Adult: Coronary
Prognostic value of natriuretic peptides and restrictive filling pattern before surgical ventricular restoration

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Abstract

Objective

Both increased natriuretic peptide levels and restrictive filling pattern (RFP) are important risk predictors in patients with heart failure. The aim of this study was to examine the role of the combined use of natriuretic peptide and RFP for the prognostic stratification of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration in the Biomarker Plus study.

Methods

A total of 186 patients (aged 64 ± 10 years) underwent echocardiographic study and N-terminal pro-B-type natriuretic peptide assay at baseline (before surgical ventricular restoration). Patients were divided into 4 groups depending on baseline diastolic filling pattern (RFP/no RFP) and N-terminal pro-B-type natriuretic peptide level (less than or greater than or equal to the upper tertile value of 2003 ŋg/L). RFP was defined as E/A ratio ≥2. All-cause death or heart failure hospitalizations within 36-month follow-up were analyzed.

Results

Despite similar ejection fraction, volumes, and mass, the 4 groups presented distinct clinical and structural pattern of presurgical ventricular restoration ventricular remodeling and significantly different clinical outcome after surgical unloading. During follow-up, 67 patients died or were hospitalized for heart failure (36%). High N-terminal pro-B-type natriuretic peptide levels and RFP, considered individually, were significantly associated with outcome (P < .0001). The combination of both was associated with the highest adjusted hazard of adverse events (hazard ratio, 3.63; 95% CI, 1.73-7.6; P < .0001).

Conclusions

The simultaneous use of 2 markers, 1 biological and 1 echocardiographic, may allow better prognostic stratification and characterization of the distinct structural and clinical phenotypes in a population of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration. This approach could be useful in the decision-making process to guide treatment choices in patients with ischemic cardiomyopathy.

Section snippets

Methods

This is a retrospective analysis of the data of the Biomarker Plus study (protocol No. 2703/78) regarding ICM patients assigned to SVR at the Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato.10 Patients, undergoing SVR from June 2012 to December 2016, for whom there were complete echocardiographic and NT-proBNP data before surgery were selected for the present study. Exclusion criteria were atrial fibrillation or other persistent cardiac rhythm alterations (n = 7),

Results

Table 1 presents baseline clinical data for the entire population as a whole and the 4 groups. We note that group 1 (low NT-proBNP and no RFP) presents the longest time lapse between myocardial infarction (MI) and SVR and the lowest average New York Heart Association functional class. Creatinine values and average New York Heart Association functional class were highest in the 2 groups (2 and 4) with high NT-proBNP. Group 2 (high NT-proBNP but no RFP) presents a remarkably short time lapse

Discussion

As illustrated in Figure 4, this study shows that combined use of a biological and a functional index of heart failure provides additional prognostic information in patients with ICM undergoing SVR. Moreover, it helps to individuate different pattern of structural LV remodeling in patients with ICM despite similar volumes, mass, and ejection fraction.

Beyond the diagnostic and prognostic role that NPs play in chronic congestive HF in general, even in patients with ICM and established HF NPs have

Conclusions

The simultaneous use of 2 markers, 1 biological and 1 echocardiographic, may allow better stratification of prognosis and characterization of the distinct structural and clinical phenotypes in a population of patients with ICM undergoing SVR. This study highlights the importance of an integrated approach, based on biological markers, instrumental parameters, and careful clinical evaluation in the clinical decision making to guide therapeutic choices in patients with ICM.

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    Partially supported by Ricerca Corrente funding from Italian Ministry of Health to Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato.

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