Clinical Investigations
A rapid test for B-type natriuretic peptide correlates with falling wedge pressures in patients treated for decompensated heart failure: A pilot study*,**

https://doi.org/10.1054/jcaf.2001.23355Get rights and content

Abstract

Objectives: To determine if changes in B-type natriuretic peptide (BNP) levels can accurately reflect acute changes in pulmonary capillary wedge pressure during treatment of decompensated heart failure. Background: Tailored therapy of decompensated congestive heart failure with hemodynamic monitoring is controversial. Other than the expense and complications of Swan-Ganz catheters, its use in titration of drug therapy has no conclusive end point. Because BNP reflects both elevated left ventricular pressure and neurohormonal modulation and has a short half-life, we hypothesized that levels of BNP would decline in association with falling wedge pressures. Final BNP levels would perhaps signify a new set point of neuromodulation. Methods and Results: Twenty patients with decompensated New York Heart Association (NYHA) class III-IV congestive heart failure (CHF) undergoing tailored therapy were studied. BNP levels were drawn every 2 to 4 hours for the first 24 hours (active treatment phase) and then every 4 hours for the next 24 to 48 hours (stabilization period). Hemodynamic data was recorded simultaneously. In 15 patients whose wedge pressure responded to treatment in the first 24 hours, there was a significant drop in BNP levels (55%) versus nonresponders (8%). There was a significant correlation between percent change in wedge pressure from baseline per hour and the percent change of BNP from baseline per hour (r = 0.79, P <.05). When the wedge pressure was kept at a stable, low level during the stabilization phase, BNP levels continued to fall another 37% (937 ± 140 pg/mL at 24 hours to 605 ± 128 pg/mL). Patients who died (n = 4) had higher final BNP levels (1,078 ± 123 pg/mL v 701 ± 107 pg/mL). Conclusions: The data suggest that rapid testing of BNP may be an effective way to improve the in-hospital management of patients admitted with decompensated CHF. Although BNP levels will not obviate the need for invasive hemodynamic monitoring, it may be a useful adjunct in tailoring therapy to these patients.

Section snippets

Patients

Between November 5, 1999 and June 1, 2000, 20 patients with decompensated congestive heart failure (CHF) who were admitted for tailored treatment with hemodynamic monitoring were studied. Criteria for inclusion included either new onset CHF confirmed by at least one cardiologist by using standard Framingham criteria (n = 1) or exacerbation of previously documented CHF (n = 19). All patients were NYHA class IV at the time of admission. Inclusion criteria also included an initial pulmonary

Patients

Table 1 shows the characteristics of our study population. Patients were all men, had a mean age of 62 ± 3 years (mean ± standard error), and a mean ejection fraction of 27% ± 3% on the basis of echocardiography or nuclear scan done at the time of admission or within the previous 8 ± 3 months. Coronary artery disease was the leading cause of CHF (60%) in the study population. All patients were NYHA class IV at the time of admission. Parenteral therapy at the time of Swan-Ganz guided therapy

Discussion

CHF is characterized by complicated cardiorenal, hemodynamic, and neurohormonal alterations 24, 25. Although patients admitted to the hospital with decompensated heart failure often have improvement in symptoms with the various treatment modalities available, there has been no good way to evaluate the long-term effects of the short-term treatment. Indeed, in-hospital mortality and readmission rate for CHF patients is extremely high 1, 2, 3, 4. The notion that tailoring therapy with Swan-Ganz

Limitations

This was an observational study in a convenience sample of male patients. Thus BNP levels, although often measured within a short time span after sampling, were not used to guide treatment. A larger, multicenter trial is now underway to expand on this data.

In conclusion, the data presented in this pilot study suggest that serial point-of-care testing of BNP may be an effective way to improve the in-hospital management of patients admitted with decompensated CHF. Although BNP levels cannot

Acknowledgements

The authors would like to thank the physicians and nursing staff working at the VA Medical Center for their cooperation and support. They would also like to thank Anthony DeMaria, Ralph Shabetai, and Ken Bueghler for their scientific input and support.

References (68)

  • JG Porter et al.

    Cloning of cDNA encoding porcine brain natriuretic peptide

    J Biol Chem

    (1989)
  • T Sudoh et al.

    Cloning and sequence analysis of cDNA encoding a precursor for human brain natriuretic peptide

    Biochem Biophys Res Commun

    (1989)
  • M Kojima et al.

    Cloning and sequence analysis of cDNA encoding a precursor for rat brain natriuretic peptide

    Biochem Biophys Res Commun

    (1989)
  • JJ Seilhamer et al.

    Human and canine gene homologs of porcine brain natriuretic peptide

    Biochem Biophys Res Commun

    (1989)
  • SN Rahman et al.

    Effects of atrial natriuretic peptide in clinical acute renal failure

    Kidney

    (1994)
  • LW Stevenson

    Patient selection for mechanical bridging to transplantation

    Ann Thorac Surg

    (1996)
  • PA Poole-Wilson

    Tailored treatment for heart failure: An emerging concept

    Am Heart J

    (1999)
  • DR Murdoch et al.

    Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: Randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy

    Am Heart J

    (1999)
  • RW Troughton et al.

    Treatment of heart failure guided by plasma amino terminal brain natriuretic peptide (N-BNP) concentrations

    Lancet

    (2000)
  • LW Stevenson et al.

    Recognition and Management of Patients With Heart Failure

  • HM Drumholtz et al.

    Predictors of readmission among elderly survivors of admission with heart failure

    Am Heart J

    (2000)
  • J Gooding et al.

    Hospital readmissions among the elderly

    J Am Geriatr Soc

    (1985)
  • MW Rich et al.

    Effect of DRGs on three month readmission rate of geriatric patients with heart failure

    Am J Public Health

    (1988)
  • JM Vinson et al.

    Early readmission of elderly patients with heart failure

    J Am Geriatr Soc

    (1990)
  • KF Adams

    Post hoc subgroup analysis and the truth of a clinical trial

    Am Heart J

    (1998)
  • AM Feldman et al.

    Effects of vesnarinone on morbidity and mortality in patients with heart failure

    N Engl J Med

    (1993)
  • LW Stevenson

    Therapy tailored for symptomatic heart failure

    Heart Failure

    (1995)
  • AF Connors et al.

    The effectiveness of right heart catheterization in the initial care of critically ill patients

    JAMA

    (1996)
  • AD Struthers

    Prospects for using a blood sample in the diagnosis of heart failure

    Quarterly Journal Med

    (1995)
  • O Nagagawa et al.

    Rapid transcriptional activation and early mRNA turnover of BNP in cardiocyte hypertrophy. Evidence for BNP as an “emergency” cardiac hormone against ventricular overload

    J Clin Invest

    (1995)
  • K Dickstein

    Natriuretic peptides in detection of heart failure

    Lancet

    (1997)
  • M Yoshimura et al.

    Different secretion pattern of atrial natriuretic peptide and brain natriuretic peptide in patients with congestive heart failure

    Circulation

    (1993)
  • K Nakao et al.

    Molecular biology and biochemistry of the natriuretic peptide system

    J Hypertens

    (1992)
  • A Clerico et al.

    Circulating levels of cardiac natriuretic peptides (ANP and BNP) measured by highly sensitive and specific immunoradiometric assays in normal subjects and in patients with different degrees of heart failure

    J Endocrinol Invest

    (1998)

    • Cited by (0)

    *

    Supported in part by a grant from Biosite Diagnostics.

    **

    Reprint requests: Alan Maisel, MD, VAMC Cardiology 111-A, 3350 La Jolla Village Drive, San Diego, CA 92161.

    View full text
    Copyright © 2001 Churchill Livingstone. Published by Elsevier Inc. All rights reserved.