaire et à l’augmentation de la contrainte pariétale ventriculaire. Ils sont utilisés depuis quelques années dans la pathologie cardiovasculaire de l’adulte, en particulier comme aide au diagnostic et au pronostic de l’insuffisance cardiaque. Cet article a pour objectif de préciser leur place en gériatrie à partir d’une revue de la littérature. Chez le sujet âgé, les valeurs discriminantes des peptides natriurétiques sont plus élevées que chez l’adulte d’âge moyen, par la fréquence de certaines comorbidités comme l’insuffisance rénale qui augmente les taux circulants. C’est dans l’insuffisance cardiaque que leur place est actuellement la mieux établie, non seulement au niveau diagnostique avec l’utilisation de deux seuils qui permettraient de réduire le nombre d’erreurs, mais aussi sur un plan pronostique. Les peptides natriurétiques pourraient être utilisés dans l’avenir dans le pronostic du syndrome coronarien aigu, dans l’évaluation du risque cardiovasculaire et le suivi des valvulopathies. Cependant, des études spécifiques aux sujets âgés seront nécessaires pour valider ces indications.
B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide are biomarkers secreted both in response to myocardial stretch and increased ventricular wall stress. They are now largely used in cardiovascular disease in adults, especially as diagnostic and prognostic tools. This article aims at synthesizing existing data concerning the usefulness of natriuretic peptides in elderly patients. With aging, co-morbidities such as renal failure are common and lead to an increase in circulating concentrations of natriuretic peptides. Nevertheless, their usefulness is relevant in geriatric practice. Their role has been well established in heart failure, not only in diagnosis, using two thresholds to decrease misclassification, but also in prognosis. In the future, natriuretic peptides could be used as prognosis tools in acute coronary syndrome, in cardiovascular risk assessment or in management of heart valve disease. However, further investigations in elderly people are needed before validating these indications in routine geriatric practice.

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Clinical InvestigationAmino Terminal B-Type Natriuretic Peptide, Renal Function, and Prognosis in Acute Heart Failure: A Hospital Cohort Study

Abstract

Background

Methods and Results

Conclusions

Section snippets

Patients

Results

Discussion

Am J Kidney Dis

J Am Coll Cardiol

J Am Coll Cardiol

Kidney Int

J Card Fail

J Am Coll Cardiol

Heart failure with preserved left ventricular systolic function: a hospital cohort study

Heart

Controlling the epidemic of cardiovascular disease in chronic renal disease: report from the National Kidney Foundation Task force on Cardiovascular Disease

J Am Soc Nephrol

Evidence for increased cardiovascular disease risk in patients with chronic kidney disease

Curr Opin Nephrol Hypertens

Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies

J Am Soc Nephrol

Cardiorenal risk: an important clinical intersection

Rev Cardiovasc Med

Cardiorenal risk as a new frontier of nephrology: research needs and areas for intervention

Nephrol Dial Transplant

Clinical Investigation
Amino Terminal B-Type Natriuretic Peptide, Renal Function, and Prognosis in Acute Heart Failure: A Hospital Cohort Study