Joana Pimenta

N-Terminal–Pro-Brain Natriuretic Peptide Predicts Outcome After Hospital Discharge in Heart Failure Patients

Background—Heart failure (HF) is responsible for a huge burden in hospital care. Our goal was to evaluate the value of N-terminal–pro-brain natriuretic peptide (NT-proBNP) in predicting death or hospital readmission after discharge of HF patients. Methods and Results—We included 182 patients consecutively admitted to hospital because of decompensated HF. Patients were followed up for 6 months. The primary end point was death or readmission. Twenty-six patients died in hospital. The median admission NT-proBNP level was 6778.5 pg/mL, and the median level at discharge was 4137.0 pg/mL (P<0.001). Patients were classified into 3 groups: (1) decreasing NT-proBNP levels by at least 30% (n=82), (2) no significant modifications on NT-proBNP levels (n=49), and (3) increasing NT-proBNP levels by at least 30% (n=25). The primary end point was observed in 42.9% patients. Variables associated with an increased hazard of death and/or hospital readmission in univariate analysis were length of hospitalization, heart rate, signs of volume overload, no use of ACE inhibitors, higher NYHA class at discharge, admission and discharge NT-proBNP, and the change in NT-proBNP levels. The variation in NT-proBNP was the strongest predictor of an adverse outcome. Independent variables associated with an increased risk of readmission or death were signs of volume overload and the change in NT-proBNP levels. Conclusions—Variations in NT-proBNP levels are related to hospital readmission and death within 6 months. NT-proBNP levels are potentially useful in the evaluation of treatment efficacy and might help clinicians in planning discharge of HF patients. Whether therapeutic strategies aimed to lower NT-proBNP levels modify prognosis warrants future investigation.

Prognostic information provided by serial measurements of brain natriuretic peptide in heart failure

BACKGROUND Brain natriuretic peptide (BNP) levels predict prognosis in heart failure patients. We aimed to evaluate if serial measurements of BNP can give additional prognostic information. METHODS Eighty-four patients with systolic dysfunction had two measurements of BNP with an interval of 8 to 12 months and were followed in order to register the occurrence of death. The study was observational and prospectively designed. During follow-up, patients were treated according to state of the art. Physicians were kept blind to BNP levels. RESULTS The median follow-up was 1190 days. The median initial BNP level was 260.4 pg/ml and decreased to 123 pg/ml in the second measurement (P=0.001). The decrease in BNP was significantly associated with ACE-i dosage and with the use of a beta-blocker. All-cause mortality was 20.2%. Patients whose initial BNP level was above the median had a significantly higher hazard of dying (HR 2.96, 95% CI 1.06-8.26). The same was observed for those whose BNP increased between the first and the second measurement (HR 2.64, 95% CI 1.00-7.00). In multivariable analysis, baseline BNP above the median and increasing BNP were associated with shorter survival. CONCLUSIONS Higher baseline BNP and the increasing levels during follow-up were independently associated with mortality. The decrease in BNP levels was proportional to ACE-i dosage and larger among patients on beta-blockers. These results confirm the prognostic information provided by BNP determination and suggest that serial measurements give additional prognostic information.

Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care

Ambulatory care by physicians especially devoted to the management of heart failure (HF) has been reported to have beneficial effects. The aim of this work was to assess the effect of outpatient management at a HF clinic, as compared with care by the usual assistant physician, on prognosis of HF patients. In this non‐randomised study, we prospectively followed 339 patients after a hospitalisation index for HF, in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting: either a specific outpatient clinic (n‐157) or the usual assistant physician (n‐182). The outcomes assessed were all‐cause death or cardiac‐cause rehospitalisation during the first month after discharge and survival over the longer term. The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic (adjusted odds ratio 0.23; 95% CI 0.12–0.46). Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer‐term follow up of average length 373 days (adjusted hazard ratio 0.52; 95% CI 0.34–0.81). The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients.

A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ÉLAN-HF Score

Background Models to stratify risk for patients hospitalised for acute decompensated heart failure (ADHF) do not include the change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels during hospitalisation. Objective The aim of our study was to develop a simple yet robust discharge prognostication score including NT-proBNP for this notorious high-risk population. Design Individual patient data meta-analyses of prospective cohort studies. Setting Seven prospective cohorts with in total 1301 patients. Patients Our study population was assembled from the seven studies by selecting those patients admitted because of clinically validated ADHF, discharged alive, and NT-proBNP measurements available at admission and at discharge. Main outcome measures The endpoints studied were all-cause mortality and a composite of all-cause mortality and/or first readmission for cardiovascular reason within 180 days after discharge. Results The model that incorporated NT-proBNP levels at discharge as well as the changes in NT-proBNP during hospitalisation in addition to age ≥75 years, peripheral oedema, systolic blood pressure ≤115 mm Hg, hyponatremia at admission, serum urea of ≥15 mmol/L and New York Heart Association (NYHA) class at discharge, yielded the best C-statistic (area under the curve, 0.78, 95% CI 0.74 to 0.82). The addition of NT-proBNP to a reference model significantly improved prediction of mortality as shown by the net reclassification improvement (62%, p<0.001). A simplified model was obtained from the final Cox regression model by assigning weights to individual risk markers proportional to their relative risks. The risk score we designed identified four clinically significant subgroups. The pattern of increasing event rates with increasing score was confirmed in the validation group (BOT-AcuteHF, n=325, p<0.001). Conclusions In patients hospitalised for ADHF, the addition of the discharge NT-proBNP values as well as the change in NT-proBNP to known risk markers, generates a relatively simple yet robust discharge risk score that importantly improves the prediction of adverse events.

Systolic and diastolic dysfunction in cirrhosis: a tissue-Doppler and speckle tracking echocardiography study

Cardiac dysfunction has been described in patients with cirrhosis. Conventional echocardiographic methods are frequently unable to detect abnormalities at rest and have limitations. We aimed to evaluate cardiac function in cirrhosis patients assessing: (i) left ventricular systolic function using speckle‐tracking imaging; (ii) diastolic function using a tissue‐Doppler based algorithm and comparing it with previously proposed definition of diastolic dysfunction (DD).

B‐type natriuretic peptide is related to cardiac function and prognosis in hospitalized patients with decompensated cirrhosis

Background: B‐type natriuretic peptide (BNP) concentrations are high in cirrhosis, possibly related to volume status and cirrhotic cardiomyopathy. The prognostic significance of BNP in cirrhosis is unknown.

BNP at discharge in acute heart failure patients: Is it all about volemia? A study using impedance cardiography to assess fluid and hemodynamic status

BACKGROUND Besides hemodynamic parameters, several other variables have been associated to B-type natriuretic peptide (BNP) levels. Limited knowledge on BNP determinants in acute heart failure (HF) can undermine the interpretation of BNP levels. METHODS AND RESULTS To identify predictors of BNP levels, we evaluated 163 hospitalized acute HF patients. Thoracic fluid content (TFC) and hemodynamic parameters were measured by impedance cardiography at discharge. Patients were followed-up for 60 days for the occurrence of death/hospital admission. Median discharge BNP levels were 659.3 pg/ml. In multivariable linear regression analysis, TFC (β=0.043, 95% CI 0.024-0.062 per U/kΩ, p<0.001) was a powerful predictor of BNP levels, independently of known markers of HF severity like severe systolic dysfunction and discharge New York Heart Association class. Other independent predictors were: new onset HF, albumin, and body mass index. Sex, left cardiac work index, stroke index, hemoglobin, renal failure and discharge furosemide and lisinopril doses were associated to BNP only in univariate analysis. During follow-up, 45 (27.6%) patients were hospitalized or died. TFC (HR=1.047 (1.016-1.080) per U/kΩ increase, p=0.003) and BNP (HR=1.003 (1.001-1.004) per 10 pg/ml increase, p<0.001) were univariate predictors of the outcome, but in multivariate Cox regression analysis, only BNP was independently associated with prognosis. CONCLUSION Discharge BNP levels in acute HF patients reflected volemia and disease severity. Persistently high BNP levels during hospitalization should raise the possibility of remaining congestion, which could negatively influence prognosis. The utility of BNP as prognostic marker in HF may reside on its ability to reflect multiple underlying pathophysiological disturbances.

Clinical syndrome suggestive of heart failure is frequently attributable to non-cardiac disorders : population-based study

To assess how often the clinical syndrome (CS) of heart failure is attributable to alternative, including non‐cardiac, explanations.

Systolic dysfunction and diastolic dysfunction do not influence medium-term prognosis in patients with cirrhosis.

OBJECTIVE Myocardial dysfunction has been described in patients with cirrhosis and may contribute to haemodynamic disturbances in advanced disease states. However, the prognostic impact of cardiac systolic and diastolic dysfunction in cirrhosis is controversial. We aimed to evaluate the performance of echocardiographic parameters of cardiac function as medium-term prognostic markers, in a cohort of cirrhotic patients. METHODS Ninety-eight patients (52 discharged after hospitalization for decompensated cirrhosis and 46 ambulatory) were prospectively evaluated. A comprehensive echocardiographic study, including tissue-Doppler and speckle tracking analysis, was performed at baseline. Patients were followed-up for 6 months for the occurrence of death. RESULTS Twenty patients died during the follow-up. None of the echocardiographic parameters were associated with the occurrence of death. A Child score>10 points (HR 13.1, 95% CI 3.79-45.0, p<0.001) and a mean arterial pressure below the median (HR 3.2, 95% CI 1.14-8.80, p=0.028) were the only independent predictors of mortality in Cox regression multivariate analysis. In previously hospitalized patients, cardiac output, C-reactive protein and albumin levels were associated with 6-month mortality in univariate analysis; this association was lost after adjusting for Child score. CONCLUSIONS Medium-term mortality in cirrhosis seems to be mainly determined by liver disease severity rather than by myocardial dysfunction. Modern echocardiographic indices of systolic and diastolic function do not seem to be useful in identifying patients at increased risk of dying.

Competing Risk of Cardiac Status and Renal Function During Hospitalization for Acute Decompensated Heart Failure

OBJECTIVES The aim of this study was to analyze the dynamic changes in renal function in combination with dynamic changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients hospitalized for acute decompensated heart failure (ADHF). BACKGROUND Treatment of ADHF improves cardiac parameters, as reflected by lower levels of NT-proBNP. However this often comes at the cost of worsening renal parameters (e.g., serum creatinine, estimated glomerular filtration rate [eGFR], or serum urea). Both the cardiac and renal markers are validated indicators of prognosis, but it is not yet clear whether the benefits of lowering NT-proBNP are outweighed by the concomitant worsening of renal parameters. METHODS This study was an individual patient data analysis assembled from 6 prospective cohorts consisting of 1,232 patients hospitalized for ADHF. Endpoints were all-cause mortality and the composite of all-cause mortality and/or readmission for a cardiovascular reason within 180 days after discharge. RESULTS A significant reduction in NT-proBNP was not associated with worsening of renal function (WRF) or severe WRF (sWRF). A reduction of NT-proBNP of more than 30% during hospitalization determined prognosis (all-cause mortality hazard ratio [HR]: 1.81; 95% confidence Interval [CI]: 1.32 to 2.50; composite endpoint: HR: 1.36, 95% CI: 1.13 to 1.64), regardless of changes in renal function and other clinical variables. CONCLUSIONS When we defined prognosis, NT-proBNP changes during hospitalization for treatment of ADHF prevailed over parameters for worsening renal function. Severe WRF is a measure of prognosis, but is of lesser value than, and independent of the prognostic changes induced by adequate NT-proBNP reduction. This suggests that in ADHF patients it may be warranted to strive for an optimal decrease in NT-proBNP, even if this induces WRF.