Vicente Miró

The use of multisite left ventricular pacing via quadripolar lead improves acute haemodynamics and mechanical dyssynchrony assessed by radial strain speckle tracking: initial results.

AIMS The objective of the present study was to evaluate the effect of multipoint pacing (MPP) on acute haemodynamics, cardiac contractility, and left ventricle (LV) dyssynchrony, in comparison with conventional cardiac resynchronization therapy (CRT). METHODS AND RESULTS An open-label, non-randomized, single-centre, prospective study was designed. Twenty-seven consecutive patients were included. Evaluation of pacing configurations was performed in a random order. Transthoracic echocardiography was used to obtain haemodynamic and dyssynchrony parameters. Left ventricular ejection fraction (LVEF) was significantly superior in MPP compared with baseline (38.4 ± 1.8% vs. 26.1 ± 2.2%; P < 0.001), and in conventional pacing configuration compared with baseline (33.2 ± 1.8% vs. 26.1 ± 2.2%; P = 0.007). Cardiac index (CI) was increased by 21.8 ± 5.4% and 34.7 ± 5.1% in conventional and MPP configurations, respectively (P = 0.19). Percentage of acute responders (CI increase ≥10%) was 62.9 and 85.2% in conventional and MPP, respectively (P < 0.001). LV dyssynchrony was defined by radial strain rate parameters. Baseline anteroseptal-to-posterior wall time delay was 168 ± 21 ms. It was reduced until 70.4 ± 29 ms in conventional and -6.6 ± 11 ms in MPP (conventional vs. baseline P = 0.04; MPP vs. conventional P = 0.05). Standard deviation of the time-to-peak radial strain of the 6 LV basal segments was 101 ± 9.7, 80.3 ± 9.2, and 66 ± 8.03 ms in baseline, conventional, and MPP configurations, respectively (MPP vs. basal P = 0.012). Finally, we observed a positive correlation (r = 0.69) between reduction in dyssynchrony and CI increase (P < 0.0001). CONCLUSION MPP showed a further reduction in LV dyssynchrony compared with conventional biventricular pacing. Moreover, MPP resulted in an additional improvement in LVEF and in CI, and this was translated into a higher number of acute responders to CRT.

NT-proBNP en orina y su relación con los parámetros de la función ventricular en la insuficiencia cardiaca

Introduccion y objetivos La concentracion plasmatica de N-terminal propeptido natriuretico cerebral (NTproBNP) es un marcador sensible de disfuncion ventricular. Se ha demostrado el valor diagnostico y pronostico de sus concentraciones urinarias. Nuestro objetivo es determinar la relacion entre parametros consolidados de la funcion ventricular y concentraciones urinarias de NTproBNP. Metodos Hemos estudiado 74 pacientes diagnosticados de insuficiencia cardiaca (54 varones, edad 66 ± 12 anos). Se les realizo un estudio eco-Doppler y se determinaron el desplazamiento del plano auriculoventricular (DPAV) (mm), la fraccion de eyeccion (FE), la velocidad de propagacion del flujo mitral (Vp) (cm/s) y la relacion E/A. Se midieron las concentraciones plasmaticas y urinarias de NT-proBNP y las de aldosterona (pg/ml). Resultados Para toda la poblacion, los valores plasmaticos de NT-proBNP fueron 948 ± 961 pg/ml, los urinarios 88,7 ± 17,8 pg/ml y los de aldosterona 165 ± 145 pg/ml. Correlacionamos las concentraciones urinarias de NT-proBNP con el DPAV (r = −0,5; p Conclusiones El NT-proBNP en la orina se correlaciona con parametros de funcion del ventriculo izquierdo.Este estudio da soporte al papel del NT-proBNP urinario como marcador bioquimico de la funcion ventricular en pacientes con insuficiencia cardiaca.

Urinary NT-proBNP Level: Relationship With Ventricular Function Parameters in Heart Failure

INTRODUCTION AND OBJECTIVES The plasma N-terminal probrain natriuretic peptide (NT-proBNP) level is a sensitive marker of ventricular dysfunction. The diagnostic and prognostic value of urinary NT-proBNP measurement has been demonstrated. The objective of this study was to determine the relationship between established parameters of ventricular function and the urinary NT-proBNP level. METHODS The study involved 74 patients with heart failure (54 male, age 66 [12] years). A Doppler echocardiographic study was performed to measure atrioventricular plane displacement (AVPD), ejection fraction, mitral flow propagation velocity, and E/A. Urinary and plasma NT-proBNP levels, and the plasma aldosterone level were measured. RESULTS In the whole group, the plasma NT-proBNP level was 948 (961) pg/mL, the urinary NT-proBNP level was 88.7 (17.8) pg/mL, and the aldosterone level, 165 (145) pg/mL. There were correlations between urinary NT-proBNP level and AVPD (r=-0.5; P< .0001), ejection fraction (r=-0.3; P< .01), and mitral flow propagation velocity (r=-0.24; P< .05). On dividing AVPD and ejection fraction measurements into quartiles, respectively, the urinary NT-proBNP levels for these quartiles were Q1: 103 (28) pg/mL, Q2: 89 (9) pg/mL, Q3: 86 (9) pg/mL, and Q4: 78 (9) pg/mL (P< .0001) and Q1: 101 (26) pg/mL, Q2: 85 (12) pg/mL, Q3: 83 (10) pg/mL, and Q4: 85 (11) pg/mL (P< .05), respectively. Multiple linear regression analysis showed that the plasma NT-proBNP level was an independent predictor of the urinary NT-proBNP level (P< .0001). When the plasma NT-proBNP level was excluded, AVPD and ejection fraction appeared as alternative independent predictors (P< .05). CONCLUSIONS There is a correlation between the urinary NT-proBNP level and left ventricular function parameters. This study supports the use of the urinary NT-proBNP level as a biochemical marker of ventricular function in heart failure patients.

NT-proBNP y desplazamiento del plano auriculoventricular. Relación e implicaciones diagnósticas

Introduction and objectives. NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values. Patients and method. We studied 215 subjects (age 66 ± 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients. Results. For the whole population NT-proBNP was 88 (02,586) pg/ml and AVPD was 11.9 ± 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p < 0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p < 0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p < 0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p < 0.05). Conclusions. This population study found higher NTproBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NTproBNP in clinical practice.

Valor pronóstico a largo plazo de los valores séricos y urinarios del fragmento N-terminal del péptido natriurético tipo B y del filtrado glomerular en pacientes con insuficiencia cardíaca

BACKGROUND AND OBJECTIVE The amino-terminal pro-brain natriuretic peptide (NT-proBNP) and estimated glomerular filtration rate (eGFR) values are related to short prognosis in patients with heart failure (HF). This study evaluates the prognostic power of serum and urinary NT-proBNP levels, and eGFR values, in HF patients during a 60-month follow-up. PATIENTS AND METHODS We studied 93 HF outpatients (66 males, age 65+/-12). Primary endpoint was defined as cardiovascular mortality and secondary endpoint as cardiovascular mortality or admissions. RESULTS Only serum NT-proBNP levels had a significant area under the curve for the prognosis of 60-month mortality and combined events, 0.70 (p=0.004) and 0.67 (p=0.019), respectively. Urinary NT-proBNP and eGFR did not have statistical significant areas under the curve. Patients with high serum NT-proBNP had the highest risk of cardiovascular death [44 (IC 95% 38-50) vs. 56 (IC 95% 53-59) months, p=0.0006] and combined events [33 (IC 95% 28-38) vs. 42 (IC 95% 28-38) months; p=0.027]. After the integration of serum NT-proBNP and renal function, patients with high peptide levels and low eGFR had the worst survival [42 (IC 95% 33-52) months; p=0.010]. Finally, only serum NT-proBNP concentration above 933 pg/mL was a predictor of poor survival (hazard ratio=2.81, p=0.033) and NT-proBNP above 550 pg/mL for combined events (hazard ratio=1.79, p=0.049). CONCLUSIONS Serum NT-proBNP levels were superior to urine NT-proBNP and eGFR values for predicting 60-month cardiovascular death and combined events in HF patients.

Plasma Concentration of Big Endothelin-1 and Its Relation With Plasma NT-proBNP and Ventricular Function in Heart Failure Patients

INTRODUCTION AND OBJECTIVES Elevated plasma concentrations of big endothelin-1 (big ET-1) are related with severity and prognosis in patients with heart failure, and N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of ventricular remodeling. The purpose of this study was to investigate the relationship between plasma levels of big ET-1 and NT-proBNP, and between the former and ventricular function. PATIENTS AND METHOD We studied 103 patients with heart failure (75 men, mean age 63 [13] years). Each participant completed a questionnaire and underwent Doppler echocardiographic study to measure ejection fraction (EF), mitral flow propagation velocity (Vp) and atrioventricular plane displacement (AVPD). Blood samples were also taken to determine plasma levels of big ET-1, aldosterone and NT-proBNP. RESULTS For the whole population big ET-1 concentration was 1.03 [0.75] fmol/m, NT-proBNP 619 (307-1328) pg/mL, aldosterone 168 [102] pg/mL, EF 37 [10], Vp 37 [11] cm/s, and AVPD 8.0 [1.7] mm. Plasma big ET-1 correlated positively with plasma NT-proBNP (r=0.50, P<.0001). However, a negative correlation was found between big ET-1 and EF (r=-0.30, P<.01), Vp, (r=-0.30, P<.01) and AVPD (r=-0.21, P<.05). When ET-1 levels were divided into quartiles and the corresponding NT-proBNP, EF, Vp and AVPD values were compared, we found significant differences (ANOVA P<.0001, P<.01, P<.05 and P<.05, respectively). CONCLUSIONS Plasma levels of big ET-1 correlated positively with NT-proBNP levels and inversely with EF, Vp and AVPD. These findings help clarify the relationships between ventricular function and the neurohormonal activation involved in heart failure, and may aid the search for therapeutic interventions.

[NT-proBNP levels and hypertension. Their importance in the diagnosis of heart failure].

INTRODUCTION N-terminal pro-brain natriuretic peptide (NT-proBNP) is useful in the diagnosis of heart failure. We compared NT-proBNP levels in patients with and without a diagnosis of arterial hypertension. PATIENTS AND METHOD Participants were recruited from a random sample of 999 inhabitants from the Community of Valencia (eastern Spain). Of these patients, 432 said they suffered from dyspnea and were referred to their hospital (10 hospitals involved), where blood samples were taken, an echo-Doppler study was performed, and the patients completed a questionnaire. Of the 432 participants with dyspnea, 215 gave informed consent for their inclusion in the study, and 202 completed the study. Hypertension was diagnosed in 72 participants and 130 were normotensive. RESULTS For the whole population, NT-proBNP, expressed as the median and range, was 88 (0-2586) pg/mL. When we compared hypertensive with normotensive participants, we found higher NT-proBNP levels in the former group: median 123, range 0-2184 pg/mL, versus median 77, range 0-2586 pg/mL (P<.01). When we excluded subjects with systolic left ventricular dysfunction, we found higher levels in participants with hypertension: 119 (0-2184 pg/mL) vs 72 (0-997 pg/mL) (P<.01). When we also excluded subjects with diastolic dysfunction, we found (median 85, range 0-430 pg/mL) and (median 66, range 0-997 pg/mL), respectively (p = NS). CONCLUSION In a population study of subjects with dyspnea, hypertensive patients have higher NT-proBNP levels than subjects with normal blood pressure. This difference disappeared when patients with diastolic dysfunction were excluded from the analysis. Hypertension can thus be a confounding factor that potentially decreases the specificity of NT-proBNP levels for the diagnosis of heart failure. These findings should be taken into account when conducting clinical and epidemiological studies in which patients with both heart failure and hypertension are included.

Urinary NT-proBNP: A Valuable Marker in the Assessment of Patients With Essential Hypertension

The aim was to evaluate the usefulness of urinary N-terminal fragment of B-type natriuretic peptide (NT-proBNP) measurement for predicting the presence of left ventricular hypertrophy (LVH) in 160 asymptomatic patients with essential hypertension. The urinary NT-proBNP/creatinine ratio was higher in patients with LVH than in either those without LVH (P< .0001) or control subjects (P< .0001). Multivariate linear regression analysis identified age (P=.034), left ventricular mass index (P=.026) and serum NT-proBNP level (P=.001) as predictors of the urinary peptide level. The area under the curve for the NT-proBNP/creatinine ratio was 0.71+/-0.04 (P< .0001) for identifying LVH. Logistic regression analysis showed that the NT-proBNP: creatinine ratio was a predictor of LVH (odds ratio=4.074; P=.009). In conclusion, the urinary NT-proBNP concentration is a new marker that could be useful for identifying LVH in subjects with essential hypertension.

596 What association predominates for N‐terminal pro‐brain natriuretic peptide plasma levels, fiber stretching or hypertrophy

596 What association predominates for N-terminal pro-brain natriuretic peptide plasma levels, fiber stretching or hypertrophy M. Rivera1, V. Mora2, J. Valencia3, A. Jordan4, R. Talens1, J.L. Bosca5, G. Grau6, V. Bertomeu7, V. Miro8, S. Marti9 1Hospital La Fe, Research Unit, Valencia, Spain; 2Hospital Peset, Cardiologia, Valencia, Spain; 3Hospital General, Cardiologia, Alicante, Spain; 4Hospital Elche, Cardiologia, Elche, Spain; 5Hospital General, Cardiologia, Valencia, Spain; 6Hospital Alcoy, Cardiologia, Alcoy, Spain; 7Hospital S Juan, Cardiologia, Alicante, Spain; 8Hospital La Fe, Cardiologia, Valencia, Spain; 9Hospital Elda, Cardiology, Elda, Spain

Medida de la anchura del jet en su origen en la valoración de la regurgitación protésica mitral. Influencia de la disposición espacial del jet

Introduccion y objetivos. Analizamos la influencia de la disposicion espacial del jet en la correlacion obtenida entre la medida de la anchura en su origen y la planimetria del area maxima en la cuantificacion de la severidad de la regurgitacion protesica mitral por Doppler color transesofagico. Material y metodos. De 165 pacientes portadores de protesis mitral a los que se realiza un ecocardiograma transesofagico por sospecha de disfuncion protesica, se seleccionan 126 pacientes por presentar regurgitacion protesica mitral patologica. En ellos se estudio la disposicion espacial del jet, la anchura maxima en su origen y la cuantificacion de la severidad mediante el area maxima de regurgitacion. Resultados. En el grupo de pacientes con jet libre (90) obtenemos un coeficiente de correlacion entre ambos parametros del 0,75, mientras que en el grupo de jets de pared (36) el grado de correlacion es del 0,59. Al analizar la presencia de insuficiencia mitral severa por planimetria y una anchura en su origen 3 5 mm, obtenemos una sensibilidad y especificidad del 72,7% y 95%, respectivamente, para jets libres, y del 70,7% y 68,4% para jets de pared. Conclusiones. Existe una mejor correlacion entre la medida del area y la anchura en su origen para jets libres que para jets de pared. Se aprecia una relacion estadisticamente significativa entre la presencia de insuficiencia mitral severa y una anchura en el origen superior o igual a 5 mm independientemente de la distribucion espacial del jet.