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ObjectivesThis study sought to assess the prognostic impact of midregional pro-adrenomedullin (MR-proADM) after an acute myocardial infarction (AMI).BackgroundAdrenomedullin (ADM) is elevated in heart failure (HF) and after AMI. Another part of its precursor, MR-proADM, is more stable in circulation and ex vivo. We investigated the cardiovascular prognostic value after AMI of MR-proADM and compared it with N-terminal pro-B-type natriuretic peptide (NTproBNP), a marker of death and HF.MethodsWe measured plasma MR-proADM and NTproBNP in 983 consecutive post-AMI patients (721 men, mean age 65.0 ± 12.2 years), 3 to 5 days after chest pain onset.ResultsThere were 101 deaths and 49 readmissions with HF during follow-up (median 342, range 0 to 764 days). The MR-proADM was increased in patients with death or HF compared with survivors (median 1.19 nmol/l, range 0.09 to 5.39 nmol/l, vs. 0.71 nmol/l, range 0.25 to 6.66 nmol/l, p < 0.0001). Using a multivariate binary logistic model, log MR-proADM (odds ratio 4.22) and log NTproBNP (odds ratio 3.20) were significant independent predictors of death or HF (with creatinine, age, gender, and history of AMI). The areas under the receiver-operating characteristic curve for MR-proADM, NTproBNP, and the logistic model with both markers were 0.77, 0.79, and 0.84 respectively. Cox models for the predictors of death or HF showed the same variables (including log MR-proADM, hazard ratio 3.63; log NTproBNP, hazard ratio 2.67). The MR-proADM provided further risk stratification in those patients who had NTproBNP levels above the median (p < 0.0001). Findings were similar for death and HF as individual end points.ConclusionsThe ADM system is activated after AMI. The MR-proADM is a powerful predictor of adverse outcome, especially in those with an elevated NTproBNP. The MR-proADM may represent a clinically useful marker of prognosis after AMI.

ObjectivesOur aim was to assess the prognostic value of midregional proatrial natriuretic peptide (MR-proANP) in patients after acute myocardial infarction (AMI).BackgroundMultimarker strategies may assist risk stratification after AMI. Midregional proatrial natriuretic peptide is a newly described stable fragment of N-terminal proatrial natriuretic peptide. We compared the prognostic value of MR-proANP and an established marker, N-terminal pro-B-type natriuretic peptide (NT-proBNP), after AMI.MethodsWe recruited 983 consecutive post-AMI patients (720 men, median age 65 [range 24 to 95] years) in a prospective study with follow-up over 343 (range 0 to 764) days.ResultsPlasma MR-proANP was raised in patients who died (n = 101) compared with that seen in survivors (median 310 [range 48 to 1,150] pmol/l vs. 108 [range 4.9 to 1,210] pmol/l, p < 0.0001). Using Cox modeling, log10MR-proANP (hazard ratio 3.87) and log10NT-proBNP (hazard ratio 3.25) were significant independent predictors of death. In patients stratified by NT-proBNP in the highest quartile (>∼5,900 pmol/l), MR-proANP in the top quartile (∼330 pmol/l) was associated with poorer outcome (p < 0.0001). Findings were similar for heart failure as an individual end point. However, neither marker predicted recurrent AMI.ConclusionsThe A- and B-type natriuretic systems are activated after AMI. Midregional proatrial natriuretic peptide is a powerful predictor of adverse outcome, especially in those with an elevated NT-proBNP. Midregional proatrial natriuretic peptide may represent a clinically useful marker of prognosis after an AMI as part of a multimarker strategy targeting the natriuretic neurohormonal pathway.

ObjectivesThe purpose of this study was to assess the prognostic value of admission and discharge mid-regional pro-adrenomedullin (sAM) levels in non–ST-elevation myocardial infarction (MI) and identify values to aid clinical decision making. N-terminal pro–B-type natriuretic peptide and GRACE (Global Registry of Acute Coronary Events) score were used as comparators.BackgroundsAM is a stable precursor of adrenomedullin.MethodsWe measured plasma sAM on admission and discharge in 745 non–ST-elevation MI patients (514 men, median age 70.0 ± 12.7 years). The primary end point was a composite of death, heart failure, hospitalization, and recurrent acute MI over mean follow-up of 760 days (range 150 to 2,837 days), with each event assessed individually as secondary end points.ResultsDuring follow-up, 120 (16.1%) patients died, and there were 65 (8.7%) hospitalizations for heart failure and 77 (10.3%) recurrent acute MIs. Both admission and discharge levels were increased (median 0.81 nmol/l [range 0.06 to 5.75 nmol/l] and 0.76 nmol/l [range 0.25 to 6.95 nmol/l], respectively) compared with established normal ranges. Multivariate adjusted Cox regression models revealed that both were associated with the primary end point (hazard ratio: 9.75 on admission and 7.54 on discharge; both p < 0.001). Admission sAM was particularly associated with early (1.11 nmol/l identified those at highest risk of death (p < 0.001). Patients with above-median admission sAM may benefit from revascularization.ConclusionssAM level is prognostic for death or heart failure. Admission levels are a strong predictor of early mortality and, when >1.11 nmol/l, complements the GRACE score to improve risk stratification.

ObjectivesMidregional pro-atrial natriuretic peptide (MR-proANP) was assessed for the importance of influencing factors, the ability to detect left ventricular systolic dysfunction, and the prognostic power compared with B-type natriuretic peptide (BNP) and amino-terminal pro–B-type natriuretic peptide (NT-proBNP) in chronic heart failure (HF).BackgroundMR-proANP is a biologically stable natriuretic peptide measured by a recently developed assay, with potential advantages over conventional natriuretic peptides such as BNP and NT-proBNP.MethodsWe measured MR-proANP, BNP, and NT-proBNP in 797 patients with chronic HF.ResultsAll 3 natriuretic peptides were independently influenced by left ventricular ejection fraction (LVEF), glomerular filtration rate (GFR), and the presence of ankle edema. Area under receiver-operator characteristic curves for detection of an LVEF