N-Terminal Pro-Brain Natriuretic Peptide

Abstract

Abstract-Natriuretic peptides are controregulatory hormones associated with cardiac remodeling, namely, left ventricular hypertrophy and systolic/diastolic dysfunction. We intended to address the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in hypertension. We prospectively studied the relationship between plasma NTproBNP and all-cause mortality in 684 hypertensive patients with no history or symptoms of heart failure referred for hypertension workup in our institution from 1998 to 2008. After a mean duration of 5.7 years, we observed 40 deaths (1.04 deaths per 100 patients per year). After adjustment for traditional cardiovascular risk factors, including ambulatory blood pressure and serum creatinine, the risk for all-cause mortality more than doubled with each increment of 1 log NT-proBNP (hazard ratio: 2.33 [95% CI: 1.36 to 3.96]). The risk of death of patients with plasma NT-proBNP Ն133 pg/mL (third tertile of the distribution) was 3.3 times that of patients with values Ͻ50.8 pg/mL (first tertile; hazard ratio: 3.30 [95% CI: 0.90 to 12.29]). This predictive value was independent of, and superior to, that of 2 ECG indexes of left ventricular hypertrophy, the Sokolov-Lyon index and the amplitude of the R wave in lead aVL. In addition, it persisted in patients without ECG left ventricular hypertrophy, which allowed refining risk stratification in this relatively low-risk patient category. In this large sample of hypertensive patients, plasma NT-proBNP appeared as a strong prognostic marker. This performance, together with the ease of measurement, low cost, and widespread availability of NT-proBNP test kits, should prompt a wide use of this marker for risk stratification in hypertension. (Hypertension. 2011;57:702-709.)Key Words: hypertension Ⅲ NT-proBNP Ⅲ survival Ⅲ risk stratification Ⅲ left ventricular hypertrophy I n hypertension, detection of cardiac damages is critical for risk stratification. 1 This is usually done by searching for left ventricular hypertrophy (LVH), a major predictor of cardiovascular events. 2,3 However, in clinical practice, LVH detection is subject to various limitations. ECG is recommended by most guidelines but has a poor sensitivity and is rarely performed in clinical practice. 4 Echocardiography is extensively used but is time consuming, expensive, and not always feasible for technical reasons. The cost-effectiveness of its systematic use in hypertensive patients is still widely debated. 5 Thus, there is still room for new cardiac markers to be used for risk stratification.In response to volume expansion and pressure load, ventricular myocytes release a cardiac hormone, the B-type natriuretic peptide (BNP), together with its amino-terminal fragment, the N-terminal proBNP (NT-proBNP). 6 BNP and NT-proBNP are strong prognostic markers in advanced stages of cardiac diseases like heart failure 7 or coronary disease. 8 They are also closely related to cardiac geometry and mass, 9 and we have recently demonstrated the good performance of plasma NTproBNP for t...

The Prognostic Value of Combined NT-pro-BNP Levels and NIHSS Scores in Patients with Acute Ischemic Stroke

“…The rapid measurement of the plasma BNP or NT-pro-BNP levels has been shown to increase the diagnostic accuracy of heart failure exacerbations. In additional, elevated plasma concentrations of BNP have been reported in other cardiac diseases such as atrial fibrillation (AF) (3), myocardial infarction and essential hypertension (4). Therefore, BNP and NT-pro-BNP have emerged as important cantionship exists between elevated levels of natriuretic peptides and the acute phase of ischemic stroke (8)(9)(10).…”

A New Approach to Residual Risk in Treated Hypertension—3P Screening

“…Intriguingly, none of them performed well in Nadir et al 10 at identifying silent heart disease, where the c-statistic for BNP/hsTnT was ≈0.2 higher than any risk score or micro albuminuria, or estimated glomerular filtration rate or any ECG abnormality or uric acid. Somewhat surprisingly in Paget et al, 17 neither creatinine nor Sokolov ECG criteria significantly predicted mortality in treated hypertensives. Another possibility is to image peripheral arteries such as using carotid intima-media thickness or pulse wave velocity.…”

“…One risk score suggests adding 20 mm Hg to the actual BP but there is little evidence base for knowing whether this is the correct figure or not. Indeed, in Paget et al, 17 treated systolic BP did not independently predict mortality. Other potential ways of personalizing risk are to use micro albuminuria, creatinine/ estimated glomerular filtration rate, and the ECG.…”

“…First, Tsang et al 15 showed that each of LVH, LVDD, LAE, and LVSD independently increases CV risk by ≥40%, whereas SMI is well recognized as a cause of sudden cardiac death in apparently healthy individuals. 16 Second, Nadir et al 10 showed that those with any of LVH, LVDD, LAE, LVSD, and SMI have an elevated level of BNP, whereas Paget et al 17 showed that a high N-terminal proBNP independently increased the risk of total mortality 3-fold in treated hypertensives. Overall, therefore, Paget et al 17 clearly indicate that N-terminal proBNP can be used to identify those with the most residual risk, whereas Nadir et al 10 show what known cardiac culprits are present in those with a high BNP (incidentally, BNP and N-terminal proBNP are usually virtually interchangeable in their diagnostic roles).…”

“…First, the patients who would be regarded as being at high risk by this new approach would have to fail both a biomarker test and specific investigations for cardiac target organ damage, each of which inflates risk independently. 15,17 Second, 3P screening is not using the biomarker to enhance current risk scores per se (as much other research is doing) but rather takes the alternative approach of using the biomarker to identify which patients have already developed silent cardiac abnormalities (irrespective of which risk factors or genes may have caused them in the first place).…”