How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure

Daniels, Lori B.; Clopton, Paul; Bhalla, Vikas; Krishnaswamy, Padma; Nowak, Richard M.; McCord, James; Hollander, Judd E.; Duc, Philippe; Omland, Torbjørn; Storrow, Alan B.; Abraham, William T.; Wu, Alan H.B.; Steg, Philippe Gabríel; Westheim, Arne; Knudsen, Cathrine Wold; Perez, Alberto; Kazanegra, Radmila; Herrmann, Howard C.; McCullough, Peter A.; Maisel, Alan S.

doi:10.1016/j.ahj.2005.10.011

Cited by 242 publications

(192 citation statements)

References 26 publications

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“…Although exclusion of patients with renal dysfunction in the study by Mahla et al [15] may have decreased the adverse cardiac event rate secondary to a decrease in cardiac clinical risk factors [16], this would not have adversely affected the sensitivity or specificity of the test [1] in their study. Finally, there is an inverse relationship between an increasing body mass index and the optimal discrimination threshold for BNP [19]. This may be an important confounder in vascular patients, as it is well documented that abdominal obesity is an independent predictor of acute MI in medical patients [20].…”

Section: ó 2008 the Authorsmentioning

confidence: 99%

A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

Rodseth¹,

Padayachee²,

Biccard

2008

Anaesthesia

114

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SummaryWe conducted a meta-analysis of the utility of pre-operative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide in predicting early (< 30 days) and intermediate (< 180 days) term mortality and major adverse cardiac events (cardiac death and nonfatal myocardial infarction) in patients following vascular surgery. A Pubmed Central and EMBASE search was conducted up to January 2008. Of 81 studies identified, seven prospective observational studies were included in the meta-analysis representing five patient cohorts: early outcomes (504 patients) and intermediate-term outcomes (623 patients). A B-type natriuretic peptide or N-terminal-pro B-type natriuretic peptide above the optimal discriminatory threshold determined by receiver operating characteristic curve analysis was associated with 30-day cardiac death (OR 7.6, 95% CI 1.33-43.4, p = 0.02), nonfatal myocardial infarction (OR 6.24, 95% CI 1.82-21.4, p = 0.004) and major adverse cardiac events (OR 17.37, 95% CI 3.31-91.15, p = 0.0007), and intermediate-term, all-cause mortality (OR 3.1, 95% CI 1.85-5.2, p < 0.0001), nonfatal myocardial infarction (OR 2.95, 95% CI 1.17-7.46, p = 0.02) and major adverse cardiac events (OR 3.31, 95% CI 2.1-5.24, p < 0.00001). B-type natriuretic peptide and N-terminal-pro B-type natriuretic peptide are potentially useful pre-operative prognostic tests in vascular surgical patients. Vascular surgery is associated with major adverse perioperative cardiac events. Unfortunately, the currently used pre-operative diagnostic tests for these patients are not statistically robust enough to accurately predict these events [1]. This was recently confirmed in a meta-analysis of six pre-operative tests for vascular surgical patients, which included: ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy, dipyridamole stress echocardiography and dobutamine stress echocardiography [2]. Dobutamine stress echocardiography had a trend to the best performance of the six tests for the prediction of major adverse cardiac events (defined as peri-operative cardiac death and nonfatal myocardial infarction (MI)) within 30 days of surgery [2], with a positive likelihood ratio (LR) and negative LR of 2.8 and 0.21 respectively. As statistically good discrimination requires a LR of < 0.2 and > 10, there are clearly clinical limitations to the utility of these pre-operative tests for vascular surgical patients [1].There has been recent interest in brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) as prognostic biomarkers of death and major cardiovascular events, even after control for other cardiovascular risk factors [3]. BNP is an

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Section: ó 2008 the Authorsmentioning

confidence: 99%

A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

Rodseth¹,

Padayachee²,

Biccard

2008

Anaesthesia

114

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“…The mechanisms behind lower circulating BNP levels in obese patients are unclear, but may include decreased production combined with increased clearance of BNP. Nevertheless, some investigators have suggested significantly lower BNP cut-off values in obese patients to indicate the presence of CHF, although there has been no consensus on which levels are appropriate (43).…”

Section: Bnp Versus Nt-probnpmentioning

confidence: 99%

Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: Review of the literature and clinical recommendations

Dokainish¹

2007

Canadian Journal of Cardiology

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Dyspnea is a common presenting symptom in patients seeking medical attention. However, determining the exact cause of dyspnea in a given patient can prove to be difficult, especially in patients with a noncardiac cause of dyspnea in the setting of known cardiac disease. Although invasively measured left ventricular (LV) filling pressure is the reference standard for establishing that pulmonary venous pressure elevation is contributing to symptoms of dyspnea in a given patient, it is not clinically feasible to subject all patients presenting with dyspnea to cardiac catheterization. Therefore, noninvasive methods of estimating LV filling pressures -B-type natriuretic peptide (BNP) measurement and the tissue Doppler (TD)-derived transmitral early diastolic/annular velocity ratio (E/Ea) -have attracted attention. Both BNP and mitral E/Ea possess important strengths and limitations. Therefore, in certain clinical scenarios, combining these indexes is superior to using either in isolation. However, there has been, to date, no clear consensus on the optimal clinical use of BNP and E/Ea in patients presenting with dyspnea. Therefore, the present paper comprehensively reviews the current literature on BNP and E/Ea, and makes clinical recommendations on the optimal use of these variables in patients with dyspnea and suspected congestive heart failure (CHF). A BRIEF HISTORY OF TD IMAGINGTD imaging of the heart is a Doppler technique that measures the frequency of ultrasound returning from moving myocardium to estimate the velocity of the myocardial wall. In 1989, Isaaz et al (1) were the first to describe clinical applications of TD in cardiac disease, demonstrating that low myocardial velocities at the posterior mitral annulus correlated with abnormal posterior wall motion on LV angiography. Gulati et al (2) demonstrated in 1996 that TD systolic mitral annular velocities correlated with global LV ejection fraction (EF), as assessed by radionuclide ventriculography. It was then shown that TD-derived Ea correlated with the invasively measured LV time constant of relation (Tau), establishing Ea as a relatively load-independent measure of myocardial Consequently, mitral E/Ea can help to establish the presence of clinical congestive heart failure in patients with dyspnea. However, E/Ea has a significant 'gray zone', and is not well validated in nonsinus rhythm and mitral valve disease. B-type natriuretic peptide (BNP) is a protein released by the ventricles in the presence of myocytic stretch, and has been correlated to LV filling pressure and, independently, to other cardiac morphological abnormalities. In addition, BNP is significantly affected by age, sex, renal function and obesity. Given its correlation with multiple cardiac variables, BNP has high sensitivity, but low specificity, for the detection of elevated LV filling pressures. Taking into account the respective strengths and limitations of BNP and mitral E/Ea, algorithms combining them can be used to more accurately estimate LV filling pressures in patients presenti...

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“…Univariable linear regression analysis was performed separately for Caucasians and Asians with NT‐proBNP as the dependent variable. Multivariable adjustment was then performed for factors known to influence NT‐proBNP levels including age, sex, body mass index (BMI), LVEF, New York Heart Association class, previous myocardial infarction, systolic blood pressure, a history of atrial fibrillation, and eGFR 19, 20, 21, 22, 23, 24…”

Section: Methodsmentioning

confidence: 99%

N‐terminal pro‐B‐type natriuretic peptide and prognosis in Caucasian vs. Asian patients with heart failure

et al. 2018

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AimsN‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) is the most frequently used biomarker in heart failure (HF), but its prognostic utility across ethnicities is unclear.Methods and resultsThis study included 546 Caucasians with HF from the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure and 578 Asians with HF from the Singapore Heart Failure Outcomes and Phenotypes study. NT‐proBNP was measured at discharge after HF hospitalization. The studied outcome was a composite of all‐cause mortality and HF hospitalization at 18 months. Compared with Caucasian patients, Asian patients were younger (63 ± 12 vs. 71 ± 11 years); less often female (26% vs. 39%); and had lower body mass index (26 vs. 27 kg/m2), better renal function (61 ± 37 vs. 54 ± 20 mL/min/1.73 m2), lower rates of atrial fibrillation (25% vs. 46%), strikingly higher rates of diabetes (59% vs. 30%), and higher rates of hypertension (76% vs. 44%). Despite these clear inter‐group differences in individual drivers of NT‐proBNP, average levels were similar in Asians [2709 (1350, 6302) pg/mL] and Caucasians [2545 (1308, 5484) pg/mL] (P = 0.514). NT‐proBNP was strongly associated with outcome [hazard ratio 1.28 (per doubling), 95% confidence interval 1.18–1.39, P < 0.001], regardless of ethnicity (P interaction = 0.719). NT‐proBNP was similarly associated with outcome in HF with reduced and preserved ejection fraction in Asian (P interaction = 0.776) and Caucasian patients (P interaction = 0.558).ConclusionsNT‐proBNP has similar prognostic performance in Asians and Caucasians with HF despite ethnic differences in known clinical determinants of plasma NT‐proBNP.

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How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure

Cited by 242 publications

References 26 publications

A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: Review of the literature and clinical recommendations

N‐terminal pro‐B‐type natriuretic peptide and prognosis in Caucasian vs. Asian patients with heart failure

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