Comparison of the diagnostic and prognostic values of B-type and atrial-type natriuretic peptides in acute heart failure

https://doi.org/10.1016/j.ijcard.2013.04.164Get rights and content

Abstract

Background

We compared diagnostic and prognostic properties of brain natruiretic peptide (BNP), proBNP, NT-proBNP and MR-pro-atrial natriuretic peptide (ANP) in patients admitted with shortness of breath (SOB).

Methods

All 4 NPs were measured in patients admitted to the emergency unit with SOB (in 2 centers) or acute heart failure (AHF) (1 FINN-AKVA cohort) and in a control population of stable chronic HF. Follow-up was 1 (2 centers) and 5 years (1 FINN-AKVA cohort). Area under the curve (AUC) was used to assess diagnostic properties. AUC, multivariate Cox regression, net reclassification improvement (NRI), and Kaplan–Meier analyses were used to assess mortality.

Results

We included 710 patients (“Biomarcoeurs” cohort n = 336; FINN-AKVA study, n = 306; stable chronic HF, n = 68). Pro-BNP was almost as powerful as BNP to diagnose AHF (AUC 0.953 vs 0.973 respectively, p = 0.003), NT-proBNP also performed well (0.922, p < 0.001 vs BNP). MR-proANP performed less well (0.901). AUC over time showed greater MR-proANP values over the first year. At 5 years, MR-proANP had the best prognostic value (AUC 0.668 vs 0.604 for BNP, p = 0.042). Kaplan Meier analysis confirmed better survival with MR-proANP  416.8 pmol/L at 5 years. NRI at 5 years was greater for MR-proANP (0.23, p < 0.05) than for proBNP, BNP or NTproBNP (p = NS).

Conclusion

Our study provides firm evidence that all NPs perform equally well for diagnostic purposes, and that MR-proANP has long term prognostic value in patients with acute heart failure.

Introduction

Shortness of breath (SOB, or acute dyspnea) is a chief complaint of many patients admitted to the emergency room or to coronary care units (CCUs). Plasma BNP and NT-proBNP are recommended in patients admitted with SOB when clinical diagnosis in uncertain, as both have been proven to have good discriminant value for distinguishing between acute heart failure (AHF) and non-AHF [1], [2], [3]. Indeed, in AHF patients, increased filling pressures raise cardiac wall stress leading to the release of BNP or NT-proBNP from cardiac myocytes into the plasma, whereas no such release occurs in patients admitted with non-HF related SOB.

In addition to BNP and NT-proBNP, which have been commercially available for clinical use for many years, mid-regional pro-atrial natriuretic peptide (MR-proANP) is a new biomarker that has recently become available to clinicians. MR-proANP, mainly synthesized by atrial sites, has been reported to have potential diagnostic and prognostic utility in AHF, comparable to that of BNP and NT-proBNP [4], [5].

Pro-BNP, the precursor of BNP and NT-proBNP can also be measured in human plasma though no kit is currently available for clinical use. Pro-BNP is cleaved by corin or furin, mainly in the cytoplasm of cardiac myocytes, to yield to N-terminal (NT-proBNP) and C-terminal (BNP) portions of proBNP. Pro-BNP is also released from cardiac myocytes and plasma Pro-BNP has been shown, in a small cohort of patients with SOB, to yield diagnostic performance similar to that of BNP and NT-pro-BNP [6]. However, the prognostic value of pro-BNP in AHF remains unknown.

The aim of the present study was to compare the diagnostic and prognostic properties of the 4 natriuretic peptides (NPs) in patients admitted with SOB, a time of major release of NPs into the plasma. Plasma concentrations of NPs at admission were analyzed according to the presence or not of heart failure. We also compared the prognostic value of the 4 NPs for long term survival.

Section snippets

Study population

The present study analyzed the plasmatic values of 4 NPs (proBNP, BNP, NT-proBNP and MR-proANP) with acute dyspnea (of cardiac or non-cardiac origin or stable chronic heart failure).

NP measurements were performed on the plasma of patients included in the “Biomarcoeurs” cohort (n = 336); namely patients admitted to the emergency room of 2 centers (Monastir University Hospital in Tunisia (n = 131) and Lariboisière University Hospital in Paris, France (n = 205)) with shortness of breath (SOB) as their

Results

Over the study period, 710 patients were included. The flowchart of the study population is shown in Fig. 1.

Discussion

Our study shows that 1) all NPs performed very well in the diagnosis of AHF with BNP and pro-BNP being the best performers, and 2) high MR-proANP was best associated with 5-year mortality.

Acknowledgments

We thank Dr Homa Rafi, Oksana Boirau, and Béatrice Lemosquet.

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