The Clinical Significance of N‐terminal Pro‐brain Natriuretic Peptide in Detecting the Residual Cardiovascular Risk in Hypertension and Other Clinical Conditions and in Predicting Future Cardiovascular Events

Abstract

It has been clinically demonstrated that hypertensive patients, even with controlled blood pressure (BP), have a higher incidence of cardiovascular events than normotensive patients.1 This has been attributed to an underlying residual cardiovascular risk (RCR) and is due to the fact that treatment of hypertension cannot completely reverse the sustained vascular damage as well as other cardiovascular morbid conditions. 1 Therefore, some researchers have investigated several biomarkers that better predict the cardiovascular consequences of the RCR.2 Of all biomarkers used, the best predictor has been the brain natriuretic peptide (BNP) and its inactive fragment N-terminal pro-brain natriuretic peptide (NT-proBNP) in hypertension and other disease states.3,4 Increased levels of RCR have been associated with a 50% increased risk of future cardiovascular events not only in controlled hypertensive patients, but also in patients with other cardiovascular diseases.5 Therefore, the baseline measurement of blood levels of NT-proBNP in either newly diagnosed untreated or pretreated hypertensive patients is important for the evaluation of RCR and its predictive value for future cardiovascular events. In order to get a better perspective of the current status of RCR and its predictive significance, a Medline search of the English language literature was conducted from 2010 to 2015 and 14 pertinent papers were selected. The findings from these studies together with collateral literature will be discussed in this commentary. CLINICAL DIAGNOSTIC SIGNIFICANCE OF NT-PROBNPThe brain (B-type) natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted by ventricular myocytes in response to the stretching effect of pressure or volume overload of the left ventricle, and its levels correlate with the degree of left ventricular dysfunction (LVD). Circulating levels of BNP and its inactive metabolite NT-proBNP are very low in healthy individuals, but they increase significantly in response to myocardial stress. 4,6 Therefore, the measurement of BNP and especially NT-proBNP, as a result of its long half-life, have been used for the early detection of LVD secondary to hypertension, myocardial ischemia, and heart failure (HF). Several studies have shown good correlation between the levels of NT-proBNP and stage of LVD. Consequently, NT-proBNP has been used for the detection of RCR and the prediction of future cardiovascular events in the general population and in patients with hypertension, cardiovascular disease (CVD), coronary heart disease (CHD), and HF. The measurement of NT-proBNP has been used effectively for the diagnosis of subclinical LVD and HF in primary care and is cost-effective in that it replaced the use of echocardiography.7,8 An NT-proBNP level <180 pg/mL ruled out major LVD and avoided the use of echocardiography and the referral to specialized centers in 38% and 23% of the cases, respectively.7 In another study, NT-proBNP levels ≤400 pg/mL or ≤300 pg/mL for initial evaluation and sequential follow-up reduced the us...

High residual cardiovascular risk after lipid-lowering: prime time for Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive medicine

“…This extra high residual CVD risk is best predicted by BNP and its inactive fragment NT-proBNP. ( 175 ) Even in treated hypertensive patients roughly 30% suffer from left ventricular hypertrophy (29%), diastolic (21%) or systolic (6%) ventricular dysfunction, left atrial expansion (15%), and silent myocardial ischemia (6%). In 13% of this group three or more of these abnormalities occur in combination ( 176 ).…”

Benefits and pitfalls of sacubitril/valsartan treatment in patients with hypertension

“…26 In addition, the lowering of blood levels of NT-proBNP is also significant since high levels of NT-proBNP predict the onset of cardiovascular events. 27 In other studies, sacubitril/valsartan has been shown to improve insulin sensitivity in obese persons and could prevent the onset of diabetes mellitus in this population. 28 The prevention of degradation of NPs is beneficial in patients with hypertension and HF, since both conditions benefit from the diuretic, natriuretic, and vasodilating effects of NPs.…”

“…Its effects in lowering the central aortic and nocturnal BP are more important than its peripheral BP effects for the prevention of cardiovascular events . In addition, the lowering of blood levels of NT‐proBNP is also significant since high levels of NT‐proBNP predict the onset of cardiovascular events . In other studies, sacubitril/valsartan has been shown to improve insulin sensitivity in obese persons and could prevent the onset of diabetes mellitus in this population .…”