B-type natriuretic peptide (BNP) – application in differential diagnosis of dyspnoea

Czech version

Authors: R. Bejšovec; I. Jokl
Published in: Vnitř Lék 2005; 51(6): 658-663
Category: Original Contributions

Overview

Objective:
To assess the benefit of determination of B-type natriuretic peptide (NT-pro BNP) in differential diagnosis of dyspnoea (differentiation of dyspnoea associated with myocardial affection from other type of dyspnoea) in settings of our admission internal outpatient clinic of the hospital Na Františku.

Patient population:
We have enrolled 68 patients (37 women and 31 men) of an average age of 75.2 years complaining of dyspnoea during preliminary examination at the outpatient clinic in the study.

Procedures:
We have drawn blood samples from patients immediately on admission for an immediate examination (statim) with complete biochemical profile including levels of NT-pro BNP. During hospitalisation we completed a variety of examinations, which were essentially necessary to the establishment of final diagnosis. On the basis of examinations performed and their results we divided patients into three groups: I.a – patients with cardiac aetiology of dyspnoea without LV dysfunction, I.b – patients with cardiac aetiology of dyspnoea with LV dysfunction, II. – patients with non-cardiac aetiology of dyspnoea (control group). Results: 68 probands were examined in total. 51 patients with cardiac aetiology of dyspnoea were enrolled in the first group, 17 patients with non-cardiac aetiology of dyspnoea were enrolled in the second group (controls). Mean value of NT-pro BNP in the first group was 9,198.45 ng/l, standard deviation was 10,596.1; in the second group with non-cardiac diagnosis the mean value of NT-pro BNP was 304.1 ng/l, standard deviation was 566.64. Relatively higher value of NT-pro BNP in non-cardiac group compared to literature sources (norm in men is up to 100 ng/l and in women up to 150 ng/l) [15,23,26] was influenced by one patient with decompensated liver cirrhosis, mean value of NT-pro BNP was 2,519.0 ng/l, and by the relatively small number of patients in control group. Nevertheless mean values of NT-pro BNP in the group with cardiac aetiology of dyspnoea are statistically significantly higher than in the control non-cardiac group (p < 0.01). In the follow-up we focused on the subgroup formed by patients with left ventricular dysfunction. We divided patients into 3 groups based on NYHA classification and we compared values of NT-pro BNP with results of echocardiographic examinations we performed during hospitalisation in our hospital in two days after the admission. We noticed statistically significant increase of NT-pro BNP in the relationship to NYHA classification (correlation coefficient 0.41). We found that the value of NT-pro BNP significantly correlates with left ventricular ejection fraction (correlation coefficient 0.46). In NYHA II group the mean LVEF was 43.75%, mean value of NT-pro BNP was 1,167.3 ng/l; in NYHA III group the mean LVEF was 38.70% and the mean value of NT-pro BNP was 4276.5 ng/l; in NYHA IV group the mean value of LVEF was 31.20% and the mean value of NT-pro BNP was 19,581.2 ng/l.

Conclusions:
The determination of natriuretic peptides is simple method, which belongs among essential parts especially in diagnosis of advanced forms of heart failure. The great advantage of this method is its availability, good reproducibility, high negative predictive value and independence on the presence of qualified specialist. The determination of NT-pro BNP became an important helper in stratification of patients coming with dyspnoea and markedly helps and advances the decision making process of the proper therapeutic approach.

Key words:
B-type natriuretic peptide – dyspnoea – differential diagnosis of dyspnoea – left ventricular ejection fraction

Sources

1. Widimský J sn. Selhání srdce. 2. ed. Praha: Triton 1999: 18–19.

2. Hughes D, Talwar S, Squire IB. An imunoluminometric assay for N-proBNP. Clin Sci 1999; 276: 1049–1057.

3. Groenning BA, Raymond I, Pedersen JC et al. N-terminal pro brain natriuretic peptide concentrations in the diagnosis of heart failure in the general population. European Journal of Heart Failure 2001; 3(Suppl 1).

4. Engliš M, Jabor A. Natriuretické peptidy v diagnostice, stanovení prognózy a optimalizaci léčby srdeční dysfunkce a srdečního selhání. Labor Aktuell 2001; 4: 4–8.

5. Masson S, Vago T, Baldi G et al. Comparative measurement of N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in ambulatory patients with heart failure. Clin Chem Lab Med 2002; 40: 761–763.

6. Nomura H, Hayyashi T, Esaki T et al. Standardization of plasma brain natriuretic peptide concentrations in older Japanese – relationship to latent renal dysfunction and ischemic heart disease. J Am Geriatr Soc 2002; 50: 1504–1509.

7. Huang C et al. Increased brain natriuretic peptide and atrial peptide plasma concentrations in dialysis–dependent chronic renal failure and in patients with elevated left ventricular filling pressure. Clin Investig 1994; 72: 430–434.

8. Harrison A, Morrison LK, Krisnaswamy P et al. B-type natriuretic peptide predicts future cardiac events in patients presenting to the emergency department with dyspnea. Emerg Med 2002; 39: 131–138.

9. Tulevski II, Hirsch A, Sanson BJ et al. Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost 2001; 86: 1193–1196.

10. Refsgaard J, Andreasen F, Gotzsche A et al. Plasma brain natriuretic peptide to predict haemodynamic changes of treatment with carvedilol in patients with congestive heart failure. European Journal of Heart Failure 2001; (Suppl 1).

11. Cabanes L, Richaud-Thiriez B, Fulla Y et al. Brain natriuretic peptide blood levels in the differential diagnosis of dyspnea. Chest 2001; 120: 2047–2050.

12. Nagaya N, Nishikimi T, Uematsu M et al. Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension. Circulation 2000; 102: 865–870.

13. Azevedo A, Frioes F, Pimenta J et al. Predictors of neuro-humoral response to therapeutic interventionsin heart failure. European Journal of Heart Failure 2001; 3(Suppl 1).

14. Feola M, Vado A, Deorsola A et al. The brain natriuretic peptide plasma level is correlated with VO2max and O2 pulse in patients with congestive heart failure European Journal of Heart Failure 2001; 3(Suppl 1).

15. Maisel A. Measurement of B–type natriuretic peptide levels can help differentiate pulmonary from cardiac causes of acute dyspnoea. J Am Coll Cardiol2002; 39: 202–209.

16. Deary AJ, Schumann AL, Murfet H et al. Influence of drugs and gender on the arterial pulse wave and natriuretic peptide secretion in untreated patients with essential hypertension. Clin Sci 2002; 103: 493–499.

17. Sagnella GA. Measurement and importance of plasma brain natriuretic peptide and related peptides. Ann Clin Biochem 2001; 38: 83–93.

18. Cheng V et al. A Rapid Bedside Test for B-Type Peptide Predicts Treatment Outcomes in Patients Admitted for Decompensated Heart Failure: A Pilot Study. J Am Coll Cardio 2001; 37: 386–391.

19. Stejskal D et al. Vlastní zkušenosti s využitím stanovení NT-proBNP v klinické praxi. Vnitř Lék 2003; 49(2): 121–126.

20. Kölbel F et al. B–typ natriuretického peptidu v diferenciální diagnostice dušnosti: užitečná pomůcka nebo nevýznamná ozdoba? Vnitř Lék 2003; 49(2): 94–96.

21. Dao Q et al. Utility of B-Type Natriuretic Peptide in the Diagnosis of Congestive Heart Failure in an UrgeNT-Care Setting. J Am Coll Cardiol 2001; 37: 379–385.

22. Oral I et al. Natriuretické peptidy – současný stav klinického využití jejich stanovení. Vnitř Lék 2003; 49(8): 521–523.

23. Morrison LK et al. Utility of a rapid Bnatriuretic Peptide Assay in Differentiating Congestive Heart Failure from Lung Disease in Patients Presenting with Dyspnea. J Am Coll Cardiol 2002; 39: 202–209.

24. Hradec J. Mohou se stát natriuretické peptidy křišťálovou koulí kardiologa? JACC–CZ 2003; 5: 255–257.

25. Málek F. Natriuretické peptidy. Remedia 2002; 12: 146–149.

26. Staněk V. Kardiologie a biochemie. Znamenají natriuretické peptidy novou éru v diagnostice a kontrole léčby srdečního selhání. Cor Vasa 2002; 44: 504–505.

27. Špinarová L, Toman J. Humorální změny u chronického srdečního selhání. Cor Vasa 2001; 43: 513–519.