NT‐proBNP is associated with mortality and adverse cardiac events in patients with atrial fibrillation presenting to the emergency department

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the emergency department. The CHA₂DS₂‐VASc score helps to predict thromboembolic risk; however, the rate of other adverse cardiac events is more difficult to predict.

Hypothesis

The biomarker N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) has prognostic value in patients presenting to the emergency department with AF.

Methods

During a 1.5‐year period, a prospective study was performed in consecutive patients presenting to the emergency department with AF on the presenting electrocardiogram. At baseline, NT‐proBNP was measured. The primary endpoints were all‐cause death and major adverse cardiac events (MACE: all‐cause mortality, myocardial infarction, or revascularization).

Results

A total of 355 patients were included (mean age, 71 years; 55% male). The median duration of follow‐up was 2 years. After adjustment for baseline variables, the logNT‐proBNP was independently correlated with death (hazard ratio [HR]: 1.54, 95% confidence interval [CI]: 1.18‐1.99) and MACE (HR: 1.27, 95% CI: 1.03‐1.58). After adjustment for baseline variables, a high NT‐proBNP value (>500 pmol/L) was independently correlated with death (HR: 2.26, 95% CI: 1.19‐4.28), and for MACE a trend was seen (HR: 1.67, 95% CI: 0.96‐2.91) compared with a low value (<250 pmol/L).

Conclusions

In patients presenting to the emergency department with AF, higher NT‐proBNP values are independently associated with an increased mortality and MACE. Therefore, this biomarker may be a useful prognostic marker in the management and treatment of these patients.     

The influence of sex on right ventricular dysfunction in patients with severely depressed left ventricular ejection fraction

AIM: To assess the influence of sex on right ventricular dysfunction (RVD) in patients with severe left ventricular systolic dysfunction. METHODS AND RESULTS: We studied 385 consecutive patients with left ventricular ejection fraction (LVEF) <0.35. All patients underwent invasive measurement of right ventricular and pulmonary artery pressures and evaluation of RVD by standard transthoracic echocardiography. Female patients (n=84, 21.8%) were significantly older than male patients (62.0+/-11.4 vs. 58.2+/-10.7 years), p=0.005. The prevalence of RVD was lower in women (26.5%) than in men (38.9%), p=0.03; both in patients with and without coronary artery disease (19.4% vs. 34.5% and 31.9% vs. 44.4%, respectively). Haemodynamic parameters and LVEF were similar in men and women. Low LVEF, pulmonary systolic pressure, degree of mitral regurgitation, male sex, and absence of significant coronary artery disease were independently correlated with RVD. CONCLUSION: Women with severe left ventricular systolic dysfunction have less RVD than men, despite similar haemodynamic parameters and LVEF.     

扩张性心肌病患者左室射血分数与胆固醇水平的相关性

目的 目的 分析扩张性心肌病（DCM）患者左室射血分数(LVEF)与血清总胆固醇（TC）的关系。方法 选取住院DCM患者123例，分为LVEF>40％组（34例）和 LVEF≤40％组（89例）。入院后收集患者一般情况及测定血液生化，以超声心动图检查患者的心脏功能及结构，并进行比较。结果 LVEF>40%组与LVEF≤40%患者比较:LVEF>40%组年龄小于LVEF≤40%组(P<0.05)；LVEF>40%组TC显著高于LVEF≤40%组(P<0.05)。TC与LVEF呈正相关（r=0.287,P<0.01）。结论 DCM患者LVEF与TC有相关性。     

高同型半胱氨酸血症与高血压患者左室射血分数的相关性研究

目的探讨高同型半胱氨酸血症（Hhcy）与原发性高血压患者左室射血分数（LVEF）的相关性,评估左室收缩功能受损程度对预测高血压心衰的临床意义。方法选取高血压患者200例,其中非左室肥厚组（NLVH）100例,男性63例,女性37例,年龄（61．2x8．9）岁;左室肥厚组（LVH）100例,男性66例,女性34例,年龄（60．8±9．2）岁;对照组100例,男性65例,女性35例,年龄（60．9±9．5）岁。对所有受试者测定血清同型半胱氨酸（Hcy）水平及行超声心动图检查测量LVEF。结果对照组、NLVH组和LVH组血清Hey水平分别为（9．32±1．91）μmol／L、（20．92±3．28）p,mol／L和（29．60＋3．73）wmol／L,每两组间比较差异均有统计学意义（P〈0．01）。对照组、NLVH组和LVH组LVEF分别为（59．00±4．63）％、（40．70±1．87）％和（39．50±1．46）％,依次显著降低,差异有统计学意义（P〈0．01）。结论Hhcy与LVH呈正相关、与LVEF呈负相关,对预测高血压心衰,减少高血压心力衰竭的发生、发展有一定的临床价值。     

左室射血分数正常的心力衰竭患者的临床特点及左室收缩功能

目的 应用超声测量左室射血分数(LVEF)正常的心力衰竭(心衰)患者的房室平面位移,观察该类患者是否存在心室长轴方向收缩功能异常.方法 收集住院心衰患者96例,LVEF正常心衰组和LVEF降低心衰组各48例,50例健康体检者入选为对照组.比较各组在NYHA心功能分级、基础病因、房室平面位移、血浆N末端B型利钠肽原浓度的差异.结果 LVEF正常心衰组和LVEF降低心衰组的NYHA心功能分级差异无统计学意义.LVEF正常心衰组常见病因为高血压性心脏病和冠心病.对照组、LVEF正常心衰组、LVEF降低心衰组的房室平面位移依次下降.房室平面位移与血浆N末端B型利钠肽原水平负相关(r=-0.35,P<0.05).结论 通过传统方法测定的LVEF正常心衰组患者存在心室长轴方向上的收缩功能异常,而非单纯的舒张性心衰.     

Increased serum N-terminal pro-B-type natriuretic peptide and left ventricle diastolic dysfunction in patients with hepatitis C virus infection

Prior studies demonstrated that patients with hepatitis C virus (HCV) infection had higher plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, which may indicate the presence of a subclinical cardiac dysfunction. However, there are few data regarding the echocardiographic assessment in HCV-infected patients. The objectives of this study were to investigate changes in the left ventricle (LV) with echocardiography and to identify echocardiographic correlates of serum NT-proBNP levels in HCV-infected patients. Ninety HCV-infected patients and 90 age and gender-matched healthy controls were included. The level of serum NT-proBNP was higher in the patient group (P < 0.001). The proportion of patients whose serum NT-proBNP levels were higher than 125 pg/mL was greater than that of controls (15.56%vs 3.33%, P = 0.011). Echocardiography did not show any significant difference of cardiac structural abnormalities between groups. In the patient group, E, E' and E/A were lower, and E/E' was higher. The proportion of patients (13, 14.44%) with impaired diastolic filling (E/A ≤ 0.75; 0.75 < E/A < 1.5 and E/E' ≥ 10) was greater than that of the control group (3, 3.33%; P = 0.018). Simple regression analysis demonstrated a statistically significant linear correlation between NT-proBNP levels and left ventricular diastolic diameter (LVDd) (r = 0.178, P = 0.013), left ventricular posterior wall diastolic thickness (LVPWd) (r = 0.147, P = 0.023) and mitral E/E' (r = 0.414, P = 0.027). Independent correlates of NT-proBNP levels (R(2) = 0.34) were older age (β' = 0.034, P = 0.011) and E/E' ratio (β' = 0.026, P = 0.018). In conclusion, the combined analysis of NT-proBNP and echocardiography showed a possible subclinical left ventricular diastolic dysfunction as evidence of a pathogenic link between HCV and CVD.     

Development of a depressed left ventricular ejection fraction in patients with left ventricular hypertrophy and a normal ejection fraction

The progression from concentric left ventricular (LV) hypertrophy to heart failure has not been well defined. Of 159 predominantly hypertensive African-American patients with LV hypertrophy and a normal ejection fraction (EF), 28 (18%) developed a reduced EF after a median follow-up of approximately 4 years. Risk factors for this outcome included a history of coronary artery disease, pulmonary edema seen on a chest x-ray, or a subsequent myocardial infarction.     

左室射血分数与老年慢性心力衰竭患者认知功能的关系

目的 探索左室射血分数与老年慢性心力衰竭患者认知功能的关系。方法 人选左室射血分数小于45%且年龄大于或等于60岁的住院慢性心衰患者共222例。使用简易智能量表(Mini-Mental State Examination,MMSE) 进行认知功能评估。收集相关临床资料。采用logistic回归分析校正混杂因素的影响。结果 以 MMSE评分<24分作为认知功能障碍的界值,46.4%(103/222)的患者存在认知功能障碍。多因素分析结果显示,在以年龄、受教育情况、长期饮酒史、伴发糖尿病史校正后,左心室射血分数减低可以增加心衰患者认知功能障碍的风险(OR=0.92,95%CI：0.87~0.97)。结论 慢性心衰患者认知障碍发生率较高,左室射血分数减低是慢性心衰患者发生认知功能障碍的独立危险因素。     

Epidemiology and diagnosis of heart failure with preserved left ventricular ejection fraction: rationale and design of the study

AIMS: Despite major advances in our understanding of 'systolic' heart failure, at present the epidemiology, pathophysiology, and therapy of heart failure with preserved left ventricular ejection fraction (HFpEF) is poorly understood, in large part because of the lack of robust and widely accepted diagnostic criteria. Although there is a good evidence base for the treatment of systolic heart failure, similar data are lacking for the treatment of HFpEF. Methods In our study, we will screen a consecutive series of 5000 subjects aged ≥60 from the community. Following symptom questionnaire and echocardiography, metabolic exercise testing will be used to confirm whether or not patients thought clinically to have HFpEF are in fact exercise limited and that this limitation is cardiac in origin. Blood samples for plasma brain natriuretic peptide (BNP) will be taken at rest and following exercise in symptomatic patients and matching controls. CONCLUSIONS: At the end of our study we will establish community prevalence and population characteristics of HFpEF, and also evaluate the diagnostic accuracy of current echocardiography parameters and BNP for the diagnosis of the condition.     

Amount of left ventricular hypertrophy determines the plasma N-terminal pro-brain natriuretic peptide level in patients with hypertrophic cardiomyopathy and normal left ventricular ejection fraction

BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) is increased in patients with hypertrophic cardiomyopathy (HCM); however, the determinants of NT-proBNP level have not been clarified in HCM. HYPOTHESIS: This study was performed to determine the relationship between NT-proBNP levels and various echocardiographic variables of patients with HCM and normal left ventricular ejection fraction (LVEF). METHODS: We assessed plasma NT-proBNP levels and echocardiographic variables of 36 patients (19 men, 58 +/- 14 years) with HCM and an LVEF of > or = 55%. Echocardiographic variables measured were LV wall thickness, end-diastolic LV internal dimension (LVIDd) and volume (LVEDV), LV mass, and LV mass index (LV mass/body surface area, LVMI). Left ventricular outflow tract pressure gradient, transmitral E and A velocities, deceleration time (DT) of the transmitral E wave, and septal annular E' velocity were measured by Doppler technique. The relationship between echocardiographic variables and plasma NT-proBNP level was analyzed. RESULTS: The plasma NT-proBNP level was 775.2 +/- 994.2 pg/ml (range 33.1-4729.0 pg/ml). It showed positive correlations with LV end-diastolic septal thickness (r = 0.39, p = 0.010) and LVMI (r = 0.27, p = 0.050), while it revealed negative correlations with LVIDd (r = -0.44, p = 0.004), LVEDV (r = -0.44, p = 0.004) and DT(r = -0.31,p = 0.034). The NT-proBNP level was higher in the patients with than in those without LV diastolic dysfunction (p = 0.033) and was independently related to LVIDd (p = 0.001), LVMI (p = 0.006) and DT (p = 0.031) by multivariate analysis. CONCLUSION: In patients with HCM and normal LVEF, the amount of LV hypertrophy and LV diastolic dysfunction may exert a significant role in determining plasma NT-proBNP level.     

fQRS as a marker of granulomatous disease in patients presenting with ventricular tachycardia and normal left ventricular ejection fraction

Background

Granulomatous myocarditis may present with sustained monomorphic ventricular tachycardia (SMVT) in the presence of normal left ventricular ejection fraction (LVEF), and could be mistaken for idiopathic ventricular tachycardia (IVT). The use of cardiac imaging for diagnosis can be limited by availability and high cost. ECG is readily available and inexpensive. Fragmented QRS (fQRS) on ECG has been found to be associated with myocardial scar. We hypothesized that fQRS could be useful in the diagnosis of granulomatous VT (GVT).

Methods

We compared the 12-lead ECG of 16 patients with GVT and 42 patients with IVT who presented with SMVT.

Results

The presence of fQRS was significantly higher in the GVT group compared to the IVT group (75% versus 19.1%, p < 0.001). The location of fQRS correlated with delayed enhancement cardiac magnetic resonance imaging (DE-CMR) in the same segment in 4/16 patients in the GVT group. It correlated with an affected segment on either DE-CMR or 18FDG positron emission computed tomography in 4/11 patients in the GVT group who had both imaging modality. Whenever fQRS was present in contiguous leads other than the inferior leads, it always corresponded to an affected segment on imaging.

Conclusions

In patients presenting with SMVT and no structural heart disease, the presence of fQRS is strongly associated with granulomatous myocarditis. fQRS on the surface ECG is a helpful tool the presence of which should prompt a CMR for a definitive diagnosis.     

Serial changes in systolic and diastolic echocardiographic indices as predictors of outcome in patients with decreased left ventricular ejection fraction.

BACKGROUND: Echocardiographic estimation of left ventricular ejection fraction aids in predicting adverse outcomes in coronary artery disease. However, in patients with impaired left ventricular function, further risk stratification is difficult. METHODS: A 2 year retrospective review was performed to identify patients with ejection fraction < or=30%. Echocardiographic measures of systolic and diastolic function were independently performed offline. Outcome information, which included MI, stroke, or death, was obtained. The patient cohort identified those with follow-up having 1) a single echocardiogram and a subset 2) with an initial echocardiogram and a second echocardiogram at greater than one year follow-up. RESULTS: This study included 110 patients, ages 20-94. Mean follow-up time was 29+/-9 months. Ejection fraction did not predict cardiovascular events. LV mass predicted of mortality (p=0.03). Diastolic indexes of mitral inflow E wave was a significant predictor of outcome (p=0.05). Impaired diastolic filling grade 2, 3, or 4 showed a 76% event rate. Decreases in ejection fraction at follow-up were seen in those who had an event, with an average decrease in ejection fraction of 17% versus those who lived with no event of 1%. Changes in mitral inflow E wave and changes in E/A ratio were both significant predictors of outcome. CONCLUSIONS: These data indicate that echocardiographic measures of both systolic and diastolic function aid in risk stratifying patients with decreased ejection fraction. The changed detected in serial echocardiographic information may be important in treatment and secondary prevention of future events.     

Left ventricular geometry and survival in patients with normal left ventricular ejection fraction

In hypertensive populations, left ventricular (LV) geometry, which is characterized by hypertrophy, predicts cardiovascular outcome. The left ventricle can also alter its shape by concentric remodeling (CR) in the absence of LV hypertrophy, a feature that is detected by echocardiography. This study assessed the prevalence and prognostic significance of various forms of LV geometry and changes in LV geometry over time in patients with normal LV systolic function. Retrospective analysis of a large clinical population (n = 35,602) that was referred for echocardiography was done, with all-cause mortality as the primary outcome. Abnormal LV geometry was identified in 46% of patients, with CR present in 35% (n = 12,362) and LV hypertrophy in 11% (n = 3,958). Patients with abnormal LV geometry were older and more obese compared with subjects with normal LV geometry. There was a strong relation between abnormal LV geometry and mortality, and patients with CR and LV hypertrophy exhibited considerably higher relative risk for all-cause mortality compared with subjects with normal LV geometry (relative risk [RR] 1.99, 95% confidence interval [CI] 1.88 to 2.18, p <0.0001; RR 2.13, 95% CI 1.89 to 2.40, p <0.0001, respectively). Subjects with CR who reverted to a normal geometric pattern had improved survival (RR 0.64, 95% CI 0.42 to 0.97, p = 0.03) compared with those who progressed to LV hypertrophy (RR 1.54, 95% CI 1.01 to 2.47, p = 0.05). In conclusion, CR, a form of cardiac adaptation, is frequently noted in patients with normal LV ejection fractions and confers a risk of death similar to that of LV hypertrophy. Normalization of CR is associated with better survival, whereas transition to LV hypertrophy increases mortality.     

特发性室性期前收缩患儿早搏负荷和早搏指数与左室射血分数的相关性

目的 探讨特发性室性期前收缩(IPVC)患儿早搏负荷和早搏指数与左室射血分数(LVEF)的相关性。方法 对就诊的60例IPVC患儿按照下列分组。根据早搏负荷将60例IPVC患儿分为早搏负荷6%~10%组,早搏负荷11%~25%组和早搏负荷>25%组;按早搏指数将60例IPVC患儿分为早搏指数≥0.85组和早搏指数<0.85组。对各亚组的LVEF进行统计分析。结果 早搏负荷>25%组的LVEF显著低于早搏负荷6%~10%组(P<0.01);早搏指数<0.85组的LVEF显著低于≥0.85组(P<0.01)。结论 早搏负荷与LVEF呈负相关,早搏指数与LVEF呈正相关。     

Chronic heart failure with preserved left ventricular ejection fraction: diagnostic and prognostic value of left atrial size

BACKGROUND: Almost 40% of patients with heart failure (HF) have preserved left ventricular (LV) ejection fraction (EF) and prognosis similar to those with reduced EF. Data on prognostic markers in such patients are limited. We analyzed the prevalence and prognostic value of left atrial (LA) size in this condition. METHODS: 89 normal subjects (Group I), 38 asymptomatic hypertensive patients (Group II) and 183 HF patients with preserved EF (EF >45%) (Group III) were studied. LA diameter (LAD), LV diastolic (LVD) and systolic (LVS) dimensions and mass (LVmass) and EF were measured. E and A wave velocities and E/A were measured. The primary end point was all cause mortality in group III patients. RESULTS: Groups did not differ in age, gender or EF. Group III patients had larger LAD (4.6+-1.0 cm) compared with both Group I (3.7+/-0.6) and Group II (3.7+/-0.5 cm) (p<0.0001). A markedly enlarged (arbitrarily defined as LAD higher or equal 5 cm) had an odds ratio of 34 (95% CI 8-144) in distinguishing HF patients from normals. After a mean follow-up period of 29+/-27 months, 40 patients (21.9%) died. In Cox univariate analysis, NYHA class (HR 2.8 95% C.I. 1.8-4.3; p<0.0001), diastolic blood pressure (DBP) (HR 0.92 95% C.I. 0.88-0.96; p<0.0001), age (HR 1.059 95% C.I. 1.01-1.11; p=0.02) and LAD (HR 1.72 95% C.I. 1.27-2.3; p=0.0005) were predictors of mortality. LAD predicted survival independently of other variables. CONCLUSION: The left atrium is frequently dilated in HF patients compared with controls despite similar EF. LAD showed powerful prognostic value independent of clinical variables.     

AHFREF和AHFPEF患者远期预后情况观察

目的：观察射血分数降低的急性心力衰竭（Heart failure with reduced left ventricular ejection fraction, AHFREF）和射血分数保留的急性心力衰竭（Heart failure with preserved left ventricular ejection fraction, AHFPEF）远期预后,并分析影响预后的危险因素。方法 选取我院急诊科2013年3月至2014年3月收治的首次入院的急性心力衰竭患者280例,根据左室射血分数（left ventricular ejection fraction, LVEF）将患者分为两组：AHFREF组,LVEF<50%,n=152;AHFPEF组,LVEF≥50%,n=128例。记录所有患者性别、年龄、左心房扩大、左心室扩大、Killip分级为IV级和急性冠脉综合征（Acute coronary syndrome, ACS）等发病率,以及吸烟史、高血压和糖尿病等合并症、心房颤动等发生率,并记录血尿酸水平、超敏C反应蛋白（high-sensitivity C-reactive protein, hs-CRP）、脑钠肽前体（pro-brain natriuretic peptide, BNP）水平。所有患者均随访3年,记录随访期内心血管源性再住院率及病死率。采用非条件Logistic回归分析影响患者再住院的危险因素,并采用多因素Cox回归分析影响患者生存时间的预后因素。结果 AHFREF组患者左心室扩大、高血压、ACS、尿酸>30umol/l、BNP>220mg/l、hs-CRP>10mg/l发生率显著高于AHFPEF组（P<0.05）;AHFREF组患者因ACS再住院率及总再住院率均高于AHFPEF组（P<0.05）。非条件Logistic回归分析发现高血压、血尿酸、血BNP、血hs-CRP 是影响急性心力衰竭患者再住院的危险因素（P<0.05）。多因素Cox回归分析发现高血压、血尿酸、血BNP、血hs-CRP是影响患者生存期的影响因素（P<0.05）。结论 AHFREF患者3年内远期预后低于AHFPEF患者,高血压、高尿酸、高hs-CRP和高BNP水平是影响急性心力衰竭患者再住院和生存期的独立危险因素。