Changes in NT‑proBNP levels in patients with atrial fibrillation related to heart failure

Czech version

Authors: V. Pokorná ¹; O. Jurkovičová ¹; J. Kalužay ¹; A. Stecová ²; P. Ponťuch ¹
Authors‘ workplace: IV. interná klinika Lekárskej fakulty UK a FNsP Bratislava, Slovenská republika, Nemocnica sv. Cyrila a Metoda, prednosta prof. MUDr. Peter Ponťuch, CSc. ¹; Medirex, a. s., Bratislava, Slovenská republika, manažérka laboratórnej diagnostiky MUDr. Anna Stecová, CSc. ²
Published in: Vnitř Lék 2010; 56(8): 788-794
Category: Original Contributions

Overview

Introduction:
NT‑proBNP, a well‑established diagnostic and prognostic marker in clinical practice, is significantly elevated in individuals with atrial fibrillation (AF), even in absence of heart failure or major structural heart disease.

Objectives:
The aim of this study was to determine the cut‑off value of NT‑proBNP for diagnosis of heart failure in individuals with atrial fibrillation.

Methods:
We compared 44 patients (25 male/19 female) with AF and concomitant overt heart failure [age 76 (62–82) years; median (interquartile range – IQR)] versus 29 patients (16 male/13 female) with AF with no signs of heart failure [age 59 (50–67) years; median (IQR)]. We considered the underlying causes of heart failure and its severity, comorbidities, echocardiographic and selected laboratory parameters, the body mass index as well as the treatment at discharge. We determined the cut‑off value for heart failure and major structural heart disease using ROC curve analysis.

Results:
Median NT‑proBNP in the group of patients with AF and concomitant heart failure was 3 218 ng/l (IQR 1 758–7 480 ng/l) vs 981 ng/l (IQR 431–1 685 ng/l) in the group of patients with AF with no signs of heart failure; this difference was statistically significant (p < 0.001). The level of NT‑proBNP higher than 1 524 ng/l in patients with AF was diagnostic of major structural heart disease and pointed towards a possible heart failure (sensitivity 80%, specificity of 76%, accuracy 78%, positive predictive value 83%, negative predictive value 71%). The NT‑proBNP levels significantly correlated with age (p < 0.001), left atrial diameter (p < 0.01) and furosemide dose at discharge (p < 0.05). The NT‑proBNP levels significantly negatively correlated with left ventricular ejection fraction (p < 0.001) and body mass index (p < 0.05).

Conclusion:
We found out that NT‑proBNP is significantly elevated in patients with AF with preserved left ventricular function and in absence of heart failure and significantly correlates with age, left ventricular ejection fraction, left atrial diameter, body mass index and the furosemide dose necessary to achieve cardiac compensation. Furthermore, we determined the NT‑proBNP cut‑off value predictive of a possible heart failure in patients with AF.

Key words:
atrial fibrillation – NT‑proBNP – heart failure

Sources

1. Baxter GF. The natriuretic peptides. Basic Res Cardiol 2004; 99: 71–75.

2. Richards AM. The natriuretic peptides in heart failure. Basic Res Cardiol 2004; 99: 94–100.

3. Latini R, Masson S, Anand I et al. The comparative prognostic value of plasma neurohormones at baseline in patients with heart failure enrolled in Val‑HeFT. Eur Heart J 2004; 25: 292–299.

4. de Lemos JA, Morrow DA, Bentley JH et al. The prognostic value of B‑type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med 2001; 345: 1014–1021.

5. Richards AM, Nicholls MG, Yandle TG et al. Plasma N‑terminal pro‑brain natriuretic peptide and adrenomedullin: new neurohormonal predictors of left ventricular function and prognosis after myocardial infarction. Circulation 1998; 97: 1921–1929.

6. Omland T, Persson A, Ng L et al. N‑terminal pro‑B‑type natriuretic peptide and long‑term mortality in acute coronary syndromes. Circulation 2002; 106: 2913–2918.

7. Buob A, Jung J, Siaplaouras S et al. Discordant regulation of CRP and NT‑proBNP plasma levels after electrical cardioversion of persistent atrial fibrillation. Pacing Clin Electrophysiol 2006; 29: 559–563.

8. Burke MA, Cotts WG. Interpretation of B‑type natriuretic peptide in cardiac disease and other comorbid conditions. Heart Fail Rev 2007; 12: 23–36.

9. Wijbenga JA, Balk AH, Boomsma F et al. Cardiac peptides differ in their response to exercise. Implications for patients with heart failure in clinical practice. Eur Heart J 1999; 20: 1424–1428.

10. Ordonez‑Llanos J, Collinson PO, Christenson RH. Amino‑terminal pro‑B‑type natriuretic peptide: analytic considerations. Am J Cardiol 2008; 101: 9–15.

11. Kalužay J, Pokorná V, Nechojdoma J et al. Diagnostika srdcového zlyhávania v bežnej klinickej praxi – nezastupiteľný prínos stanovenia nátriuretických peptidov. Interná Med 2008; 8: 110–113.

12. Januzzi JL Jr, Camargo CA, Anwaruddin S et al. The N‑terminal Pro‑BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005; 95: 948–954.

13. Vytiska M, Kala P, Klabenešová I et al. Faktory se vztahem k hodnotám NT‑proBNP u hemodynamicky stabilních pacientu s normální systolickou funkcí levé komory. Vnitř Lék 2008; 54: 150–155.

14. Januzzi JL, van Kimmenade R, Lainchbury J et al. NT‑proBNP testing for diagnosis and short‑term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT‑proBNP Study. Eur Heart J 2006; 27: 330–337.

15. Januzzi JL Jr, Chen‑Tournoux AA, Moe G. Amino‑terminal pro‑B‑type natriuretic peptide testing for the diagnosis or exclusion of heart failure in patients with acute symptoms. Am J Cardiol 2008; 101: 29–38.

16. Pokorná V, Jurkovicová O. Diferenciálna diagnóza zvýšených hladín NT‑proBNP. Cardiol 2009; 18: 263–270.

17. Thejus J, Francis J. N‑terminal pro‑brain natriuretic peptide and atrial fibrillation. Indian Pacing Electrophysiol J 2009; 9: 1–4.

18. Shin DI, Jaekel K, Schley P et al. Plasma levels of NT‑pro‑BNP in patients with atrial fibrillation before and after electrical cardioversion. Z Kardiol 2005; 94: 795–800.

19. Danicek V, Theodorovich N, Bar‑Chaim S et al. Sinus rhythm restoration after atrial fibrillation: the clinical value of N‑terminal pro‑BNP measurements. Pacing Clin Electrophysiol 2008; 31: 955–960.

20. Möllmann H, Weber M, Elsässer A et al. NT‑ProBNP predicts rhythm stability after cardioversion of lone atrial fibrillation. Circ J 2008; 72: 921–925.

21. Badgett RG, Lucey CR, Mulrow CD. Can the clinical examination diagnose left‑sided heart failure in adults? JAMA 1997; 277: 1712–1719.

22. Dickstein K, Cohen‑Solal A, Filippatos G et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008; 10: 933–989.

23. Shelton RJ, Clark AL, Goode K et al. The diagnostic utility of N‑terminal pro‑B‑type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation. Eur Heart J 2006; 27: 2353–2361.

24. Ricós C, Alvarez V, Cava F et al. Current databases on biological variation: pros, cons and progress. Scand J Clin Lab Invest 1999; 59: 491–500.

25. Špinar J, Janský P, Kettner J et al. Doporučení pro diagnostiku a léčbu akutního srdečního selhání. Cor Vasa 2006; 48: K3–K31.

26. Corell P, Gustafsson F, Kistorp C et al. Effect of atrial fibrillation on plasma NT‑proBNP in chronic heart failure. Int J Cardiol 2007; 117: 395–402.

27. Hwang HJ, Son JW, Nam BH et al. Incremental predictive value of pre‑procedural N‑terminal pro‑B‑type natriuretic peptide for short‑term recurrence in atrial fibrillation ablation. Clin Res Cardiol 2009; 98: 213–218.

28. Mehra MR, Uber PA, Park MH et al. Obesity and suppressed B‑type natriuretic peptide levels in heart failure. J Am Coll Cardiol 2004; 43: 1590–1595.

29. Wang TJ, Larson MG, Levy D et al. Impact of obesity on plasma natriuretic peptide levels. Circulation 2004; 109: 594–600.

30. Jessup M, Abraham WT, Casey DE et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119: 1977–2016.

31. Felker GM, Hasselblad V, Hernandez AF et al. Biomarker‑guided therapy in chronic heart failure: a meta‑analysis of randomized controlled trials. Am Heart J 2009; 158: 422–430.

32. Málek I, Hegarová M, Lupínek P et al. Sledování dynamiky B‑natriuretického peptidu může zásadně ovlivnit volbu léčebného postupu u pacienta se srdečním selháním. Cor Vasa 2009; 51: 45–48.

33. Gage BF, Waterman AD, Shannon W et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285: 2864–2870.

34. Al‑Omari MA, Finstuen J, Appleton CP et al. Echocardiographic assessment of left ventricular diastolic function and filling pressure in atrial fibrillation. Am J Cardiol 2008; 101: 1759–1765.