Congestive Heart Failure
Stability of B-type natriuretic peptide levels during exercise in patients with congestive heart failure: Implications for outpatient monitoring with B-type natriuretic peptide*,**

https://doi.org/10.1067/mhj.2002.120148Get rights and content

Abstract

Background B-natriuretic peptide (BNP), a neurohormone secreted from the cardiac ventricles, reflects left ventricular pressure and correlates to disease severity and prognosis. The fact that BNP levels can now be measured by a rapid assay suggests its potential usefulness in the outpatient clinic. However, if patient activity were to markedly alter BNP levels, its use would be less attractive for monitoring patients in the outpatient clinical setting. Methods A total of 30 patients (10 normal, 10 New York Heart Association [NYHA] class I-II, 10 NYHA class III-IV) exercised with an upright bicycle protocol. Exercise was carried out to 75% of maximum heart rate, and venous blood was sampled before, immediately after, and 1 hour after completion of exercise. Plasma levels of BNP, epinephrine, and norepinephrine were measured. Results BNP levels at baseline were 29 ± 11 pg/mL for normal subjects, 126 ± 26 pg/mL for NYHA I-II subjects, and 1712 ± 356 pg/mL for NYHA III-IV subjects. The change in BNP levels with exercise was significantly lower than the change in epinephrine and norepinephrine (P <.001). In normal subjects, BNP increased from 29 pg/mL to 44 pg/mL with peak exercise, still within the range of normal (<100 pg/mL). This is compared with larger increases of norepinephrine (716 pg/mL to 1278 pg/mL) and epinephrine (52 pg/mL to 86 pg/mL) with exercise in normal subjects. There were also only small increases in BNP with exercise in patients with congestive heart failure (NYHA I-II, 30%; NYHA III-IV, 18%). For the same groups, epinephrine levels increased by 218% and 312%, respectively, and norepinephrine levels increased by 232% and 163%, respectively. One hour after completion of exercise, there were only minimal changes in BNP levels from baseline state in normal subjects (+0.9%) and patients with NYHA I-II (3.8%). In patients with NYHA III-IV, there was a 15% increase from baseline 1 hour after exercise. Conclusions BNP levels show only minor changes with vigorous exercise, making it unlikely that a normal patient would be classified as having congestive heart failure based on a BNP level obtained after activity. Prior activity should not influence BNP levels in patients with congestive heart failure. Therefore, when a patient presents to clinic with a marked change in their BNP level, it may reflect a real change in their condition. (Am Heart J 2002;143:406-11.)

Section snippets

Study population

This study was approved by University of California Institutional Review Board. Twenty subjects with CHF observed at the San Diego Veterans Affairs Healthcare Systems Cardiomyopathy Clinic were enrolled in the study based on their symptoms according to the New York Heart Association (NYHA) classification. A total of 10 subjects with NYHA class I or II CHF and 10 subjects with NYHA class III or IV CHF were enrolled. Ten control subjects were selected who had no CHF or other cardiac or pulmonary

Results

Patient characteristics are reported in Table I. The mean BNP value of the NYHA III-IV group was significantly higher than the mean BNP value of the NYHA I-II group (P <.001), which in turn, was significantly higher than the mean of the no CHF group (P <.001). In contrast, there were no significant differences in epinephrine (P =.89) or norepinephrine (P =.22) levels among the groups. The scope of exercise as a function of both the maximum predicted heart rate and maximum Borg scale was similar

Discussion

Although major advances in our understanding of the pathophysiologic condition of CHF have resulted in treatments that lead to symptomatic improvement and longer life, CHF remains a major clinical challenge. Not only do we have difficulty making the diagnosis of heart failure, we have an even greater challenge in assessing the results of treatment, both in the hospital and the outpatient setting. The fact that the direct costs of heart failure exceed $38 billion, greater than 5% of total health

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      However, the literature data about the dynamics of NT-pro-BNP during physical stress are controversial. Some studies showed that there are no significant changes of this hormone during physical stress [91,94], while others showed an increase in plasma levels [29,46,53,62], not only during dynamic but also during static load [16], which is in accordance with our results. The increase of NT-pro-BNP can be explained by the fact that exercise might generate transitory ischemia, increase of wall stress and diastolic dysfunction [6], which are stimuli for the NT-pro-BNP secretion [36,47], in order to obtain further necessary regulation of cardiac function in stress condition.

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    *

    This study was supported in part by an unrestricted grant from Biosite Diagnostics, San Diego, Calif.

    **

    Reprint requests: Alan Maisel, MD, VAMC Cardiology 111-A, 3350 La Jolla Village Drive, San Diego, CA 92161.E-mail: [email protected].

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