Combining blood flow and tissue Doppler imaging with N-terminal pro-type B natriuretic peptide for risk stratification of clinically stable patients with systolic heart failure

Abstract

AimsThis study was designed to ascertain whether the combination of Doppler assessment of the ratio of mitral blood flow to myocardial early diastolic velocities (E/E m ratio) and plasma N-terminal pro-type B natriuretic peptide (NT-proBNP) testing is useful to better stratify patients with stable systolic heart failure (HF). Methods and resultsA total of 362 outpatients with chronic systolic HF (left ventricular ejection fraction 45%) underwent clinical assessment, NT-proBNP testing, and comprehensive echo-Doppler study. The endpoint was all-cause mortality or HFrelated hospital admissions (i.e. hospitalization for worsening HF, biventricular pacemaker implantation, or mitral valve surgery). Median follow-up duration was 25 months. Two hundred and fifty-nine patients were judged clinically stable by a Framingham's criteria-based HF score. In multivariate Cox's proportional hazards analysis, plasma NTproBNP (P , 0.0001) and E/E m ratio (P ¼ 0.04) were among the significant predictors of the combined endpoint. Survival free from cardiac mortality and HF-related hospitalization was 55% in patients with the E/E m ratio in the higher third (12), 77% in those with the E/E m ratio in the intermediate third, and 86% in those with the E/E m ratio in the lower third (7) (P , 0.0001). By stratifying patients according to NT-proBNP above the median, patients' outcome was predicted in 13 out of 17 in the intermediate third (P ¼ 0.002) and in 9 out of 10 in the lower third of E/E m ratio (P ¼ 0.005). ConclusionIn patients with stable HF categorized according to the E/E m ratio, NT-proBNP testing improves risk stratification, particularly in those with minor degrees of diastolic dysfunction.--

The Role of Natriuretic Peptides for the Diagnosis of Left Ventricular Dysfunction

“…This suggests that diastolic stretch is one of the major determinants of NP induction [34]. Finally, in a more recent study that compared BNP levels with venous pressure, capillary wedge pressure, and diastolic filling pattern, evaluated by echo, authors showed that as BNP cutoff >400 pg/mL is able to identify patients with higher wedge pressure, it correlates well with all hemodynamic parameters [35]. …”

The potential value of integrated natriuretic peptide and echo-guided heart failure management

“…We need a better way to titrate and personalize therapy in our HF patient (Table  2). It is up to the cardiology and echocardiography community to build the missing evidence required to shift the practice of HF from art of clinicians to evidence- based tailored and individualized treatment of HF guided by low cost portable radiation-free imaging techniques [39,40]. …”

Combining echo and natriuretic peptides to guide heart failure care in the outpatient setting: A position paper

“…The value of integrated NPs and echo‐guided management of outpatients with chronic HF can be established when this strategy will be prospectively compared with the standard of care . In a recent retrospective study, we observed a greater survival benefit in patients in the echo‐ and BNP‐guided group than in a clinically guided group (Figure ).…”