Nadia Aspromonte

State of the art: using natriuretic peptide levels in clinical practice

Natriuretic peptide (NP) levels (B‐type natriuretic peptide (BNP) and N‐terminal proBNP) are now widely used in clinical practice and cardiovascular research throughout the world and have been incorporated into most national and international cardiovascular guidelines for heart failure. The role of NP levels in state‐of‐the‐art clinical practice is evolving rapidly. This paper reviews and highlights ten key messages to clinicians:

Epidemiology of cardio-renal syndromes: workgroup statements from the 7th ADQI Consensus Conference

Sean M. Bagshaw, Dinna N. Cruz, Nadia Aspromonte, Luciano Daliento, Federico Ronco, Geoff Sheinfeld, Stefan D. Anker, Inder Anand, Rinaldo Bellomo, Tomas Berl, Ilona Bobek, Andrew Davenport, Mikko Haapio, Hans Hillege, Andrew House, Nevin Katz, Alan Maisel, Sunil Mankad, Peter McCullough, Alexandre Mebazaa, Alberto Palazzuoli, Piotr Ponikowski, Andrew Shaw, Sachin Soni, Giorgio Vescovo, Nereo Zamperetti, Pierluigi Zanco, Claudio Ronco and for the Acute Dialysis Quality Initiative (ADQI) Consensus Group

Cardiorenal Syndromes: An Executive Summary from the Consensus Conference of the Acute Dialysis Quality Initiative (ADQI)

The cardiorenal syndrome (CRS) is a disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The general definition has been expanded into five subtypes reflecting the primacy of organ dysfunction and the time-frame of the syndrome: CRS type 1 = acute worsening of heart function leading to kidney injury and/or dysfunction; CRS type 2 = chronic abnormalities in heart function leading to kidney injury or dysfunction; CRS type 3 = acute worsening of kidney function leading to heart injury and/or dysfunction; CRS type 4 = chronic kidney disease leading to heart injury, disease and/or dysfunction, and CRS type 5 = systemic conditions leading to simultaneous injury and/or dysfunction of heart and kidney. Different pathophysiological mechanisms are involved in the combined dysfunction of heart and kidney in these five types of the syndrome.

Definition and classification of Cardio-Renal Syndromes: workgroup statements from the 7th ADQI Consensus Conference

Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy. Brunkhorst FM et al. Acute renal failure in patients with severe sepsis and septic shock a significant independent risk factor for mortality: results from the German Prevalence Study. Van Biesen W et al. Clinical characteristics of patients developing ARF due to sepsis/systemic inflammatory response syndrome: results of a prospective study. et al. Prognostic factors in acute re-nal failure due to sepsis. Results of a prospective multicentre study. Brain natriuretics peptide: a marker of myo-cardial dysfunction and prognosis during severe sepsis. Persistent preload defect in severe sepsis despite fluid loading: a longitudinal echocardiographic study in patients with septic shock. Myocardial necrosis in ICU patients with acute non-cardiac disease: a prospective study. Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes. Chronic kidney disease associated mortality in diastolic versus systolic heart failure: a propensity matched study. Am J Cardiol 2007; 99: 393–398 72. Hillege HL, van Gilst WH. Accelerated decline and prognostic impact of renal function after myocardial infarction and the benefits of ACE inhibition: the CATS randomized trial.

How often we need to measure brain natriuretic peptide (BNP) blood levels in patients admitted to the hospital for acute severe heart failure? Role of serial measurements to improve short-term prognostic stratification.

BACKGROUND Brain natriuretic peptide (BNP) is increasingly used in the management of patients with heart failure (HF). It is still unclear how to use serial BNP measurement in HF. AIM To evaluate the usefulness of three consecutive measurements of BNP in patients (pts) hospitalized for acute HF. METHODS Clinical evaluation, BNP levels and echocardiography were assessed in 150 pts (67% males, age: 69+/-12 years; left ventricular ejection fraction: 34+/-14%) admitted for severe HF (NYHA class III-IV: 146/150). BNP measurements were obtained: at admission (basal, T0), at discharge (T1) and at first ambulatory control (T2), after optimization of medical therapy in those with discharge BNP level >250 pg/mL. End-points were death and hospital readmission during 6-month follow-up. RESULTS According to BNP levels 3 groups of patients were identified: Group 1 (62 pts, 41%), in whom discharge (T1) BNP was high and persisted elevated at T2 despite aggressive medical therapy; at 6-month follow-up 72% died or were hospitalized for HF. Group 2 (36 pts, 24%), in whom discharge (T1) BNP was high but decreased after medical therapy (T2); death and HF-readmission were observed in 8 pts (26%). Group 3 (52 pts, 35%), in whom discharge (T1) BNP levels were <250 pg/mL and persisted below this value at T2; death and HF-hospital readmission were observed in 6 pts (12%). Event rate differences among groups were statistically significant (p<0.001). At Cox-analysis discharge BNP cutoff of 250 pg/mL was the only parameter predictive of a worse outcome. CONCLUSION These data suggest that 3 BNP measurements, at admission, at discharge and few weeks later can allow to identify HF pts whom, despite a further potentiation of medical therapy, will present a worsening or even will die during short-term follow-up.

The NT-proBNP assay identifies very elderly nursing home residents suffering from pre-clinical heart failure.

Little is known about the prevalence of heart failure among very old people, although hospitalisation rates for chronic heart failure are very high. Recently, brain natriuretic peptides have emerged as important diagnostic and prognostic serum markers for congestive heart failure.

ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference

Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.

The cardiopulmonary exercise test is safe and reliable in elderly patients with chronic heart failure.

Aim To assess safety and feasibility of cardiopulmonary exercise test (CPX) in elderly patients with chronic heart failure (CHF) and left ventricular dysfunction. Methods and results We analysed 395 cardiopulmonary exercise tests (CPXs) performed in 227 clinically stable patients with CHF [mean age 76 years, males 70%, mean New York Heart Association (NYHA) class 2.2 ± 0.5] and impaired left ventricular function (mean ejection fraction 43 ± 12%). Ninety-eight out of 395 CPXs (25%) were performed in patients older than 80 years. A standard bicycle exercise ramp protocol was used, with increments of 10 W/min. An expiratory exchange ratio (RER) ≥ 1.05 at the peak of CPX was considered as the index of maximal exercise. Average workload was 65 ± 23 W. No adverse reactions were observed, although one test was stopped for non-sustained ventricular tachycardia. The main reasons for stopping were exhaustion (50%), dyspnoea (30%), maximal predicted heart rate (17%), orthopaedic problems (2.5%) and significant ST segment depression (0.5%). In the overall cohort, 80% of patients achieved an RER ≥ 1.05 and, in 56% of them, the RER was ≥ 1.15. The anaerobic threshold (AT) was detectable in 80% of CPXs, and mean oxygen consumption (VO2) at AT was 9 ± 6 ml/kg per min, whereas mean peak VO2 was 11 ± 3 ml/kg per min. In the cohort of patients aged > 80 years, 71% reached an RER ≥ 1.05 and 47% reached an RER ≥ 1.15. In these older patients, AT was detectable in 68% of CPXs performed, and the mean peak VO2 was 10 ± 3 ml/kg per min. Conclusions In elderly patients with CHF, the CPX is safe, feasible and able to provide basic information for individual risk assessment. These findings potentially extend the indications of CPX, which is currently applied to selected middle-aged patients with CHF, to the elderly population.

Efficacy and safety of loop diuretic therapy in acute decompensated heart failure: a clinical review

Intravenous loop diuretics are widely used to treat the symptoms and signs of fluid overload in acute heart failure (AHF). Although diuretic therapy is widely used and strongly recommended by most recent clinical guidelines, prospective studies and randomized clinical trials are lacking and so reliable evidence is missing about the best therapy in terms of doses and methods of administration. In addition, clinical efficacy and safety outcomes are often affected by the presence of contrasting evidence. The efficacy of loop diuretics is impaired by diuretic resistance characterized by a decreased diuretic and natriuretic effect. This review focuses on the current management of AHF with diuretic therapy. Continuous diuretic infusion seems to be a good choice, from a pharmacokinetic point of view, when fluid overload is refractory to conventional therapy. Some available evidence comparing bolus injection to continuous infusion of loop diuretics proved the latter to be an effective and safe method of administration. Continuous infusion seems to produce a constant plasmatic concentration of drug with a more uniform daily diuretic and natriuretic effect and a greater safety profile (fewer adverse events such as worsening renal failure, electrolyte imbalances, ototoxicity). The analyses of the published studies did not provide conclusive data about the effects on clinical outcomes (mortality, rate of hospital readmissions, length of hospital stay and adverse events). Furthermore, recent studies focus their attention on alternative strategies of fluid removal, such as vasopressin antagonists, adenosine antagonists and ultrafiltration but available data are often inconclusive.

Prevention of cardio-renal syndromes: workgroup statements from the 7th ADQI Consensus Conference

Peter A. McCullough, Mikko Haapio, Sunil Mankad, Nereo Zamperetti, Barry Massie, Rinaldo Bellomo, Stefan D. Anker, Inder Anand, Nadia Aspromonte, Sean M. Bagshaw, Ilona Bobek, Dinna N. Cruz, Luciano Daliento, Andrew Davenport, Hans Hillege, Andrew A. House, Nevin Katz, Alan Maisel, Alexandre Mebazaa, Alberto Palazzuoli, Piotr Ponikowski, Federico Ronco, Andrew Shaw, Geoff Sheinfeld, Sachin Soni, Giorgio Vescovo, Pierluigi Zanco, Claudio Ronco and Tomas Berl 7,* for the Acute Dialysis Quality Initiative (ADQI) Consensus Group