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Value of N-Terminal Pro-Brain Natriuretic Peptide in the Assessment of Aerobic Capacity in Heart Failure Patients
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
active metabolites. Repeated LEVO infusions (rLEVO) could be a medical option in patients (pts) with refractory Heart Failure (HF) on continuous i.v. inotropes or with early relapse of low-output state after weaning. This study describes the outcome of pts with refractory HF in whom treatment with rLEVO was attempted for weaning from continuous inotropes or as maintenance therapy. Methods: Survival free from urgent heart transplantation (HTX) or left ventricular assist device (LVAD) implant (INTERMACS profile 1 to 3) was evaluated in 72 consecutive pts (females 15%, mean age 56+/-11 years, ischemic etiology 49%) in whom rLEVO was attempted for weaning from continuous inotropes (n= 24) or for maintaining stable conditions (n= 48) from 2006 to 2014. LEVO was administered every 4-3 weeks, 0.1-0.2 mcg/ Kg/min for 24-48 hours without loading dose. Baseline characteristics were compared in pts who received 1 or 2 vs those who received at least 3 LEVO infusions, classified respectively as non responders (LEVO-NR, n= 25) and responders (LEVO-R, n= 47). Results: By the end of June 2015, 13 deaths, 18 HTx (2 urgent) and 23 LVAD implants (11 as INTERMACS 1-3) had been observed. 1-y actuarial urgent HTX/LVAD-free survival was 54%, and was lower in LEVO-NR than in LEVO-R pts (32% vs 66%, p= .001). With respect to LEVO-R, LEVO-NR were slightly younger (51+/-13 vs 56+/-11 y, p= .07), more frequently treated for weaning from continuous inotropes (60% vs 19%, p= .04), and had more severe signs of neuroendocrine activation (sodium 136+/-4 vs 139+/-3 mEq/l, p= .03; NTproBNP 9842+/-13914 vs 5239+/-6098 ng/ml, p= .12). No differences were found in etiology, diuretic dose, concomitant oral therapy, echocardiographic, hemodynamic, and other laboratory data. Median time spent at home by LEVO-R pts was 155 days in the first 6 months of treatment vs 135 in the previous 6 months, and median time to treatment failure was 203 days. Conclusion: Repeated LEVO infusions allow weaning from continuous inotropes in a minority of pts with refractory HF. With respect to reported medical outcomes in similar cohorts, 1-y survival free from urgent HTX/LVAD appears acceptable in pts with initially favourable response. However, event rate is high, and possible benefits are limited in time. 3( 59) The Hemodynamic Effects of Milrinone in the Beta-Blocker Era S. Kalantari Tannenbaum , J. Grinstein, B. Smith, K. Marinescu, N. Sarswat, S. Adatya, G. Sayer, G.H. Kim, T. Ota, V. Jeevanandam, N. Uriel. Cardiology, University of Chicago, Chicago, IL. Purpose: Advanced heart failure patients are treated with inotropes as bridge to heart transplantation, left ventricular assist device, or as palliative care. The combination of this therapy with beta-blocker therapy is well tolerated; however the physiological effects of both medications together seem contradictory. This study aims to describe the hemodynamic changes in response to milrinone in patients with or without beta-blocker therapy. Methods: Patients with systolic heart failure referred for right heart catheterization who underwent milrinone drug study in the cath lab between June 2014 to October 2015 were identified on retrospective chart review (n= 30). Invasive hemodynamics were measured before and after milrinone administration at 5 mcg/kg/min for 10 min. The hemodynamic response was compared between patients receiving and not receiving beta-blocker therapy. Results: There were no significant differences in baseline characteristics, left ventricular ejection fraction (mean = 26%), or cardiac output between those on beta-blockers (n= 21 [70%]) and those not on beta-blockers. Patients on beta-blockers had a significantly higher increase in cardiac output compared to patients not receiving beta-blockers (1.5 ± 0.8 L/min vs. 0.8 ± 0.9 L/min, p = 0.03) (Figure 1). A higher reduction of mean pulmonary artery pressure (mPAP) and central venous pressure (CVP) was achieved on beta blockers, however it did not reach statistical significance: mPAP (-5.2 ± 5.7 mmHg vs. -2.2 ± 3.3 mmHg, p = 0.16), CVP (-4.3 ± 2.8 mmHg vs. -2.8 ± 2.8 mmHg, p = 0.2). There was no statistically significant change in pulmonary capillary wedge pressure (-5.9 ± 4.8 mmHg vs. -4.1 ± 6.5 mmHg, p = 0.44). Conclusion: Patients on beta-blockers have an increased positive hemodynamic response to milrinone challenge compared to patients not on betablockers. These differences cannot be explained by myocardial reserve alone and the mechanisms behind the synergistic effects of this combination needs further investigation.
3( 60) Value of N-Terminal Pro-Brain Natriuretic Peptide in the Assessment of Aerobic Capacity in Heart Failure Patients J. Huang . Department of Heart Transplant Center, Fuwai Hospital, Peking Union Medical College, Beijing, China. Purpose: Cardiopulmonary exercise test (CPET) has been the most accurate method to assess the aerobic capacity among heart failure (HF) patients and is also of great value to estimate prognosis and detect candidates for heart transplantation. We studied the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) and aerobic capacity in heart failure patients. Methods: We retrospectively analyzed data from 123 patients with definite diagnoses of heart failure between December 2012 and August 2015. All of them had performed the symptom limited maximal CPET to calculate the maximum oxygen consumption (PeakVO2). Blood samples had been taken within 24 hours to test NT-proBNP plasma levels, which is used to estimate Peak VO2 among these patients. Results: Plasma levels of NT-proBNP correlates significantly with Peak VO2 among the HF patients(r= -0.342, P< 0.001). NT-proBNP> 1176pg/ml showed 64% sensitivity and 76% specificity for estimating Peak VO2< 14 ml/ kg/min (area under the curve [AUC]= 0.72, P< 0.001). NT-proBNP> 1817 pg/ ml showed 80% sensitivity and 71% specificity for estimating Peak VO2< 10 ml/kg/min (AUC= 0.79, P< 0.001). After adjusted for age, gender, BMI and eGFR, the plasma level of NT-proBNP > 1176pg/ml was to predict Peak VO2< 14 ml/kg/min (OR= 5.71, 95%CI= 2.54-12.88) and > 1817 pg/ml was to predict Peak VO2< 10 ml/kg/min (OR= 9.93, 95%CI 2.61-37.79). Conclusion: NT-proBNP could reflect aerobic capacity in HF patients. More HF patients who were potential heart transplant recipients should perform CPET especially when plasma levels of NT-proBNP were above 1800pg/ml. 3( 61) Correlation of GDF-15 with Worsening Functional Capacity and Echocardiographic Parameters in Idiopathic Dilated Cardiomyopathy N. Nair ,1 E. Gongora.2 1Cardiology, S &W, Temple , TX, Texas Tech Health Sciences Center, Lubbock, TX; 2Cardiology, S &W, Temple , TX, Memorial Heart and Vascular Center, Hollywood, FL. Purpose: This study focuses on the utility of GDF-15 in clinical evaluation of heart failure in idiopathic dilated cardiomyopathy (IDCM). The role of GDF15 in this subgroup remains less well-defined. Association of GDF-15 with New York Heart Association (NYHA) functional class and echocardiographic parameters (left ventricular ejection fraction (LVEF) and Left ventricular Internal Dimension in diastole (LVIDd)) were therefore evaluated to assess structure /function relationships. Methods: The study population consisted of 23 IDCM patients and 8 control subjects aged 51+/- 13 and 59+/-10 respectively (p= 0.031). All DCM patients had a normal angiogram and no definite etiology for heart failure. Plasma levels of GDF-15 and Brain Natriuretic peptide (BNP) were measured by enzyme-linked immunoassays. LVEF and LVIDd were measured
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
active metabolites. Repeated LEVO infusions (rLEVO) could be a medical option in patients (pts) with refractory Heart Failure (HF) on continuous i.v. inotropes or with early relapse of low-output state after weaning. This study describes the outcome of pts with refractory HF in whom treatment with rLEVO was attempted for weaning from continuous inotropes or as maintenance therapy. Methods: Survival free from urgent heart transplantation (HTX) or left ventricular assist device (LVAD) implant (INTERMACS profile 1 to 3) was evaluated in 72 consecutive pts (females 15%, mean age 56+/-11 years, ischemic etiology 49%) in whom rLEVO was attempted for weaning from continuous inotropes (n= 24) or for maintaining stable conditions (n= 48) from 2006 to 2014. LEVO was administered every 4-3 weeks, 0.1-0.2 mcg/ Kg/min for 24-48 hours without loading dose. Baseline characteristics were compared in pts who received 1 or 2 vs those who received at least 3 LEVO infusions, classified respectively as non responders (LEVO-NR, n= 25) and responders (LEVO-R, n= 47). Results: By the end of June 2015, 13 deaths, 18 HTx (2 urgent) and 23 LVAD implants (11 as INTERMACS 1-3) had been observed. 1-y actuarial urgent HTX/LVAD-free survival was 54%, and was lower in LEVO-NR than in LEVO-R pts (32% vs 66%, p= .001). With respect to LEVO-R, LEVO-NR were slightly younger (51+/-13 vs 56+/-11 y, p= .07), more frequently treated for weaning from continuous inotropes (60% vs 19%, p= .04), and had more severe signs of neuroendocrine activation (sodium 136+/-4 vs 139+/-3 mEq/l, p= .03; NTproBNP 9842+/-13914 vs 5239+/-6098 ng/ml, p= .12). No differences were found in etiology, diuretic dose, concomitant oral therapy, echocardiographic, hemodynamic, and other laboratory data. Median time spent at home by LEVO-R pts was 155 days in the first 6 months of treatment vs 135 in the previous 6 months, and median time to treatment failure was 203 days. Conclusion: Repeated LEVO infusions allow weaning from continuous inotropes in a minority of pts with refractory HF. With respect to reported medical outcomes in similar cohorts, 1-y survival free from urgent HTX/LVAD appears acceptable in pts with initially favourable response. However, event rate is high, and possible benefits are limited in time. 3( 59) The Hemodynamic Effects of Milrinone in the Beta-Blocker Era S. Kalantari Tannenbaum , J. Grinstein, B. Smith, K. Marinescu, N. Sarswat, S. Adatya, G. Sayer, G.H. Kim, T. Ota, V. Jeevanandam, N. Uriel. Cardiology, University of Chicago, Chicago, IL. Purpose: Advanced heart failure patients are treated with inotropes as bridge to heart transplantation, left ventricular assist device, or as palliative care. The combination of this therapy with beta-blocker therapy is well tolerated; however the physiological effects of both medications together seem contradictory. This study aims to describe the hemodynamic changes in response to milrinone in patients with or without beta-blocker therapy. Methods: Patients with systolic heart failure referred for right heart catheterization who underwent milrinone drug study in the cath lab between June 2014 to October 2015 were identified on retrospective chart review (n= 30). Invasive hemodynamics were measured before and after milrinone administration at 5 mcg/kg/min for 10 min. The hemodynamic response was compared between patients receiving and not receiving beta-blocker therapy. Results: There were no significant differences in baseline characteristics, left ventricular ejection fraction (mean = 26%), or cardiac output between those on beta-blockers (n= 21 [70%]) and those not on beta-blockers. Patients on beta-blockers had a significantly higher increase in cardiac output compared to patients not receiving beta-blockers (1.5 ± 0.8 L/min vs. 0.8 ± 0.9 L/min, p = 0.03) (Figure 1). A higher reduction of mean pulmonary artery pressure (mPAP) and central venous pressure (CVP) was achieved on beta blockers, however it did not reach statistical significance: mPAP (-5.2 ± 5.7 mmHg vs. -2.2 ± 3.3 mmHg, p = 0.16), CVP (-4.3 ± 2.8 mmHg vs. -2.8 ± 2.8 mmHg, p = 0.2). There was no statistically significant change in pulmonary capillary wedge pressure (-5.9 ± 4.8 mmHg vs. -4.1 ± 6.5 mmHg, p = 0.44). Conclusion: Patients on beta-blockers have an increased positive hemodynamic response to milrinone challenge compared to patients not on betablockers. These differences cannot be explained by myocardial reserve alone and the mechanisms behind the synergistic effects of this combination needs further investigation.
3( 60) Value of N-Terminal Pro-Brain Natriuretic Peptide in the Assessment of Aerobic Capacity in Heart Failure Patients J. Huang . Department of Heart Transplant Center, Fuwai Hospital, Peking Union Medical College, Beijing, China. Purpose: Cardiopulmonary exercise test (CPET) has been the most accurate method to assess the aerobic capacity among heart failure (HF) patients and is also of great value to estimate prognosis and detect candidates for heart transplantation. We studied the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) and aerobic capacity in heart failure patients. Methods: We retrospectively analyzed data from 123 patients with definite diagnoses of heart failure between December 2012 and August 2015. All of them had performed the symptom limited maximal CPET to calculate the maximum oxygen consumption (PeakVO2). Blood samples had been taken within 24 hours to test NT-proBNP plasma levels, which is used to estimate Peak VO2 among these patients. Results: Plasma levels of NT-proBNP correlates significantly with Peak VO2 among the HF patients(r= -0.342, P< 0.001). NT-proBNP> 1176pg/ml showed 64% sensitivity and 76% specificity for estimating Peak VO2< 14 ml/ kg/min (area under the curve [AUC]= 0.72, P< 0.001). NT-proBNP> 1817 pg/ ml showed 80% sensitivity and 71% specificity for estimating Peak VO2< 10 ml/kg/min (AUC= 0.79, P< 0.001). After adjusted for age, gender, BMI and eGFR, the plasma level of NT-proBNP > 1176pg/ml was to predict Peak VO2< 14 ml/kg/min (OR= 5.71, 95%CI= 2.54-12.88) and > 1817 pg/ml was to predict Peak VO2< 10 ml/kg/min (OR= 9.93, 95%CI 2.61-37.79). Conclusion: NT-proBNP could reflect aerobic capacity in HF patients. More HF patients who were potential heart transplant recipients should perform CPET especially when plasma levels of NT-proBNP were above 1800pg/ml. 3( 61) Correlation of GDF-15 with Worsening Functional Capacity and Echocardiographic Parameters in Idiopathic Dilated Cardiomyopathy N. Nair ,1 E. Gongora.2 1Cardiology, S &W, Temple , TX, Texas Tech Health Sciences Center, Lubbock, TX; 2Cardiology, S &W, Temple , TX, Memorial Heart and Vascular Center, Hollywood, FL. Purpose: This study focuses on the utility of GDF-15 in clinical evaluation of heart failure in idiopathic dilated cardiomyopathy (IDCM). The role of GDF15 in this subgroup remains less well-defined. Association of GDF-15 with New York Heart Association (NYHA) functional class and echocardiographic parameters (left ventricular ejection fraction (LVEF) and Left ventricular Internal Dimension in diastole (LVIDd)) were therefore evaluated to assess structure /function relationships. Methods: The study population consisted of 23 IDCM patients and 8 control subjects aged 51+/- 13 and 59+/-10 respectively (p= 0.031). All DCM patients had a normal angiogram and no definite etiology for heart failure. Plasma levels of GDF-15 and Brain Natriuretic peptide (BNP) were measured by enzyme-linked immunoassays. LVEF and LVIDd were measured