Search

Background: Patients with low left ventricular ejection fraction (LVEF), low-flow, low-gradient (i.e. classical low flow [CLF]) aortic stenosis (AS) have a dismal short-term outcome without aortic ...

Background The study aimed at determining the response of BNP and tissue Doppler (TD) E/e´ to standard heart failure (HF) therapy in an African black population as data on these are lacking in Africa. BNP assessment in relation to HF severity and its association with its predictors were also determined. Methods It was a longitudinal-analytical study with a one month follow-up among 100 HF patients seen at Ahmadu Bello University Teaching Hospital, Zaria-Nigeria. Two-way Repeated Measures ANOVA determined BNP levels before and after treatment according to the HF severity. Wilcoxon-Signed Ranks test determined the difference in BNP and TD E/e´ before and after treatment. Pearson’s correlation assessed log-transformed BNP’s association with its predictors. Results BNP significantly (p

Aims B-type natriuretic peptide (BNP) has been suggested to improve risk prediction of cardiovascular (CV) events and mortality. We aimed to evaluate the value of BNP to predict the composite primary endpoint of CV events and mortality alongside traditional and HIV specific risk factors in a HIV-infected population. Methods In this prospective multicenter HIV-HEART study we followed 808 HIV-positive subjects in the German Ruhr area for a median follow up of 120 (IQR:113–129) months since 2004. Association of BNP with the composite primary endpoint was assessed using Cox regression adjusting for traditional cardiovascular and HIV specific risk factors. Results At baseline, median BNP was 10.3 (IQR 5.4–18.9) pg/ml. The composite endpoint occurred in 158 (19.6%) patients. Subjects with high BNP levels showed significantly increased frequencies of CV events and death (22% for BNP ≤5 pg/ml, 30% for BNP >5 up to ≤20 pg ml, 38% for BNP >20 up to ≤35 pg ml, 59% for BNP >35 up to ≤100 pg ml and 86% for BNP >100 pg/ml, p-value 100 pg/ml, HR in the fully adjusted model was 3.25 (95%CI 1.50–7.08; p Conclusions Increased BNP is associated with significant excess of incident CV events and mortality in HIV-infected patients. BNP is a valuable marker to improve the prediction of CV events and mortality.

Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2, has caused widespread morbidity and mortality worldwide. Cardiac injury is reported to be common in hospitalized patients. We evaluated whether Pro B-type Natriuretic Peptide (proBNP) levels measured on admission in COVID-19 patients were associated with worse outcomes. A retrospective analysis of laboratory-confirmed COVID-19 patients who were admitted between February 2020 and July 2020 to Al Kuwait Hospital, Dubai, UAE. Patients were divided into two groups: normal proBNP (≤125 ng/L) and high proBNP (>125 ng/L) upon admission. Clinical characteristics and outcomes were compared between the two groups. A total of 389 patients were studied. Overall, mean age was 50.2 years (range 16-94 years), 77.3% were males, 35.7% diabetics, 35.2% hypertensives and 5.6% had history of cardiovascular disease. Compared to the group with normal proBNP; patients with high proBNP on admission were: older, more diabetics and hypertensives, with more history of cardiovascular disease; they presented with abnormal chest radiograph; and had lower lymphocytes, higher neutrophils, lower eGFR, higher D-dimers, higher CRP and higher procalcitonin on admission laboratory tests. These patients had more risk of developing critical illness during the hospitalization, undergoing mechanical ventilation and risk of death. Elevated pro B-type natriuretic peptide levels on admission in COVID-19 patients may predict subsequent risk of developing critical illness, undergoing mechanical ventilation, and significant high risk of death.

The natriuretic peptides play a vital role in normal physiology and as counter-regulatory hormones in heart failure (HF). Clinical assessment of their levels (for B-type natriuretic peptide [BNP], N-terminal proBNP, and the midregion of N-terminal pro-atrial natriuretic peptide) have become valuable tools in diagnosing patients with HF as well as risk stratifying and guiding therapy. Their roles have further expanded beyond HF to other cardiovascular conditions and for risk stratification in asymptomatic individuals. Understanding the clinical use of these hormones is vital to achieving their full potential.

Background: The utility of BNP (B-type natriuretic peptide), NT-proBNP (N-terminal proBNP), and hs-cTn (high-sensitivity cardiac troponin) concentrations for diagnosis and risk-stratification of syncope is incompletely understood. Methods: We evaluated the diagnostic and prognostic accuracy of BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations, alone and against those of clinical assessments, in patients >45-years old presenting with syncope to the emergency department in a prospective diagnostic multicenter study. BNP, NT-proBNP, hs-cTnT and hs-cTnI concentrations were measured in a blinded fashion. Cardiac syncope, as adjudicated by 2 physicians based on all information available including cardiac work-up and 1-year follow-up, was the diagnostic end point. EGSYS (Evaluation of Guidelines in Syncope Study), a syncope-specific diagnostic score, served as the diagnostic comparator. Death and major adverse cardiac events at 30 and 720 days were the prognostic end points. Major adverse cardiac events were defined as death, cardiopulmonary resuscitation, life-threatening arrhythmia, implantation of pacemaker/implantable cardioverter defibrillator, acute myocardial infarction, pulmonary embolism, stroke/transient ischemic attack, intracranial bleeding, or valvular surgery. ROSE (Risk Stratification of Syncope in the Emergency Department), OESIL (Osservatorio Epidemiologico della Sincope nel Lazio), SFSR (San Fransisco Syncope Rule), and CSRS (Canadian Syncope Risk Score) served as the prognostic comparators. Results: Among 1538 patients eligible for diagnostic assessment, cardiac syncope was the adjudicated diagnosis in 234 patients (15.2%). BNP, NT-proBNP, hs-cTnT, and hs-cTnI were significantly higher in cardiac syncope versus other causes ( P P P Conclusions: BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations provide useful diagnostic and prognostic information in emergency department patients with syncope. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01548352.

Background: N-terminal fragment B-type natriuretic peptide (NT-proBNP) prognostic utility is commonly determined post hoc by identifying a single optimal discrimination threshold tailored to the individual study population. The authors aimed to determine how using these study-specific post hoc thresholds impacts meta-analysis results. Methods: The authors conducted a systematic review of studies reporting the ability of preoperative NT-proBNP measurements to predict the composite outcome of all-cause mortality and nonfatal myocardial infarction at 30 days after noncardiac surgery. Individual patient-level data NT-proBNP thresholds were determined using two different methodologies. First, a single combined NT-proBNP threshold was determined for the entire cohort of patients, and a meta-analysis conducted using this single threshold. Second, study-specific thresholds were determined for each individual study, with meta-analysis being conducted using these study-specific thresholds. Results: The authors obtained individual patient data from 14 studies (n = 2,196). Using a single NT-proBNP cohort threshold, the odds ratio (OR) associated with an increased NT-proBNP measurement was 3.43 (95% CI, 2.08 to 5.64). Using individual study-specific thresholds, the OR associated with an increased NT-proBNP measurement was 6.45 (95% CI, 3.98 to 10.46). In smaller studies ( Conclusions: Post hoc identification of study-specific prognostic biomarker thresholds artificially maximizes biomarker predictive power, resulting in an amplification or overestimation during meta-analysis of these results. This effect is accentuated in small studies.

Background The B-type natriuretic peptides are now available on many automated clinical analysers. Clinical practice guidelines for heart failure include recommendations for where the B-type natriuretic peptides are possibly useful for clinical practice. A number of systematic reviews considering B-type natriuretic peptides in relation to heart failure patients have been published. Methods This review will consider the evidence presented in the systematic reviews and how this can be applied to clinical practice. Results Twenty-six systematic reviews are summarised in tables considering applications to diagnostic, prognostic and guiding therapy. Important clinical considerations for these applications are discussed to facilitate appropriate implementation in the clinical laboratory. Conclusion Most clinical laboratories should be considering the appropriate implementation of the B-type natriuretic peptide as a diagnostic test to assist in ruling out heart failure. In the application of prognosis and guiding therapy a number of questions remain to be answered.

Aim B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NTproBNP) have been shown to correlate with the size of the patent ductus arteriosus (PDA) in preterm infants. We investigated whether BNP or NTproBNP was more closely correlated with PDA size. Methods This prospective observational study included preterm infants born

Assessment of serum levels of natriuretic peptides, especially the amino-terminal portion (NT-proBNP) and the carboxy-terminal portion (BNP) of pro-B-type natriuretic peptide, has had a highly significant clinical impact on the diagnosis and prognostic stratification of patients with heart failure (HF). They are now an instrument with recognized value in this context and several studies have demonstrated their value in tailoring therapy for these patients. Following the recent advent of angiotensin receptor-neprilysin inhibitors (ARNIs), there is a need to review how these two biomarkers are interpreted in HF. The use of ARNIs is associated with a reduction in NT-proBNP but an increase in BNP levels. The authors of this concise article review the interpretation of natriuretic peptide levels in the light of the most recent evidence., A determinação dos níveis séricos de peptídeos natriuréticos (porção aminoterminal do peptídeo natriurético tipo B---NT-proBNP ou da porção carboxiterminal - BNP) constituiu avanço científico com impacto clínico muito relevante no diagnóstico e na determinação prognóstica de doentes com insuficiência cardíaca (IC). São hoje um instrumento com valor reconhecido nesse contexto e diversos estudos sugerem o seu interesse na titulação da terapêutica desses doentes. Recentemente, com o conhecimento do valor terapêutico do uso de inibidores da neprilisina/antagonista dos recetores da angiotensina, o uso desses dois biomarcadores na IC carece de interpretação diversa. O uso desses fármacos associa-se à redução dos níveis de NT-proBNP mas a aumento dos níveis de BNP. Os autores neste artigo conciso reveem a interpretação e valorização dos níveis de peptídios natriuréticos à luz da evidência mais recente., © 2017 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.

B-type natriuretic peptide (BNP) is a member of a fournatriuretic peptide family that shares a common 17-peptide ring structure. The N-terminal fragment (NT-pro-BNP) is biologically inert, but both are secreted in the plasma in equimolar quantities and both have been evaluated for use in the management of congestive heart failure. BNP and NT-pro-BNP are frequently used in the diagnosis of congestive heart failure and distinguishing between patients with dyspnoea of cardiac or pulmonary origin. Values of NT-pro-BNP are affected by age or the presence of one or several co-morbidities such as chronic renal failure, type 2 diabetes, and acute coronary syndrome. 'Normal' values of these peptides also vary depending on the type of test used. The performance characteristics of these tests vary depending on the patients on whom they are used and the manufacturer. For this reason, the determination of reference values for this peptide represents such a challenge.

B‐type natriuretic peptide (BNP) and N‐terminal‐proBNP (NT‐proBNP) are increasingly recognized as prognostic markers in patients with acute coronary syndrome (ACS). The need for novel and more effective tools for risk assessment cannot be more emphasized than in older patients with ACS given their atypical presentation, multiple comorbidities, and higher risk for mortality and morbidity. Accurate interpretation of B‐type NP values in older patients with ACS, however, may be confounded by several aging‐related physiologic changes. Advanced age, reduction in body mass, and kidney function and anemia have been associated with higher BNP and NT‐proBNP concentrations, and may create challenges with interpreting NP levels in the elderly. This review highlights the need to better understand the physiology of BNP and NT‐proBNP in older individuals and their prognostic value in older patients with ACS. Clin. Cardiol. 2012 doi: 10.1002/clc.22035 Dr. de Lemos has received grant support from Roche Diagnostics and Abbott Diagnostics. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Objective to evaluate the short-term and long-term effects of cardiac resynchronization therapy in heart failure patients. Methods We continuous assessed forty-eight heart failure patients who underwent CRT implantation in our hospital from January 2008 to December 2012, evaluate/measure NYHA grade, left ventricular diastolic diameter (LVEDd), left ventricular ejection fraction (LVEF) and B-type natriuretic peptides (BNP) before cardiac resynchronization therapy and half year, one year, two years after cardiac resynchronization therapy. Results Compared to the results before cardiac resynchronization, half year, one year and two years later, NYHA grade, LVEF, LVEDd, BNP improved significantly (P 0.05). Conclusions CRT could improve cardiac function in patients with congestive heart failure, however, when we followed up the patients for two years, cardiac function did not improve further.

Background There is accumulating evidence that transient exercise-induced ischemia triggers the release of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP). The aim of this study was to either confirm or refute a previous investigation suggesting that myocardial ischemia can reliably be detected by exercise-induced changes in BNP or NT-proBNP levels in selected patients. Methods A total of 139 consecutive patients with normal left ventricular function and normal resting BNP and NT-proBNP levels referred for rest/stress myocardial perfusion single-photon emission computed tomography (SPECT) were analyzed. Levels of BNP and NT-proBNP were determined before and immediately after symptom-limited bicycle ergometry. Results Inducible myocardial ischemia on perfusion images was detected in 46 patients (33%). Median exercise-induced increases in BNP (ΔBNP) and NT-proBNP (ΔNT-proBNP) were similar in patients with and without inducible ischemia (ΔBNP 12.7 pg/ml vs. 9.4 pg/ml, p =0.109; ΔNT-proBNP 7 pg/ml vs. 6 pg/ml, p =0.309). The area under the receiver operating characteristic curve for the ability to detect myocardial ischemia was 0.583 (95% CI, 0.479–0.688) for ΔBNP, and 0.553 (95% CI, 0.450–0.656) for ΔNT-proBNP. Conclusions Exercise-induced changes in BNP and NT-proBNP do not reliably detect myocardial ischemia in selected patients.

In patients with chronic heart failure (HF), amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels are among the strongest independent predictors of hazard, and their measurement is useful for prognostication across the entire spectrum of HF disease severity. In patients with chronic HF, repeated determinations of NT-proBNP levels appear to convey additional prognostic value for relevant adverse outcomes, including death or HF hospitalization. Although "hard targets" for NT-proBNP values are not entirely defined, morbidity and mortality in chronic HF appear to increase markedly with an NT-proBNP concentration >1,000 ng/L. Confounding factors (such as renal function or obesity) should be kept in mind when prognostically evaluating patients using NT-proBNP measurements; however, the value of NT-proBNP is retained in these patients. Thus, serial assessment of NT-proBNP is valuable for prognostication in chronic HF in outpatients, and, as such, a measurement at each patient visit or the following of changes in clinical stability is recommended.

The B-type natriuretic peptides (BNPs) now have a well-established role in the diagnosis of heart failure. There is also a wealth of evidence on their ability as prognostic markers in patients with heart failure. The other potential role of BNPs is in the arena of therapy monitoring, although much less is known regarding this putative application. This review summarizes what evidence there is both for and against using BNPs to monitor heart failure patients.

Objective: The aim of this study was to prospectively investigate changes in brain natriuretic peptide (BNP) and amino terminal pro-BNP (NT-pro-BNP) in relation to functional status after surgical ventricular restoration (SVR). Methods: Between March 2003 and May 2006, 29 patients (20 men and 9 women, mean age 65 years, mean ejection fraction 24%) with post-infarction left ventricular aneurysm and depressed left ventricular function underwent SVR according to the Dor technique at our institution. Twenty-two patients (76%) were in New York heart association (NYHA) functional class III or IV. Multi-vessel disease was present in 26 patients. Natriuretic peptides, functional status, ejection fraction and left ventricular volumes were analyzed at baseline, after 6 months, and late postoperatively. Results: There was no early mortality. Survival at 24 months was 93%. Six months postoperatively 25/29 (86%) patients were in NYHA class I and II (p p

Determination of B-Type Natriuretic Peptides: Clinical And Analytical QualityB-type natriuretic peptide (BNP), a neurohormone synthesized in the cardiac ventricles, is released as preproBNP and then enzymatically cleaved to the N-terminal-proBNP (NT-proBNP) and BNP upon ventricular myocite stretch. This hormone has a role in the body's defense against hypertension and plasma volume expansion. Measurements of circulating B-type natriuretic peptides have been shown to be of diagnostic value in patients with heart failure. BNP levels correlate with the severity of heart failure, as well as with prognosis. Better control of the preanalytical and analytical sources of variations will undoubtedly lead to improvement in B-type natriuretic peptides measurements. A number of preanalytical and analytical factors including specimen type and stability, assay imprecision, and standardization are reviewed here. Further research is required to better define the performance characteristics necessary for assays bearing the designation natriuretic peptides. These characteristics include developing guidelines for the total analytical error from a careful review of the intraindividual biological variability of the analyte under conditions that will be encountered in clinical practice, then validating these guidelines in the clinical setting, and completing the standardization efforts.

Background: A plethora of studies have shown elevated preoperative natriuretic peptide measurements to predict postoperative mortality and adverse cardiac events.Objectives: The current study aimed to demonstrate this overwhelming association and to show that further studies of this nature are unwarranted.Methods: A cumulative meta-analysis of 28 studies was conducted where the primary outcomes of mortality and adverse cardiac events were associated with elevated preoperative natriuretic peptides.Results: Cumulative meta-analysis demonstrated an odds ratio trending to a constant of 5.66, with a marked narrowing in the 95% confidence interval.Conclusions: Further studies aiming only to demonstrate an association between a preoperative natriuretic peptide threshold and the risk of postoperative adverse cardiac events are not justified. Future investigation should focus on the clinical implications of these data and the application of these findings with regard to further investigation, optimisation and appropriate adaptation of perioperative management.Keywords: BNP, major adverse cardiac event, myocardial injury, natriuretic peptides, non-cardiac surgery, NT-proBNP, outcomes

Background The B-type naturietic peptides (NPs) are associated with heart failure (HF). This investigation was designed to evaluate heart failure clinical practice guideline (CPG) recommendations for the use of NPs. Methods A search for English language CPGs for HF published since 2011 was conducted. A search for systematic reviews (SR) and meta-analysis for NPs in HF was conducted for the years 2004–2012. Each HF CPG was evaluated by two independent reviewers. Key recommendations for NPs and the supporting references were abstracted. The key findings from each SR were abstracted. Results Seven English language HF CPGs were found, all of which made recommendations for the use of NPs in diagnosis. Four made recommendations for prognosis and three for management. The European CPG scored highly for rigor of development with the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) while the others did not. North American CPGs made stronger recommendations citing higher grades of evidence for the use of NPs in HF than the European or Australian CPGs. The CPGs mostly cited primary studies 47/66 to support the recommendations. From twelve available SRs, five were cited by CPGs. One CPG conducted a SR. Conclusions The SR evidence to support NP use in CPGs has not been well cited in the CPGs and the recommendations are only partially supported by the SR evidence. Future CPGs should consider improving the methodology used to evaluate laboratory tests.

Among all natriuretic peptides and neurohormones, B-type natriuretic peptide (BNP) and its N-terminal prohormone fragment (NT-proBNP) have been shown to be the best and most powerful markers to identify patients with acute and chronic heart failure (HF). The fully automated BNP and NT-proBNP assays require only 15–20 min to achieve a test result so that a turn-around time of less than 60 min is possible, as requested by the guidelines of the cardiological societies. The in-vitro stabilities of BNP and NT-proBNP are sufficient for routine use. Most of the commercially available assays, except if they are sublicensed, use different antibodies. This may explain that in general, BNP and NT-proBNP assays show close correlations, but do not agree in absolute values. The assays have not been standardized so far and the application of various calibration materials may contribute to different results. Thus, reference ranges are dependent on the assay used, and reference ranges have to be determined for each assay separately. The increasing values with age may be related to the increasing frequency of subclinical renal or cardiac dysfunction in the elderly. Estrogens stimulate the natriuretic peptide production in females, and reference ranges depend on sex from adolescence to menopause. Immediately after birth, BNP and NT-proBNP levels are substantially higher in neonates than in their mothers. The high biological variation of natriuretic peptides must be considered when interpreting serial BNP and NT-proBNP results. Therefore, only marked BNP or NT-proBNP changes during follow-up are related to changes in the clinical HF status. A conclusion of all major studies is that in patients with chronic HF BNP and NT-proBNP are rather rule-out than rule-in markers because of limited cardiac specificities. Patients with acute HF usually show higher BNP and NT-proBNP levels than patients with chronic HF. The greatest efficiency of BNP and NT-proBNP testing was demonstrated in patients presenting to the emergency department with acute dyspnoea or in outpatients with symptoms suggesting chronic HF. Many studies indicate that short- and long-term prognosis in HF can be assessed by BNP or NT-proBNP determination. These hormones are independent predictors of death or HF hospitalizations. Natriuretic peptides are increased in all diseases affecting the cardiac or renal function and fluid balance. BNP and NT-proBNP are markers of cardiac dysfunction in patients with renal failure as well, but higher decision limits have to be used. Decreased BNP and NT-proBNP concentrations in obesity are not fully understood and controversial reports are found in the literature. In summary, BNP or NT-proBNP determination is a powerful test for ruling out HF. Furthermore, these markers are a useful addition to the standard clinical investigations of patients with suspected ventricular dysfunction.

B-type natriuretic peptides (BNP, NT-proBNP) are involved in cardiovascular remodeling, fluid and electrolyte balance, and myocardial response to coronary ischemia. Recent literature has demonstrated the usefulness of natriuretic peptides in the diagnosis of congestive heart failure (CHF). Further studies also have shown that B-type natriuretic peptides (BNPs) are useful to guide therapy in patients with established CHF and might be useful to estimate prognosis in patients with CHF and in those with left ventricular dysfunction due to acute coronary syndromes. Consequently, the majority of laboratories in the United States perform testing for BNP or its inactive aminoterminal fragment, NT-proBNP Most experts agree that blood levels of BNP and NT-proBNP can be used interchangeably, although important differences have been identified. Although the clinical usefulness of BNPs has been well described, few studies have reported data on the utilization of these markers or their impact on patient outcomes and hospital operations. This review describes the biochemical characteristics, clinical usefulness, patterns of utilization, and economic impact of laboratory testing for the BNPs.

SummaryFifty percent of patients who experience death or develop heart failure after acute coronary syndromes (ACS) have extremely elevated concentrations of plasma B-type natriuretic peptides. These elevations, however, seem not to reflect permanent ventricular dysfunction or heart failure and are assumed to exist already at the onset of ischemic symptoms. The underlying mechanisms of BNP/Nt-proBNP elevations in patients withACS are still not known at present. Furthermore, the relationship of elevated BNP/Nt-proBNP with mortality but not with atherothrombotic complications of underlying disease makes it difficult to choose optimal therapeutic strategies based on plasma levels of these peptides. The remarkably high short- and long-term mortality rate associated with increases of BNP/Nt-proBNP elevations clearly show the need of further investigation to focus on this high-risk group of patients in order to clarify underlying pathomechanisms and to find optimal therapeutic approaches.

Diagnostic, prognostic and therapeutic applications of B-type natriuretic peptides (NPs) will probably become part of routine management of heart failure within five years. Cardiac release of NPs rises with increasing cardiac dysfunction. Their secretion and plasma levels respond to intracardiac distending pressures, with other modulating influences including age, sex, renal function and other aspects of neurohormonal status. Single and serial plasma NP measurements, particularly of B-type and N-terminal pro-B-type NP, show promise in diagnosis of heart failure, risk stratification in those with known heart disease, and in adjustment of anti-failure therapy. Recombinant B-type NP is an effective parenteral treatment in decompensated heart failure. These applications of B-type NPs require confirmation before they become established in routine management of heart failure.

The aim of this review article is to give an update on the state of the art of the immunoassay methods for the measurement of B-type natriuretic peptide (BNP) and its related peptides. Using chromatographic procedures, several studies reported an increasing number of circulating peptides related to BNP in human plasma of patients with heart failure. These peptides may have reduced or even no biological activity. Furthermore, other studies have suggested that, using immunoassays that are considered specific for BNP, the precursor of the peptide hormone, proBNP, constitutes a major portion of the peptide measured in plasma of patients with heart failure. Because BNP immunoassay methods show large (up to 50%) systematic differences in values, the use of identical decision values for all immunoassay methods, as suggested by the most recent international guidelines, seems unreasonable. Since proBNP significantly cross-reacts with all commercial immunoassay methods considered specific for BNP, manufacturers should test and clearly declare the degree of cross-reactivity of glycosylated and non-glycosylated proBNP in their BNP immunoassay methods. Clinicians should take into account that there are large systematic differences between methods when they compare results from different laboratories that use different BNP immunoassays. On the other hand, clinical laboratories should take part in external quality assessment (EQA) programs to evaluate the bias of their method in comparison to other BNP methods. Finally, the authors believe that the development of more specific methods for the active peptide, BNP1-32, should reduce the systematic differences between methods and result in better harmonization of results.

The growing burden of heart failure (HF) in the elderly population cannot be overstated (1-4). More than 9% of American men and close to 5% of women ages 60 to 79 years report a diagnosis of HF, whereas above the age of 80 years these figures increase to 13.8% and 12.2%, respectively (5). Increasing HF prevalence in the elderly population reflects a steady or increasing incidence and greater survival (6-8). Despite reports of decreasing rates of first HF hospitalization (9), the health care burden associated with HF is alarming: hospitalizations for HF in the U.S. exceeded 1.1 million in 2006 (up from 877,000 in 1996), and there were an estimated 3.4 million HF visits in the same year (5). As a result, the estimated direct and indirect health care costs for HF in the U.S. alone exceed $37 billion in 2009 (5). Projections into the middle part of this century suggest that as the population ages, the prevalence and cost of HF care will continue to increase (2).

Given that ethanol ingestion is associated with a disruption of water and electrolyte balance in addition to being a significant risk factor for cardiovascular disease, we have investigated the gene expression of ANP and BNP in response to acute doses of ethanol. Wistar rats were administered either a 5 g/kg dose of ethanol or an equivalent volume of water, and atrial and ventricular tissue samples were removed at 30, 60, and 120 min for analyses. Although no differences in ANP mRNA were observed between ethanol and water-treated rats during the time course, BNP mRNA levels in ethanol-treated rats were 43% of those present in water-treated animals in atrial tissue at 120 min. In ventricular tissue, BNP mRNA levels were reduced similarly to 38% of control. These results suggest a possible differential regulation of A- and B-type natriuretic peptides under the influence of ethanol ingestion.

Editors' Note: Is brain natriuretic peptide a good predictor of outcome in neurologic diseases? Duello et al. and Montaner et al. agree that, in order to find a statistically significant relationship between brain natriuretic peptide and mortality in patients with stroke or subarachnoid hemorrhage, a very large number of patients is needed. Does widespread Bacille Calmette-Guerin vaccination at birth explain the low incidence of multiple sclerosis in the Indian subcontinent? Sethi and Ristori et al. discuss. —Chafic Karam, MD, and Robert C. Griggs, MD We read with interest the article by Garcia-Berrocoso et al.1 The correlation of B-type natriuretic peptides (BNP) elevation with stroke mortality is noteworthy …

There is increasing interest in the B-type natriuretic peptides in many clinical settings, with most research centered on patients with heart failure. These peptides have a strong negative predictive value in patients suspected of having this diagnosis, but are also known to be powerfully predictive of an adverse outcome. This latter property is particularly important in patients with advanced heart failure, allowing the selection of at-risk individuals for therapies that are in scarce resource. There is also ongoing research into B-type natriuretic peptide as a treatment for decompensated heart failure, as well as in other clinical contexts. This review aims to summarize the contemporary and established data on the B-type natriuretic peptides, with particular emphasis in the context of advanced heart failure.

Exercise is associated with changes in circulating B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP). However, the biological relevance of this phenomenon is poorly examined. We sought to assess determinants of absolute (Δ) and relative (Δ%) exercise-induced changes in BNP and NT-proBNP.BNP (n = 418) and NT-proBNP (n = 478) at rest and peak exercise were measured in patients undergoing symptom-limited cycle ergometer tests. Multivariate logistic regression was performed to identify predictors of high ΔBNP/ΔNT-proBNP and high ΔBNP/Δ%NT-proBNP defined as their highest quartiles (Q4).The median (interquartile range) ΔBNP and ΔNT-proBNP was 12 (0-28) pg/ml and 7 (2-21) pg/ml respectively, and Δ%BNP and Δ%NT-proBNP was 21 (0-46) % and 7 (3-12) % respectively. Higher BNP [odds ratio (OR) 3.92 per ln unit; p0.001] or NT-proBNP [OR 4.88 per ln unit; p0.001] at rest was the strongest predictor of ΔBNP in Q4 (≥ 28 pg/ml) or ΔNT-proBNP in Q4 (≥ 21 pg/ml). In contrast, higher maximal work rate expressed as the percentage of the predicted value (OR 1.015 per %; p = 0.007) was the only independent predictor of Δ%BNP in Q4 (≥ 46%), and lower resting heart rate (OR 0.97 per bpm; p = 0.001) and lower age (OR 0.95 per year; p = 0.001) were the only independent predictors of Δ%NT-proBNP in Q4 (≥ 12%).Higher ΔBNP and ΔNT-proBNP primarily reflected higher BNP and NT-proBNP plasma levels at rest. In contrast, higher Δ%BNP and Δ%NT-proBNP were associated with several prognostically favorable features, indicating that higher Δ%BNP and Δ%NT-proBNP may be markers of health rather than disease.

The aim of the present study was to evaluate whether B-type natriuretic peptides (BNPs) could serve as screening markers for the detection of preclinical vascular disease in the community. BNP and N-terminal-pro-BNP were analyzed in 1,000 subjects aged 70 years participating in the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study and were related to different measures of endothelial function and activation, arterial compliance, carotid atherosclerosis, and echocardiographic findings. The median levels were 42.0 ng/L for BNP and 110.7 ng/L for N-terminal-pro-BNP. On adjusted multivariate analysis, the 2 BNPs were related to increased left ventricular mass and impaired left ventricular systolic and diastolic function but not to any of the other assessed entities reflecting preclinical vascular disease. In conclusion, BNPs are strong markers of increased left ventricular mass and impaired cardiac performance but cannot be regarded as useful screening markers for the detection of preclinical states of vascular disease in elderly subjects.

Cardiopulmonary exercise testing is the method of choice for the differentiation of exercise intolerance. This study sought to assess the utility of B-type natriuretic peptide (BNP) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) for the identification of a cardiocirculatory exercise limitation.In 162 patients undergoing cardiopulmonary exercise testing, rest and peak exercise BNP and NT-proBNP levels were measured. In 94 patients fulfilling criteria for appropriate effort and sufficient diagnostic certainty, the accuracy of BNP and NT-proBNP for the prediction of a cardiocirculatory limitation, as assessed based on clinical and exercise testing data, was determined.A cardiocirculatory limitation was identified in 27 (29%) patients. Median (interquartile range) resting BNP [162 (45-415) vs 39 (19-94) vs 24 (15-46) pg/mL; P.001] and NT-proBNP [506 (129-1167) vs 77 (35-237) vs 34 (19-77) pg/mL; P.001] were higher in patients with cardiocirculatory as compared with those with pulmonary limitation (n=28) and those without cardiocirculatory or pulmonary limitation (n=39). The area under the receiver operator characteristics curve for BNP and NT-proBNP to identify a cardiocirculatory limitation was 0.79 and 0.84, respectively (P=.15 for comparison of the curves). Sensitivity and specificity of the optimal BNP cutoff of 85 pg/mL were 63% and 84%, respectively. Sensitivity and specificity of the optimal NT-proBNP cutoff of 223 pg/mL were 74% and 85%, respectively. Peak exercise biomarkers were not more accurate than resting levels.Among patients referred for cardiopulmonary exercise testing for evaluation of unexplained exercise intolerance, BNP and NT-proBNP were similarly useful to identify those with a cardiocirculatory limitation.

Screening of general populations with amino-terminal pro-B-type natriuretic peptides (NT-proBNP) holds promise for the detection of significant underlying cardiac structural and functional abnormalities, as well as for the early detection of the propensity to develop future cardiovascular events. In comparative studies to date, NT-proBNP performs at least as well as BNP in the detection of heart disease and prognostication in the general population. In some studies and subgroups, NT-proBNP appears to outperform BNP in population screening. More needs to be learned about noncardiac sources of NT-proBNP variation in "apparently well" populations. Better understanding of these factors may allow optimization of thresholds for screening of apparently well patients and concomitant delineation of patient populations in whom NT-proBNP screening is less appropriate.