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Using BNP to Develop a Risk Score for Heart Failure in Primary Care
Using BNP to Develop a Risk Score for Heart Failure in Primary Care
This group received 120 mmol of Na intake. Group 2 (30 men, 16 women) received an IV bolus of furosemide (500 – 1000 mg/twice a day) alone, for 4 to 6 days. This group received 80 mmol of Na intake. Body weight, blood pressure, heart rate, and laboratory data were checked in all patients during hospitalization. The BNP levels were measured on admission, and 6 and 30 days after discharge. Impedance plethysmography was done on admission and 6 days later. Results: The investigators found a significant increase in daily diuresis and natriuresis in the HSS group (p⬍0.05). The BNP values showed significant intragroup and intergroup differences, 6 and 30 days after treatment. Patients from the HSS group reached a better volume status than the non-HSS group after 6 days. Furthermore, the HSS group showed a significant reduction in length of hospital stay and readmission rate. Perspective: Although the data from this study are compelling, I would be very nervous to give hypertonic saline to a patient in refractive heart failure. Clear criteria are needed before hypertonic saline is administered in patients with refractory HF. Ragavendra Baliga
Adlam D, Silcocks P, Sparrow N. Eur Heart J 2005;26:1086 –93. Study Question: What are the independent variables that predict mortality in a primary care population of HF patients prescribed loop diuretics? Is there a valid risk-scoring system that incorporates B-type natriuretic peptide (BNP) for heart failure (HF) that can be utilized in general practice? Methods: The study comprised 532 consecutive patients followed for a mean period of 6.4 years in a research clinic. Clinical assessment, electrocardiogram (ECG), echocardiography and BNP were conducted in these patients. Results: Multivariate analysis was used to determine independent prognostic variables and to generate a prognostic risk-scoring system. The score generated was [0.50⫻BNP ⫹5⫻age⫹50⫻ (CVA⫹gender⫹diabetes⫹ECG)]. The cutoff scores for risk groups were: 25th percentile, 411; 50th percentile, 475; 75th percentile, 524; Harrell’s c⫽0.75. This combined risk score was superior to BNP alone in predicting mortality. Conclusions: The investigators concluded that developing a prognostic scoring system provides a means of risk-stratifying patients without relying on a single cut-off diagnostic value for BNP. Perspective: It would be interesting to see whether this BNP-incorporated scoring system would be superior to already well-validated scoring systems such as Aaronson’s heart failure survival score (HFSS). Further studies are needed. Ragavendra Baliga
Insulin Resistance and Risk of Congestive Heart Failure Ingelsson E, Sundström J, A¨rnlöv J, Zethelius B, Lind L. JAMA 2005;294:334 – 41. Study Question: Whether insulin resistance may predict congestive heart failure (CHF) and may provide the link between obesity and CHF. Methods: The Uppsala Longitudinal Study of Adult Men was a prospective, community-based, observational cohort in Uppsala, Sweden. The researchers investigated 1187 elderly (ⱖ70 years) men free from CHF and valvular disease at baseline between 1990 and 1995, with follow-up until the end of 2002. Variables reflecting insulin sensitivity (including euglycemic insulin clamp glucose disposal rate) and obesity were analyzed together with established risk factors (prior myocardial infarction, hypertension, diabetes, electrocardiographic left ventricular hypertrophy, smoking and serum cholesterol level) as predictors of subsequent incidence of CHF, using Cox proportional hazards analyses. The primary outcome measure was first hospitalization for heart failure. Results: A total of 104 men developed CHF during a median follow-up of 8.9 (range 0.01–11.4) years. In multivariable analyses, increased risk of CHF was associated with a 1-SD increase in the 2-h glucose value of an oral glucose tolerance test (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.08 –1.93), fasting serum proinsulin level (HR, 1.29; 95%CI, 1.02–1.64), body mass index (HR, 1.35; 95%CI, 1.11–1.65) and waist circumference (HR, 1.36; 95%CI, 1.10 –1.69), whereas a 1-SD increase in clamp glucose disposal rate decreased the risk (HR, 0.66; 95%CI, 0.51– 0.86). When adding clamp glucose disposal rate to
Changes in Brain Natriuretic Peptide Levels and Bioelectrical Impedance Measurements After Treatment With High-Dose Furosemide and Hypertonic Saline Solution Versus High-Dose Furosemide Alone in Refractory Congestive Heart Failure: A Double-Blind Study Paterna S, Di Pasquale P, Parrinello G, et al. J Am Coll Cardiol 2005;45:1997–2003. Study Question: What is the effect of a new treatment (combination of high-dose furosemide and small-volume hypertonic saline solution [HSS]) for refractory congestive heart failure (CHF) on brain natriuretic peptide (BNP) plasma levels and fluid status? Methods: This double-blinded study consisted of 94 patients (60 men, 34 women) with refractory CHF (age 55– 80 years). To be enrolled in the study the patients had to have an ejection fraction ⬍35%, serum creatinine ⬍2 mg/dL, blood urea nitrogen ⬍60 mg/dL, a reduced urinary volume, and a low natriuresis (⬍500 mEq/24 h and ⬍60 mEq/24 h, respectively). Patients were then randomized to two groups: group 1 (30 men, 18 women) received IV furosemide (500 –1000 mg) plus HSS twice a day in 30 min.
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This group received 120 mmol of Na intake. Group 2 (30 men, 16 women) received an IV bolus of furosemide (500 – 1000 mg/twice a day) alone, for 4 to 6 days. This group received 80 mmol of Na intake. Body weight, blood pressure, heart rate, and laboratory data were checked in all patients during hospitalization. The BNP levels were measured on admission, and 6 and 30 days after discharge. Impedance plethysmography was done on admission and 6 days later. Results: The investigators found a significant increase in daily diuresis and natriuresis in the HSS group (p⬍0.05). The BNP values showed significant intragroup and intergroup differences, 6 and 30 days after treatment. Patients from the HSS group reached a better volume status than the non-HSS group after 6 days. Furthermore, the HSS group showed a significant reduction in length of hospital stay and readmission rate. Perspective: Although the data from this study are compelling, I would be very nervous to give hypertonic saline to a patient in refractive heart failure. Clear criteria are needed before hypertonic saline is administered in patients with refractory HF. Ragavendra Baliga
Adlam D, Silcocks P, Sparrow N. Eur Heart J 2005;26:1086 –93. Study Question: What are the independent variables that predict mortality in a primary care population of HF patients prescribed loop diuretics? Is there a valid risk-scoring system that incorporates B-type natriuretic peptide (BNP) for heart failure (HF) that can be utilized in general practice? Methods: The study comprised 532 consecutive patients followed for a mean period of 6.4 years in a research clinic. Clinical assessment, electrocardiogram (ECG), echocardiography and BNP were conducted in these patients. Results: Multivariate analysis was used to determine independent prognostic variables and to generate a prognostic risk-scoring system. The score generated was [0.50⫻BNP ⫹5⫻age⫹50⫻ (CVA⫹gender⫹diabetes⫹ECG)]. The cutoff scores for risk groups were: 25th percentile, 411; 50th percentile, 475; 75th percentile, 524; Harrell’s c⫽0.75. This combined risk score was superior to BNP alone in predicting mortality. Conclusions: The investigators concluded that developing a prognostic scoring system provides a means of risk-stratifying patients without relying on a single cut-off diagnostic value for BNP. Perspective: It would be interesting to see whether this BNP-incorporated scoring system would be superior to already well-validated scoring systems such as Aaronson’s heart failure survival score (HFSS). Further studies are needed. Ragavendra Baliga
Insulin Resistance and Risk of Congestive Heart Failure Ingelsson E, Sundström J, A¨rnlöv J, Zethelius B, Lind L. JAMA 2005;294:334 – 41. Study Question: Whether insulin resistance may predict congestive heart failure (CHF) and may provide the link between obesity and CHF. Methods: The Uppsala Longitudinal Study of Adult Men was a prospective, community-based, observational cohort in Uppsala, Sweden. The researchers investigated 1187 elderly (ⱖ70 years) men free from CHF and valvular disease at baseline between 1990 and 1995, with follow-up until the end of 2002. Variables reflecting insulin sensitivity (including euglycemic insulin clamp glucose disposal rate) and obesity were analyzed together with established risk factors (prior myocardial infarction, hypertension, diabetes, electrocardiographic left ventricular hypertrophy, smoking and serum cholesterol level) as predictors of subsequent incidence of CHF, using Cox proportional hazards analyses. The primary outcome measure was first hospitalization for heart failure. Results: A total of 104 men developed CHF during a median follow-up of 8.9 (range 0.01–11.4) years. In multivariable analyses, increased risk of CHF was associated with a 1-SD increase in the 2-h glucose value of an oral glucose tolerance test (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.08 –1.93), fasting serum proinsulin level (HR, 1.29; 95%CI, 1.02–1.64), body mass index (HR, 1.35; 95%CI, 1.11–1.65) and waist circumference (HR, 1.36; 95%CI, 1.10 –1.69), whereas a 1-SD increase in clamp glucose disposal rate decreased the risk (HR, 0.66; 95%CI, 0.51– 0.86). When adding clamp glucose disposal rate to
Changes in Brain Natriuretic Peptide Levels and Bioelectrical Impedance Measurements After Treatment With High-Dose Furosemide and Hypertonic Saline Solution Versus High-Dose Furosemide Alone in Refractory Congestive Heart Failure: A Double-Blind Study Paterna S, Di Pasquale P, Parrinello G, et al. J Am Coll Cardiol 2005;45:1997–2003. Study Question: What is the effect of a new treatment (combination of high-dose furosemide and small-volume hypertonic saline solution [HSS]) for refractory congestive heart failure (CHF) on brain natriuretic peptide (BNP) plasma levels and fluid status? Methods: This double-blinded study consisted of 94 patients (60 men, 34 women) with refractory CHF (age 55– 80 years). To be enrolled in the study the patients had to have an ejection fraction ⬍35%, serum creatinine ⬍2 mg/dL, blood urea nitrogen ⬍60 mg/dL, a reduced urinary volume, and a low natriuresis (⬍500 mEq/24 h and ⬍60 mEq/24 h, respectively). Patients were then randomized to two groups: group 1 (30 men, 18 women) received IV furosemide (500 –1000 mg) plus HSS twice a day in 30 min.
ACC CURRENT JOURNAL REVIEW October 2005
27