NT-proBNP in heart failure: therapy decisions and monitoring

With increasing cardiac dysfunction, a complex neurohormonal response results in increasing circulating levels of an array of plasma hormones. Increments in plasma levels of atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) and their amino-terminal congeners are more closely related to cardiac structure and function and to cardiovascular prognosis than changes in other plasma neurohormones. Reports suggest that changes in plasma BNP levels in the course of treatment of acutely decompensated heart failure provide a more powerful prognostic indicator of the likelihood of survival or recurrent decompensation than symptomatic assessment. This observation requires a randomised controlled trial in which changes in peptide levels determine aggression and duration of in-patient therapy in order to establish whether this indicator can improve results from management of acute in-patient heart failure. Plasma BNP or NT-proBNP is a powerful independent predictor of mortality and morbidity in long-term follow-up of heart failure cohorts. In addition, it appears likely to be a good predictor of beneficial response to the addition of beta blockade to anti-heart failure pharmacotherapy. Finally, adjustment of therapy for heart failure according to serial measurements of NT-proBNP promises to improve outcomes in comparison with adjusting therapy according to unassisted clinical acumen.     

血浆脑钠肽水平与慢性心衰患者的左室重构和预后价值

目的探讨血浆脑钠肽（BNP）水平与慢性心衰（CHF）患者的预后价值。方法入选126例CHF患者，测定血浆BNP浓度，随访住院期间、30d和6个月的主要心脏不良事件（MACE，包括心血管病死亡、新发心衰／心衰恶化再入院）。结果126例CHF患者根据BNP四分位数水平分4组：Quarter 1：8．0-91．9ng／L；Quarter2：94．9-344．0ng／L;Quarter 3：366．0-978．0ng／L；Quarter4：998．0-5000．0ng／L。随BNP水平的升高，各组MACE发生率明显增加。通过多变量logistic回归分析，BNP是独立于年龄、左室质量指数（LVMI）、左室舒张期内径指数（LVIDdI）、左室射血分数（LVEF）等危险因素之外的CHF预后因素，可预测30d和6个月MACE发生（r分别为0．769和0．831，P〈0．01）。BNP预测6个月MACE发生的ROC曲线下面积为0．851（95％C10．778—0．924，P〈0．01）。结论BNP水平能很好地对CHF患者进行危险分层，是CHF患者近期临床预后的较好指标。     

Incremental prognostic value of changes in B-type natriuretic peptide in heart failure

Purpose

B-type natriuretic peptide is one of the most sensitive and specific biohumoral markers of heart failure. We hypothesized that B-type natriuretic peptide changes during treatment of heart failure may provide independent information on disease progression and outcome in patients enrolled in the Val-HeFT trial.

Methods

Patients were divided into four groups according to concentrations of B-type natriuretic peptide at baseline versus 4 months (n = 3740) or 12 months (n = 3343), with respect to the baseline median (97 pg/mL): low→low (stable below median, 44%-46%), high→high (stable above median, 32%-37%), high→low (above to below median, 12%-14%), and low→high (below to above median, 6%-9%). Cox multivariate regression analysis was used to assess the risk of death and morbidity, with adjustment for baseline B-type natriuretic peptide concentrations.

Results

Patients who improved their B-type natriuretic peptide at 4 months (high→low) had a similar risk for mortality (hazard ratio = 1.191, 95% confidence interval [CI] 0.870-1.631, P =.2746) compared with the low→low patients. Conversely, patients who worsened in their B-type natriuretic peptide (low→high) had a risk for mortality (hazard ratio 2.578, CI, 1.861-3.571, P <.0001) higher than patients in the low→low group, and indistinguishable from the high→high group. Worsening of B-type natriuretic peptide (low→high) was associated with 0.03 cm/m² increase in left ventricular end-diastolic diameter, whereas it decreased by 0.10 cm/m² in high→low and low→low groups (P <.001).

Conclusions

Changes in B-type natriuretic peptide over time with respect to a threshold value of 97 pg/mL convey an independent and additional prognostic value compared with a single determination of B-type natriuretic peptide in a large population of patients with chronic symptomatic heart failure and might be helpful in the management of these patients.     

肥胖对重症心力衰竭患者血浆脑钠肽水平的影响

目的探讨肥胖对重度心力衰竭患者血浆脑钠肽(BNP)水平的影响。方法纳入心功能分级为Ⅳ级的冠心病心力衰竭患者293例,采用ELISA法测定血浆BNP浓度。以体重指数(BMI)将患者分为肥胖组(BMI28 kg/m2,n=198)和非肥胖组(BMI28 kg/m2,n=95),比较两组患者BNP水平差异。结果肥胖组与非肥胖组患者比较,年龄、性别构成及左室射血分数(LVEF)、左室舒张末容积(LVEDd)水平、合并高血压病及2型糖尿病情况均差异无统计学意义(P0.05)。肥胖组血浆BNP水平(623.4±405.5 pg/ml)明显低于非肥胖组患者(948.7±607.4 pg/ml),差异具有统计学意义(P0.05)。男、女性肥胖患者、高血压、2型糖尿病肥胖患者血浆BNP水平同样低于非肥胖者,差异均具有统计学意义(P0.05)。结论心力衰竭患者BNP水平均明显增高,但肥胖患者增高程度低于非肥胖患者,临床诊断治疗中应考虑肥胖对心衰患者BNP水平的影响。     

cTnI CRP和BNP联合测定对缺血型心力衰竭患者诊断和预后的判断价值

目的探讨心肌肌钙蛋白I（cTnI）、C-反应蛋白（CRP）和B型钠尿肽（BNP）联合检测对缺血型心力衰竭（心衰）诊断和预后的判断价值。方法收集并测定98例缺血型心衰的不同心功能分级患者及95例冠心病无心衰患者血清cTnI、CRP和血浆BNP等指标,并进行比较,随访观察患者近期心脏事件再发生情况。结果心衰患者不同心功能分级组血清cTnI、CRP和血浆BNP水平与无心衰组之间差异均有统计学意义,且心功能越差,其浓度越高（ P均＜0.05）。发生心脏事件组患者出院时血清cTnI、CRP和血浆BNP浓度明显高于未发生心脏事件组（ P均＜0.05）。结论血清cTnI、CRP和血浆BNP在心衰患者中明显升高,三者联合检测对心衰患者临床诊断和预后判断有重要意义。     

Role of oral amiodarone in patients with atrial fibrillation and congestive heart failure

Background

Amiodarone is recognized as the most effective therapy for maintaining sinus rhythm (SR) post cardioversion in patients with atrial fibrillation (AF). It is also recommended for controlling AF in patients with congestive heart failure (CHF). We retrospectively examined the efficacy and safety of oral amiodarone in patients with AF and CHF.

Methods

Forty-eight consecutive AF patients whose left ventricular ejection fraction (LVEF) was less than 50% and B-type natriuretic peptide (BNP) was higher than 100 pg/ml were investigated retrospectively, and divided into 3 groups: paroxysmal AF, 16 patients; persistent AF, 9 patients; and permanent AF, 23 patients.

Results

The permanent AF group had a longer history of AF, larger left ventricular end-diastolic diameter (LVDd) and left atrial diameter (LAD) than paroxysmal and persistent AF groups (p < 0.05). After median follow-up of 265 days, amiodarone suppressed paroxysms in 88% of paroxysmal AF patients, while SR was maintained in all persistent AF patients, and 35% of permanent AF patients. Of the 32 persistent and permanent AF patients, 12 (71%) out of 17 maintained SR after successful electrical cardioversion, and conversion to SR occurred spontaneously in 5 (33%) out of 15. The effective group had significantly smaller LVDd and LAD than the ineffective group. In the effective group, BNP decreased significantly from 723 ± 566 pg/ml to 248 ± 252 pg/ml, (p < 0.0005) and LVEF increased significantly from 33 ± 7% to 50 ± 13% (p < 0.0005) during follow up, while no changes were observed in the ineffective group. The patients with low LVEF (≤30%) benefited comparably from amiodarone to the patients with LVEF >30%. Complications occurred in 24 (50%) patients leading to discontinuation of amiodarone in 11 (23%).

Conclusions

Oral amiodarone helped restore SR in paroxysmal and persistent AF patients with CHF. The successful rhythm control by amiodarone resulted in the improvement of LV function and the decrease of BNP levels.     

sST2联合NT-proBNP评估ARNI干预射血分数中间值的心力衰竭患者预后价值分析

目的 探讨可溶性生长刺激因子2(sST2)联合N末端B型利钠肽原(NT-proBNP)评估血管紧张素受体脑啡肽酶抑制剂(ARNI)沙库巴曲缬沙坦(SV)干预射血分数中间值的心力衰竭(HFmrEF)患者全因死亡和心衰再入院的预后价值.方法 入选2018年10月～2020年1月于河北大学附属医院心血管内科住院的HFmrEF...     

B型利钠肽对心力衰竭患者心源性事件的预测价值

目的:评价B型利钠肽(BNP)对左心衰竭患者的预后预测价值.方法:使用荧光免疫的方法测定心力衰竭患者的BNP,并进行随访.主要临床终点为:心源性死亡和再入院.根据随访结果将患者分为无再发事件组(162例),心源性再入院组(47例),心源性死亡组(54例).用Kaplan-Meier法计算生存率和无心脏事件生存率,多因素分析采用COX回归分析法.结果:300例患者平均随访(9.5±5.6)个月,心源性再入院组[482.0(227.0,793.0)pg/ml]及心源性死亡组[565.0(327.3,1192.5)pg/ml]的BNP水平均显著高于无再发事件组[146.5(51.7,374.3)pg/ml)(P均＜0.001).不论单因素还是多因素分析,包括年龄、性别、纽约心功能分级(NYHA)、超声心动图所测左心房前后径、左心室舒张末内径、左心室射血分数(LVEF)及Log BNP,仅Log BNP与心源性死亡时问及心源性再入院时间独立相关.当分别引入Log BNP,性别,年龄,NYHA,LVEF和左心室舒张末内径及是否伴有心房颤动、心房扑动、室性心动过速、糖尿病共10个因素,单因素分析中:Log BNP、性别、NYHA、LVEF和室性心动过速是心源性事件发生的预测因子.但进一步COX多元回归分析中,只有Log BNP(回归系数:0.9898;P=0.002)和室性心动过速(回归系数:0.893;P=0.005)是独立相关影响因素.两者中,又以Log BNP的相关性最强.根据受试者工作特征曲线(ROC),BNP 288 pg/ml为划分有无心源性事件发生的最佳阈值点.BNP≤288 pg/ml患者的无心源性事件生存时间约是＞288 pg/ml患者的两倍(18.06个月vs 9.94个月,P=0.000).结论:BNP对心力衰竭患者的预后预测价值好.Log BNP和室性心动过速是心源性死亡、再入院事件独立相关影响因素.     

Diagnostic and therapeutic approach to acute decompensated heart failure

Heart failure afflicts large numbers of patients and is the leading cause for hospitalizations in the United States. Diagnosis and management of decompensated heart failure present a clinical challenge, requiring complex decision-making. History and physical examination findings are important in the diagnosis of heart failure. Diagnostically, B-type natriuretic peptide levels appear very useful to separate cardiac from noncardiac causes of dyspnea and provide information about heart failure severity and prognosis. Immediate management goals include improvement of symptoms and hemodynamic parameters. Diuretics, vasodilators, and inotropic agents are useful in the acute setting. This article provides a systematic approach to the diagnosis and management of acute decompensated heart failure.     

The natriuretic peptides in heart failure

Abstract. Synthesis and release of the natriuretic peptides rises incrementally with increasing degrees of cardiac dysfunction. The prime stimulus is intracardiac distending pressures with modulating inuences including age, gender, renal function and other aspects of neurohormonal status. Measurements of plasma natriuretic peptide concentrations and of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide, in particular, show promise in diagnosis of heart failure, risk stratication in those with known heart disease, and in adjustment of therapy. Recombinant B-type natriuretic peptide itself can be administered as a treatment. These diagnostic, prognostic and therapeutic applications of B-type natriuretic peptide require a considerable expansion beyond current evidence, but it appears likely that the true role of plasma peptide measurements and peptide administration will become rmly established within the coming 5 year period.     

慢性阻塞性肺部疾病合并充血性心力衰竭患者B型脑钠肽的变化及临床意义

目的探讨慢性阻塞性肺部疾病（COPD）合并充血性心力衰竭（CHF）患者血浆B型脑钠肽（BNP）水平的变化及临床意义。方法选择120例COPD患者作为研究对象,其中COPD合并CHF组54例,COPD急性发作（AECOPD）组66例,选择健康体检正常者36例作为对照组,采用免疫荧光法快速测定BNP水平。比较三组间血浆BNP水平的差异。COPD合并CHF患者治疗好转后复查血浆BNP水平,比较治疗前、后血浆BNP水平的变化。结果COPD合并CHF组和AECOPD组血浆BNP水平分别为（798．41±231．64）pg／ml和（148．73±87．39）pg／ml;对照组血浆BNP水平为（46．83±15．54）pg／ml。COPD合并CHF患者与对照组及AECOPD患者比较,血浆BNP水平差异均有统计学意义（P〈0．01）;治疗后血浆BNP水平[（136．73±64．82）pg／ml]与治疗前比较明显下降（P〈0．01）。结论血浆BNP水平测定对COPD合并CHF患者有重要的鉴别诊断价值,可作为COPD合并CHF患者治疗效果的评价指标。     

脑钠肽对心力衰竭患者发生心房颤动的预测价值

目的通过测定心力衰竭(心衰)患者的血清脑钠肽(BNP)浓度,探讨BNP对心衰患者并发心房颤动(房颤)的预测价值。方法入选2010年7月至2013年12月在河南省安阳地区医院心内二科住院的心衰患者169例,152例完成随访,失访17例,其中男性79例,女性73例,年龄37~71岁,平均年龄(48±11)岁,根据随访结果将患者分为两组,房颤组(n=29)和窦性心律组(n=123)。所有患者在入选前以及随访1年均行Holter检查,同时检测患者血清BNP水平。结果随访1年后,152例患者完成随访,其中有29例患者记录到房颤。房颤组[(312.21±52.78)pg/ml]BNP水平明显高于窦性心律组[(218.24±67.45)pg/ml],差异具有统计学意义(P0.01)。多因素分析结果显示,年龄OR值为4.162,95%CI:1.521-7.132;LVEF OR值为1.027,95%CI:0.939-1.058。年龄和左室射血分数(LVEF)是心衰患者并发房颤的独立危险因素。结论血清BNP水平对心衰患者是否发生房颤有重要的预测价值。     

Using BNP to develop a risk score for heart failure in primary care.

AIMS: Chronic heart failure is a common condition with high mortality. Accurate diagnosis in primary care is difficult. Elevated B-type natriuretic peptide (BNP) is associated with left ventricular systolic dysfunction and increased mortality. Prognostic scoring systems using BNP may help to stratify risk in primary care patients. The aim of this research was to establish the independent variables which predict mortality in a primary care population-prescribed loop diuretics and to generate and validate a scoring system for heart failure in general practice. METHODS AND RESULTS: Five hundred and thirty-two patients were followed up for a mean of 6.4 years after attending a research clinic for clinical assessment, electrocardiogram (ECG), echocardiography, and BNP. Multivariate analysis was used to establish independent prognostic variables and to generate a prognostic scoring system. The score generated was [0.50 x BNP+5 x age+50 x (CVA+sex+diabetes+ECG)]. The cut-off scores for risk groups were; 25th percentile, 411; 50th percentile, 475; 75th percentile, 524; Harrell's c=0.75. CONCLUSION: Developing prognostic scoring systems provides a means of risk stratifying patients without relying on a single cut-off diagnostic value for BNP. Further validation of such scoring systems may improve future management of community heart failure patients.     

心力衰竭患者心电图QRS波时间和血浆脑钠肽值与临床心功能及预后的关系

目的评价心衰患者心电图QRS波宽度和血浆脑钠肽（BNP）与临床心功能的相关性和对预后的预测价值。方法入选282例临床明确诊断为心衰的患者,评价NYHA心功能分级,测定BNP值和心电图QRS时间,随访6个月观察死亡和再入院。结果分组方差分析提示心衰患者随着心功能恶化,其BNP的增高和QRS的增宽均具有显著意义;BNP增高和QRS增宽,心功能恶化和低左室射血分数值具有相关性;同时,多变量回归分析提示,两者都是提示死亡和再入院的独立危险因子。结论结合BNP值增高和心电图QRS波增宽能较准确地判断心衰患者的临床心功能,并预测预后不良的风险。     

血清钙离子浓度对脑钠肽评价心功能的影响

目的:探讨血清Ca2+对脑钠肽(BNP)评价心功能的影响及其机制。方法:选择急性左心功能不全患者101例,根据心功能NYHA分级及所有患者血BNP浓度中位数(793 pg/mL),将患者分为A组:心功能NYHAⅠ、Ⅱ且BNP793 pg/mL,23例;B组:心功能NYHAⅢ、Ⅳ且BNP793 pg/mL,24例。比较2组患者的左室射血分数(LVEF)、左室短轴EF值(LVFS)、左室舒张末内径(LVEDD)、室间隔缺损(IVSD)、左房内径(LA)和血BNP、钾、钠、氯、血清Ca2+、葡萄糖、尿素氮、血肌酐、血红蛋白、肌酸激酶、肌酸激酶同功酶MB、尿酸、TNT、高敏CRP。结果:全部患者LVEF(50.0±10.2)%和BNP(1037.6±1136.2)pg/mL之间存在显著负相关(r=-0.258,P0.05),A组血清Ca2+浓度明显低于B组[(1.86±0.08)mmol/L vs(2.05±0.03)mmol/L,P0.05]。结论:血清Ca2+浓度是影响BNP评价心功能的重要因素。     

NT-proBNP and BNP: biomarkers for heart failure management

Guidelines for the pharmacological treatment of heart failure (HF) are based on results from large clinical trials demonstrating benefit. State of the art pharmacological management of HF assumes that target doses should be the same as those used in trials. Thus equal doses are recommended for all in practical guidelines, but this strategy might not fit individual needs. NT-proBNP and BNP emerged as potential biomarkers of clinical interest in HF management. NT-proBNP and BNP are related to HF severity and to clinical status. NT-proBNP and BNP are strongly associated with prognosis across the whole spectrum of HF patients. A pilot study has shown that NT-proBNP-guided therapy is associated with improved outcome in HF. Although at present there are still few data to make firm recommendations on the use of NT-proBNP or BNP levels as biomarkers for HF management, future studies will provide further insight on this issue.     

血浆NT-proBNP评估舒张性心衰合并糖尿病患者预后的价值

目的：探讨血浆 N末端B型利钠肽原（NT-proBNP）评估舒张功能不全性心力衰竭（DHF）合并2型糖尿病（T2DM）患者预后的价值。方法：回顾性分析我院206例住院的 DHF合并 T2DM患者资料,依据转归结局不同分为：无事件组108例,事件组98例[发生主要心血事件（MACE）]。检测并比较两组患者住院期间 NT-proB-NP、糖化血红蛋白（HbA1c）、总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）水平以及左室舒张末期内径（LVEDd）、左室舒张早期/舒张晚期峰值流速（E/A）比值、左室射血分数（LVEF）值。结果：与无事件组相比,事件组的 NT-proBNP、LVEDd显著增加,LVEF、E/A比值明显降低（P 均＜0.05）,单因素直线分析显示 NT-proBNP、HbA1c、LVEDd、E/A比值与 MACE发生率呈正相关（r＝0.075～0.091,P均＜0.05）,多元 Logistic回归分析显示,NT-proBNP为 MACE的独立预测因子（OR＝1.003,P＝0.009）。NT-proBNP预测患者住院死亡的 ROC曲线下面积为0.803（P＜0.05）,血浆 NT-proBNP≤4010pg/ml者的生存率明显高于 NT-proBNP＞4010 pg/ml者（OR＝5.028,P＜0.05）。结论：血浆 N末端 B型利钠肽原能独立预测舒张功能不全性心力衰竭合并2型糖尿病患者的预后。     

B-型脑钠肽在慢性心衰治疗中的监测价值

目的研究血浆B-型脑钠肽(BNP)水平值在慢性心衰患者临床诊疗中的监测价值。方法选取153例慢性心衰患者分为慢性心衰组(91例)和非心衰组(62例),采取荧光酶标记的免疫学方法,检测两组受检者血浆BNP值并比较。结果慢性心衰组患者血浆中的BNP值含量明显高于非心衰组,并且BNP含量与心功能不全(CHF)的程度呈正相关性,BNP含量越高,CHF越严重。讨论揭示患者处于不同心衰阶段相对应的标准BNP值,该标准对慢性心衰患者的诊疗有一定的指导作用,并且检测血浆BNP含量的方法操作简单,特异性强,灵敏度高。