Natriuretic Peptides for the Detection of Paroxysmal Atrial Fibrillation in Patients with Cerebral Ischemia – the Find-AF Study

Abstract

Background and PurposeDiagnosis of paroxysmal atrial fibrillation (AF) can be challenging, but it is highly relevant in patients presenting with sinus rhythm and acute cerebral ischemia. We aimed to evaluate prospectively whether natriuretic peptide levels and kinetics identify patients with paroxysmal AF.MethodsPatients with acute cerebral ischemia were included into the prospective observational Find-AF study. N-terminal pro brain-type natriuretic peptide (NT-proBNP), brain-type natriuretic peptide (BNP) and N-terminal pro atrial-type natriuretic peptide (NT-proANP) plasma levels were measured on admission, after 6 and 24 hours. Patients free from AF at presentation received 7 day Holter monitoring. We prospectively hypothesized that patients presenting in sinus rhythm with NT-proBNP>median were more likely to have paroxysmal AF than patients with NT-proBNP<median.Results281 patients were included, of whom 237 (84.3%) presented in sinus rhythm. 220 patients naïve to AF with an evaluable prolonged Holter ECG were analysed. In patients with NT-proBNP>median (239 pg/ml), 17.9% had paroxysmal AF in contrast to 7.4% with NT-proBNP<239 pg/ml (p = 0.025). The ratio of early (0 h) to late (24 h) plasma levels of NT-proBNP showed no difference between both groups. For the detection of paroxysmal atrial fibrillation, BNP, NT-proBNP and NT-proANP at admission had an area under the curve in ROC analysis of 0.747 (0.663–0.831), 0.638 (0.531–0.744) and 0.663 (0.566–0.761), respectively. In multivariate analysis, BNP was the only biomarker to be independently predictive for paroxysmal atrial fibrillation.ConclusionsBNP is independently predictive of paroxysmal AF detected by prolonged ECG monitoring in patients with cerebral ischemia and may be used to effectively select patients for prolonged Holter monitoring.

The intracardiac concentrations of the N-terminal-pro B-type natriuretic peptide (NT-proBNP) and the determinants of its secretion in patients with atrial fibrillation

“…The exact cut-off values of 265.5 pg/mL for stroke of known aetiology and 912.0 pg/mL for cryptogenic stroke had high sensitivity and specificity for the diagnosis of paroxysmal AF in patients after stroke [20]. The same diagnostic utility for the detection of paroxysmal AF was confirmed for BNP in patients with cerebral ischaemia [21].…”

Role of B‐Type Natriuretic Peptide and N‐Terminal Prohormone BNP as Predictors of Cardiovascular Morbidity and Mortality in Patients With a Recent Coronary Event and Type 2 Diabetes Mellitus

“…This ability could be attributed to higher levels of natriuretic peptides in patients with asymptomatic myocardial ischemia15, 16 and paroxysmal atrial fibrillation,17, 18 which could predispose to both MI and stroke.…”

“…However, as the incidences of outcomes differ between patients with HF8 and patients with a recent ACS9 in a stable phase, it is less established how natriuretic peptides are associated with cardiovascular outcomes, especially subsequent MI and stroke, in the latter population 3, 10, 11, 12, 13, 14. Concentrations of natriuretic peptides may be affected by both asymptomatic myocardial ischemia15, 16 and atrial fibrillation,17, 18 which could make BNP and NT‐proBNP relevant as predictors of MI and stroke. However, trials investigating patients at high risk of atherosclerotic events have found conflicting results regarding both the predictive ability of natriuretic peptides and cardiovascular outcomes—including MI and stroke—as well as the predictive strength of BNP versus NT‐proBNP 19, 20, 21, 22…”

Continuous ECG Monitoring for Tracking Down Atrial Fibrillation after Stroke: Holter or Automated Analysis Strategy?

“…Several approaches have been suggested such as BNP level at admission, PAC number, and clinic-radiological scores (e.g. STAF score) [6,20,22,23,24,25,26]. The first-hour risk score in our experience does not appear efficient enough to be included in relevant parameters.…”