Plasma brain natriuretic peptide predicts short-term clinical outcome in heart failure patients with restrictive filling pattern.

OBJECTIVE: Plasma brain natriuretic peptide (BNP) is an important parameter of severity in congestive heart failure (CHF). We analyzed if BNP might stratify 6-month clinical outcome in outpatients with CHF with restrictive mitral filling pattern. METHODS: All subjects with New York Heart Association (NYHA) class II to IV and restrictive filling pattern were enrolled at hospital discharge after an acute decompensation. NYHA class, BNP, and echocardiogram for the evaluation of left ventricular ejection fraction (LVEF) and diastolic function were analyzed. Death and hospital readmission for CHF were the clinical events observed. RESULTS: A total of 250 patients (66% were male, mean age 73 years) were enrolled. The mean NYHA class was 2.5 +/- 0.6, LVEF was 38% +/- 15%, and mean deceleration time was 120 +/- 16 ms. The mean BNP was 643 +/- 566 pg/mL. During the 6-month follow-up, 35 patients (14%) died and 106 patients (42.4%) were readmitted for CHF (event group); in 109 patients (43.6%) no events were observed (no-event group). Higher NYHA class (2.7 +/- 0.6 vs 2.4 +/- 0.6, P = .001) and reduced LVEF (34% +/- 13% vs 42% +/- 17%, P = .01) but similar deceleration time (119 +/- 16 ms vs 122 +/- 17 ms, P = not significant) were observed in the event group. A higher level of mean BNP (833 +/- 604 pg/mL vs 397 +/- 396 pg/mL, P = .01) was recorded in the event group. The multivariate Cox analysis confirmed that LVEF (P = .04), NYHA class (P = .02), and plasma BNP (P = .0001) were associated with adverse short-term clinical outcome. CONCLUSION: Patients with CHF with a restrictive diastolic pattern had poor short-term clinical outcome. NYHA class and LVEF at discharge might predict cardiovascular events, but plasma BNP proved to be the strongest predictor.

Fall in readmission rate for heart failure after implementation of B-type natriuretic peptide testing for discharge decision: a retrospective study.

BACKGROUND: B-type natriuretic peptide is the most powerful predictor of long term prognosis in patients hospitalised with heart failure. On an outsetting basis, a decrease in B-type natriuretic peptide levels is associated to a decrease in event rate for outpatients managed using the neuro-hormone levels as the target in heart failure therapy. We have retrospectively checked whether the addition of pre-discharge B-type natriuretic peptide levels to a clinical-instrumental decisional score for discharge decision in patients admitted for heart failure reduced readmission rate for heart failure and related cost. METHODS: We studied two series of consecutive patients admitted to the Heart Failure Unit due to acute heart failure as a main diagnosis. One-hundred and forty-nine patients discharged on the basis of the sole clinical acumen were compared to one hundred and sixty-six subjects discharged adding B-type natriuretic peptide levels to the decisional score. RESULTS: During a six-month follow-up period, there were 52 readmissions (35%) among the clinical group (n=149) compared with 38 (23%) readmissions in the B-type natriuretic peptide group (n=166) (chi(2)=5.5; P=0.02). Survival did not differ between groups (87%). Changes in B-type natriuretic peptide values were correlated to clinical events: a B-type natriuretic peptide value on discharge of < or =250 pg/ml or a reduction of > or =30% in B-type natriuretic peptide values predicted a 23% event rate (death, plus readmission for heart failure), whereas a far higher percentage (71%) were observed in the remaining patients (chi(2)=32.7; P=0.001). Likewise, the overall costs of care were lower (-7%) in the B-type natriuretic peptide group: 2.781+/-923 vs 2.978+/-1.057 euros per patient respectively. CONCLUSIONS: our study suggest that the addition of pre-discharge B-type natriuretic peptide levels to a clinical-instrumental decisional score for discharge decision in patients admitted for heart failure may contribute to reduce the number of readmissions and related cost.

[BNP-guided therapy optimizes the timing of discharge and the medium term risk stratification in patients admitted for congestive heart failure]. / La terapia guidata dal BNP consente l'ottimizzazione del timing di dimissione e la stratificazione del rischio a medio termine nel paziente ricoverato per scompenso cardiaco.

BACKGROUND: Congestive heart failure (HF) is one of the most important cause of hospitalizations and is associated with high cost. Despite a consistent body of data demonstrating the benefits of drug therapy in HF, persistently high rates of readmission, especially within six months of discharge, continue to be documented. Neurohormonal activation characterizes the disease; plasma brain natriuretic peptide (BNP), is correlated with the severity of left ventricular dysfunction and relates to outcome. OBJECTIVE: The aim of the study was to evaluate if plasma levels of BNP would provide an index to guide drug treatment and to predict medium-term prognosis in HF patients (pts) after hospital discharge. METHODS AND RESULTS: We evaluated 200 consecutive pts (age 77 +/- 10 (35-96) years, 49% male versus 51% female) hospitalized for HF (DRG 127). Standard echocardiography was performed and left ventricular systolic/diastolic function was assessed; plasma BNP levels were measured with a rapid point-of-care assay (Triage BNP Test, Biosite Inc, San Diego, CA) on days 1 and after initial treatment. Using a cut-off of 240 pg/ml and/or changes in plasma BNP (days 2-3 after admission), 2 groups were identified: the low BNP group-responders (n = 68, BNP < 240 pg/ml and/or > or = 30% reduction) and the high BNP group-non responders (n = 132, BNP > or = 240 pg/ml and/or < 30% reduction). The high BNP group showed a different pattern of clinical variables according to the severity of the disease New York Heart Association (NYHA) functional class, left ventricular ejection fraction, ischemic etiology and age. A sustained elevation of plasma BNP (> 240 pg/mL) indicated the presence of a clinical unstable condition requiring further intervention whereas pts with low BNP values were discharged after 24 hours. During a mean follow-up period of 3 months, there were 62 cardiac events, including 15 cardiac deaths, 22 readmissions for worsening heart failure and 25 clinical decompensation requiring diuretic treatment. The incidence of clinical events was significantly greater in pts with higher levels of BNP (admission and discharge) than in those with lower levels (42% vs. 10%) and plasma values > 500 pg/ml identified a subgroup at high risk of death. CONCLUSIONS: The influence of BNP in the clinical course and prognosis of patients hospitalized for HF has not been studied. After initial treatment pts need to be risk stratified by means of the BNP test, to guide further management and to identify subjects with poor prognosis. An aggressive therapeutic and follow-up strategy may be justified for pts with high BNP levels and/or no changes after hospital admission for worsening HF. The changes in plasma BNP level at discharge were significantly related to cardiac events.

[Heart failure in Eastern Veneto: prevalence, hospitalization rate, adherence to guidelines and social costs]. / Lo scompenso cardiaco nel veneto orientale: prevalenza, ospedalizzazione, aderenza alle linee guida e costi sociali.

Heart failure is a prominent problem of public health, requiring innovating methods of health services organization. Nevertheless, data are still not available on prevalence, hospitalization rate, adherence to Guidelines and social costs in the general Italian population. The necessity to identifying patients with heart failure derives from the efficacy of new therapeutic interventions in reducing morbidity and mortality. In this study we aimed to identify, in a subset of the Eastern Veneto population, patients with heart failure through a pharmacologic-epidemiologic survey. The study was divided in 5 phases: (1) identification of patients on furosemide in the year 2000 in the ASL 10 of Eastern Veneto general population, through an analysis of a specific pharmaceutic service database; (2) definition of the actual prevalence of heart failure in a casual sample of these patients, through data base belonging to general practitioners, cardiologists, or others. Diagnosis was based on the following criteria: (a) previous diagnosis of heart failure; (b) previous hospitalization for heart failure; (c) clinical evidence, with echocardiographic control in unclear cases; (3) survey of hospitalizations; (4) evaluation of adhesion to guidelines, through both databases and questionnaires; (5) analysis of the social costs of the disease, with a retrospective "bottom up" approach. From a total population of 198,000 subjects, we identified 4502 patients on furosemide. In a casual sample of 10,661 subjects we defined a prevalence of heart failure in Eastern Veneto of 1.1%, that increased to 7.1% in octagenarians. The prescription of life saving drugs was satisfactory, while rather poor was the indication to echocardiography and to cardiologic consultation. Hospitalization rate for DRG 127 was low: 2.1/1000 inhabitants/year in the general population and 12.5 /1000 inhabitants/year in patients >70 years of age. Yearly mortality was 10.3%. Social costs were elevated (15.394 Euros/patient/year), due to a relevant sanitary component (hospital 53%, drugs 28%) and particularly a to an indirect cost component. In conclusion, the assumption of furosemide lends itself as a good marker for identifying patients with heart failure. Patient identification is simple, cheap and cost-efficient, and can be easily reproduced in other regional areas.

Rapid brain natriuretic peptide test and Doppler echocardiography for early diagnosis of mild heart failure.

BACKGROUND: The early identification of patients at risk for the development of clinical heart failure (HF) is a new challenge in an effort to improve outcomes. METHODS: We prospectively evaluated whether the combination of brain natriuretic peptide (BNP) measurements (Triage BNP test, Biosite Diagnostics) and echocardiography would effectively stratify patients with new symptoms in a cost-effective HF program aimed at early diagnosis of mild HF. A total of 252 patients were referred by 100 general practitioners. RESULTS: Among the study population, the median BNP value was 78 ng/L (range, 5-1491 ng/L). BNP concentrations were lower among patients without heart disease [median 15 ng/L (range, 5-167 ng/L); n = 96] than among patients with confirmed HF [median, 165 ng/L (22-1491 ng/L); n = 157; Mann-Whitney U-test, 12.3; P <0.001]. Patients were grouped into diastolic dysfunction [BNP, 195 (223) ng/L], systolic dysfunction [BNP, 290 (394) ng/L], and both systolic and diastolic dysfunction [BNP, 776 (506) ng/L]. In this model, a cutoff value of 50 ng/L BNP increases the diagnostic accuracy in predicting mild HF, avoiding 41 echocardiograms per 100 patients studied, with a net saving of 14% of total costs. CONCLUSIONS: Blood BNP concentrations, in a cost effective targeted screening, can play an important role in diagnosing mild HF and stratifying patients into risk groups of cardiac dysfunction.

B-type natriuretic peptide predicts postdischarge prognosis in elderly patients admitted due to cardiogenic pulmonary edema.

To examine the prognostic role of predischarge B-type natriuretic peptide (BNP) levels in elderly patients admitted to the hospital due to cardiogenic pulmonary edema, 203 patients consecutively admitted to the Heart Failure Unit of the Cardiology Department were retrospectively evaluated. The primary clinical end point selected was a combination of: 1) deaths; plus 2) readmissions to the hospital for heart failure in the 6 months after discharge. Thirty-one deaths (15.3%) and 44 readmissions for heart failure (21.7%) were recorded. Cox multivariate regression analysis confirmed that BNP cutoff values (identified on receiver-operated curve analysis) are the most accurate predictor of events. Hazard ratios (HRs) increased from the lowest, for BNP < or = 200 pg/mL (HR=1), through BNP 201-499 pg/mL (HR=2.3200; p=0.0174), to the highest, for BNP > or = 500 pg/mL (HR=3.6233; p=0.0009). This study demonstrates that BNP is useful in predischarge risk stratification of elderly patients with cardiogenic pulmonary edema.