N‐terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism

Pruszczyk, Piotr; Kostrubiec, Maciej; Bochowicz, Anna; Styczyński, Grzegorz; Szulc, Marcin; Kurzyna, Marcin; Fijałkowska, Anna; Kuch-Wocial, Agnieszka; Chlewicka, I; Torbicki, Adam

doi:10.1183/09031936.03.00023303

Cited by 188 publications

(102 citation statements)

References 17 publications

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“…In addition, elevation of BNP has prognostic importance in pulmonary embolism; in one study (33), a BNP level of less than 21.7 pg/mmol excluded fatal pulmonary embolism with 99% accuracy, while a second study (34) demonstrated that a BNP level of less than 50 pg/mmol excluded an adverse outcome from acute pulmonary embolism with 95% accuracy. Similar findings were made with NT-proBNP levels in patients with acute pulmonary embolism (35). Therefore, being released by RV dysfunction in the absence of LV dysfunction, BNP elevations do not always suggest the presence of LV failure.…”

Section: Bnp Versus Nt-probnpsupporting

confidence: 73%

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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Section: Bnp Versus Nt-probnpsupporting

confidence: 73%

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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“…The study of Vuilleumier et al shows that NT-proBNP is the biomarker with the strongest predictive value in the risk stratification of patients with acute PE [16]. In other studies, the cut-off levels for NT-proBNP for the prediction of adverse events vary between 300 and 1,000 pg/ml [12][13][14][15][16]. This variation in cut-off levels is probably the result of factors as differences in assays, outcome definition, duration of clinical follow-up, inclusion criteria, and type of institution (primary versus secondary or tertiary care [16].…”

Section: Discussionmentioning

confidence: 99%

“…The inactive pro-hormone (pro-BNP) is split into the active hormone BNP and the inactive N-terminal fragment (NT-proBNP) [11]. Low (NT-pro)BNP concentrations are associated with an uncomplicated course in patients with acute PE and are therefore useful to identify low risk patients [12][13][14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

A prognostic model for short term adverse events in normotensive patients with pulmonary embolism

et al. 2011

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Risk stratification of patients with PE has gained interest in terms of the identification of patients in whom treatment on an outpatient base can be considered. Previous studies are of limited value due to their focus on adverse clinical events within several months after diagnosis of PE. We developed a prognostic model, based on easily accessible, clinical, and laboratory parameters, to predict adverse events during the first 10 days after the diagnosis of acute PE. We have analyzed the data of 210 outpatients with confirmed PE. Collected data included medical history, pulse rate, blood pressure, NT-proBNP, and D-dimer concentrations. The primary outcome was the occurrence of adverse clinical events in a 10 day follow-up period. Our final prognostic model to predict short-term adverse events consists of NT-proBNP levels, D-dimer concentrations, pulse rate, and the occurrence of active malignancy; the total score ranges from 0 to 37 points. Patients with a low score (no active malignancy, pulse rate <90 bpm, NT-proBNP <500 pg/ml, and D-dimer <3,000 lg/l FEU) have a 10-day adverse event risk <1.5%. This risk increases to over 30% in patients with a maximum score, based on high pulse rate, D-dimer concentrations, and NT-proBNP levels. Our prognostic model, once prospectively validated in an independent sample of patients, can be used in the early risk stratification of PE to estimate the risk of adverse events and to differentiate between candidates for in-or out-hospital treatment. Am. J. Hematol. 86:646-649, 2011. V

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“…Indeed, 4 studies have shown that low levels of natriuretic peptides on admission predict a benign clinical course. [1][2][3][4] The negative predictive value for in-hospital mortality ranged from 99% 3 to 100%. 1,2,4 Dr Krüger et al describe several PE patients with syncope who had normal pro-brain natriuretic peptide (BNP) levels but elevated troponin T levels on admission, suggesting that BNP mRNA synthesis, prohormone synthesis, and prohormone secretion into the circulation may take several hours after the onset of myocardial stretch.…”

Section: Responsementioning

confidence: 99%

Utility of Brain Natriuretic Peptide to Predict Right Ventricular Dysfunction and Clinical Outcome in Patients With Acute Pulmonary Embolism

2003

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We read the paper by Kucher et al,1 which demonstrated the association between high levels of pro-brain natriuretic peptide (BNP) and increased risk of adverse clinical outcome (death, resuscitation, mechanical ventilation, pressors, thrombolysis, catheter fragmentation, and surgical embolectomy) in patients with acute pulmonary embolism. The authors concluded that patients with acute pulmonary embolism and low pro-BNP levels have an uneventful course and good prognosis.We studied 50 patients with confirmed acute pulmonary embolism prospectively and followed them up for their inhospital course and complications. 2 Echocardiography and BNP measurement were performed in all patients at admission. Thirtyone patients (62%) of our study population had right ventricular (RV) dysfunction (dilatation of the right ventricle with a diastolic diameter Ͼ30 mm, RV/left ventricular end-diastolic diameter ratio Ͼ1, or hypokinesis of the right ventricle). We found that patients without RV dysfunction had significantly lower BNP levels compared with patients with RV dysfunction. There was a significant correlation between RV end-diastolic diameter and BNP. In addition, BNP discriminated between patients with and those without RV dysfunction (area under the receiver operating characteristic, 0.78). A BNP Ͼ90 pg/mL was associated with a risk ratio of 28.4 for the diagnosis of RV dysfunction. However, all patients presenting with syncope necessitating cardiopulmonary resuscitation showed normal BNP levels. Thus, normal BNP levels do not exclude severe pulmonary embolism. This might be due to an insufficient time span for right ventricular BNP production and secretion as a consequence of sudden RV pressure overload resulting in syncope with cardiac arrest in these patients. All of the patients with syncope and normal BNP levels showed elevated troponin T levels, stressing the value of troponin T measurements in identifying patients with severe pulmonary embolism. Kucher et al 1 mention that a possible limitation of their study lies in the absence of serial pro-BNP testing and thus in an underestimation of pro-BNP elevation given the possible transient nature of its release. Indeed, in our study, we found highly dynamic BNP release kinetics with rapidly falling BNP levels after initiation of therapy aimed at improving RV dysfunction, especially after thrombolysis. On the other hand, in patients admitted with subacute pulmonary embolism Ͼ2 days after onset of symptoms, we still found BNP levels significantly elevated.Overall, we found BNP levels not to be predictive for mortality or in-hospital complications. Patients with RV dysfunction as determined by echocardiography had significantly more in-hospital complications, confirming that echocardiography remains the bedside gold standard for the detection of RV dysfunction. Further studies in larger patient populations possibly comparing pro-BNP and BNP kinetics and their respective predictive values appear warranted.

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N‐terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism

Cited by 188 publications

References 17 publications

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

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

A prognostic model for short term adverse events in normotensive patients with pulmonary embolism

Utility of Brain Natriuretic Peptide to Predict Right Ventricular Dysfunction and Clinical Outcome in Patients With Acute Pulmonary Embolism

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