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European Journal of Heart Failure 2006 8(8):797-803; doi:10.1016/j.ejheart.2006.03.002
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© 2006 European Society of Cardiology

Correlation between serial measurements of N-terminal pro brain natriuretic peptide and ambulatory cardiac filling pressures in outpatients with chronic heart failure{star}

Frieder Braunschweiga,*, Astrid Fahrleitner-Pammerb, Maurizio Mangiavacchic, Stefano Ghiod, Parwis Fotuhie, Uta C. Hoppef and Cecilia Lindea

a Department of Cardiology, Karolinska University Hospital 171 76, Stockholm, Sweden
b Department of Endocrinology, Medical University Graz, Austria
c Unitá Operativa di Cardiologia Clinica, Istituto Clinico Humanitas Milan, Italy
d Divisione di Cardiologia, IRCCS Policlinico S Matteo Pavia, Italy
e Department of Cardiology, Charité Hospital Berlin, Germany
f Department of Internal Medicine III, University of Cologne Germany

* Corresponding author. Tel.: +46 8 5177 1629; fax: +46 8 31 10 44. E-mail address: frieder.braunschweig{at}karolinska.se


   Abstract
Top
 Notes
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Background: Serial measurements of N-terminal pro brain natriuretic peptide (NT-proBNP) have been suggested for the management of outpatients with chronic heart failure (CHF). The relationship between NT-proBNP plasma levels and central haemodynamic parameters in this setting is not known.

Methods: In 19 outpatients with CHF, NT-proBNP was related to central haemodynamic information, continuously measured with an implanted haemodynamic monitor (IHM) during 24 h of daily living activities ("24 h") and during supine rest ("rest"). In 13 patients, three to seven serial measurements were obtained with a mean time interval of 39 days (range 19–113).

Results: At the first visit (n=19), NT-proBNP plasma levels were dispersed over a wide range of filling pressures and not correlated with the 24 h median of the right ventricular systolic pressure (RVSP) and the estimated pulmonary artery pressure (ePAD). However, in the individual patient, serial measurements yielded significant positive correlations between NT-proBNP and RVSP (p=0.006) and ePAD (p=0.001). During "24 h" compared with "rest", the median RVSP and ePAD were elevated by 20±16% and 32±18%, respectively, and corresponded better with NT-proBNP (p<0.05).

Conclusion: In outpatients with CHF, single measurements of NT-proBNP are not correlated with cardiac filling pressures. However, serial measurements of NT-proBNP in each individual patient show a significant positive correlation with central haemodynamic parameters and reflect changes in the haemodynamic state over time.

Key Words: Natriuretic peptides • Chronic heart failure • Haemodynamics • Implantable devices

Received October 24, 2005; Revised February 3, 2006; Accepted March 8, 2006


   1. Introduction
Top
 Notes
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Chronic heart failure (CHF) is a growing public health care problem characterized by an increasing prevalence, high morbidity and poor prognosis [1]. The follow-up of outpatients with CHF is complicated by the unreliability of physical signs and symptoms and the lack of easily available and reliable indicators of the disease state [2]. Brain natriuretic peptide (BNP) and its inactive amino-terminal fragment NT-proBNP have been established as valuable markers in the diagnostic assessment of heart failure. Elevated in various conditions of left ventricular dysfunction, these peptides provide a high diagnostic accuracy to exclude or verify the presence of heart failure [3] and have been established as independent predictors of survival [4]. Moreover, recent reports suggest that natriuretic peptides may guide outpatient treatment in patients with chronic heart failure [5-8].

Since BNP release is triggered by increased volume load and wall stretch [9,10], it has been suggested that natriuretic peptide plasma levels reflect the central haemodynamic state [9,11]. Conversely, recent studies in patients with acute or chronic severe heart failure revealed only a weak correlation between single BNP measurements and cardiac filling pressures [12-14]. However, whether serial measurements of BNP and cardiac filling pressures are correlated at the individual patient level has not been investigated. Such a link would further advocate the usefulness of serial BNP testing in the context of CHF outpatient visits as a means of estimating changes in cardiac filling pressures over time.

Therefore, the aim of this study was to describe the relationship between serial measurements of NT-proBNP plasma levels and central haemodynamics in outpatients with chronic heart failure. Haemodynamic information was obtained from implanted monitors, providing the unique capability of safe and reliable serial haemodynamic evaluations without the need for repeated invasive procedures [15-17]. A potential advantage of this technique is that haemodynamic data can be recorded continuously during daily living activities. This ambulatory haemodynamic data may represent the patients "haemodynamic reality" and thus the trigger for NT-proBNP release, better than instantaneous measurements in the recumbent position. Therefore, haemodynamics were assessed (a) as the ambulatory 24 h median during activities of daily living and (b) during supine rest.


   2. Methods
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
Patients with moderate to severe CHF due to either ischaemic or idiopathic dilated cardiomyopathy and a left ventricular (LV) ejection fraction <35% were included. They had been implanted with the Chronicle® implantable haemodynamic monitoring system (IHM, Medtronic Inc., Minneapolis, USA) for at least 4 weeks and participated in the European Chronicle Network, a multi-centre study assessing different clinical and research applications of continuous haemodynamic monitoring. The presence of primary pulmonary hypertension, right heart valve disease or right heart valve prosthesis had been ruled out. Baseline data on LV ejection fraction and the LV end-diastolic diameter was obtained by standard transthoracic echocardiography. The study protocol was approved by the local ethics committees and patients provided written informed consent.

2.1. The haemodynamic monitor
The IHM consists of an electronic memory device and a transvenous lead carrying the pressure sensor. The device is implanted similar to a pacemaker system with the lead positioned in the right ventricular outflow tract. It collects information on heart rate (HR) and multiple pressure-related haemodynamic parameters. In the present study, HR, the right ventricular systolic pressure (RVSP) and an estimate of the pulmonary artery diastolic pressure (ePAD) were analyzed. The ePAD-defined as the RV pressure at the time of pulmonary valve opening as indicated by the maximum dP/dt-is highly correlated to actual PA pressures under various haemodynamic circumstances [18,19]. A piezoelectric activity sensor measured the activity level of the patient. Each patient carried an external pressure reference (EPR, Model 2805, Medtronic Inc.), which measured and stored the barometric pressure once every minute. At all follow-up visits, the EPR was linked to the programmer that calculated a correction of the absolute pressure data obtained by the IHM. The accuracy and stability of the IHM system over time has been confirmed in a multicentre trial using serial right heart catheterizations and comparing IHM signals with simultaneously acquired balloon-tipped catheter values at 3, 6 and 12 months after implantation [17]. These studies revealed a small baseline error at 12 months that was similar to the error at the time of implantation (<1.0 mm Hg). Further technical details of the Chronicle® have been published elsewhere [16,17].

2.2. NT-proBNP samples
Patients were assessed over a 10 month period on the basis of outpatient follow-up visits. The minimum time interval between two consecutive NT-proBNP measurements was set to 2 weeks. Analysis of serial measurements was performed in patients with at least three tests. Blood samples were always taken in the morning after an overnight fast, at the same time of the day (S.D.±44 min) and after 15 min of supine rest. Blood was drawn from an antecubital vein into tubes containing EDTA, immediately put on ice and centrifuged within 20 min at 4 °C and 4000 rpm for 10 min. The supernatant plasma was aliquoted and immediately stored at –70 °C. Plasma was analyzed in a core laboratory (AF) using a commercial biochemical assay (ELISA, Biomedica, Vienna, Austria). The coefficient of variation (CV) for intra-assay precision was <6.5%, the CV for inter-assay variation was <4.4%, and the lower and upper detection limit was 5 and 6000 pmol/L, respectively. All samples were measured in duplicate and averaged. If the CV was greater than 10%, the sample was re-assayed. A NT-proBNP level <250 pmol/L was considered normal.

2.3. Haemodynamic data acquisition
Two different haemodynamic conditions were assessed. (A) Ambulatory haemodynamics were measured as the median of HR, RVSP, ePAD and activity during 24 h prior to the NT-proBNP blood sample ("24 h"). For this purpose, the IHM continuously measured all haemodynamic parameters in a beat-to-beat fashion and stored a median value for each 24 min period in the device memory. Thus, 60 data points were generated over a 24 h period. (B) Haemodynamics at supine rest, resembling the conventional setting of haemodynamic assessment, were measured at the end of the 15 min resting period preceding each blood sample ("rest", Fig. 1). Haemodynamic variables were measured beat-to-beat and a median over 3 min was calculated. The normal ranges for the RVSP and ePAD are 15-30 mm Hg and 4-12 mm Hg, respectively.


Figure 1
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  		Fig. 1 Acquisition of haemodynamic data in relation to the NT-proBNP sample (patient example). The arrow indicates when blood was drawn for analysis of NT-proBNP after 15 min of rest. During daily living activities, the right ventricular systolic pressure (RVSP) as well as other ambulatory haemodynamic data was calculated as the median over 24 h preceding the resting period. Haemodynamics at rest were analyzed as the median over the last 3 min of the resting period preceding the blood sample. In this patient, the difference in RVSP between the 24 h median and rest was 6.5 mm Hg. The pressure variability during daytime is partly explained by different levels of physical activity (dotted line), but there is still considerable variability during the night at low levels of activity.

 
2.4. Statistics
Statistical analysis was performed using commercial available software (Statistica®, StatSoft Inc., Tulsa, USA; SAS® system, SAS Institute Inc., Cary, NC, USA). Normal distribution of the datasets at first visit and from serial pro-BNP measurements was confirmed by the Kolmogorov-Smirnov test. Continuous variables are presented as mean±standard deviation or as median, where indicated. Haemodynamic data during "24 h" and at "rest" were compared with a two-sided paired t-test. Simple linear regression analysis was used to determine the relation between NT-proBNP and haemodynamic variables. To analyze the significance of individual ("intra-patient") correlations between serial measurements of NT-proBNP and central haemodynamic variables with a different number of observations between patients (n=3-7), the procedure Mixed in SAS was used. The analysis was set up as a random coefficient model involving a random intercept and slope for each subject [20]. The Wilcoxon matched pairs test was used for the comparison of intra-individual correlation coefficients during "24 h" and "rest". A p-value less than 0.05 was considered statistically significant.


   3. Results
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
Nineteen patients were included (Table 1). All patients were treated with loop diuretics and ACE inhibitors or angiotensin receptor blockers, 15 with β-receptor blockers and 11 with spironolactone. Patients 9 and 15 were treated with continuous ambulatory dobutamine via an external drug infusion pump throughout the study. Patients 7 and 8 also had biventricular pacemakers implanted, and patients 2, 6, 11 and 12 had implantable cardioverter defibrillators. Dual device implants in these six patients were well tolerated without complications over time. After 10 months follow-up, three patients died (patient numbers 9, 16 and 17) and three underwent heart transplantation (patient numbers 5, 12 and 19). All NT-proBNP levels obtained during the study (n=69) were elevated (mean 872±407 pmol/L, range 271-1994).


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  		Table 1 Patient characteristics

 
3.1. Single measurements at first visit
The results from single measurements at the first follow-up visit (n=19) are presented in Table 2. During "rest", the activity count from the piezoelectric sensor was zero in all cases, confirming that patients had complied with strict physical rest. Mean NT-proBNP, RVSP and ePAD were above the normal range. During daily living conditions ("24 h"), HR, RVSP and ePAD increased significantly by 6±10%, 20±16% and 32±18%, respectively, as compared to "rest". The HR of patient no. 2 was identical to the pacemaker back-up rate of 60 bpm at both "24 h" and "rest". In some patients, RVSP (n=5) and ePAD (n=10) at rest were lower than any 24-min median value measured during daily living. NT-proBNP showed no significant correlation with the haemodynamic parameters at "rest" and "24 h" and was not correlated with physical activity.


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  		Table 2 Single measurements of NT-proBNP and haemodynamic parameters at first visit

 
3.2. Serial measurements
In 13/19 patients, at least 3 blood samples (range 3-7) were obtained for analysis of serial measurements with a mean interval of 39 days (range 19-113) between two consecutive samples. During follow-up, individual changes in NT-proBNP, "24 h"-RVSP and "24 h"-ePAD ranged between 85-877 pmol/L (12-107%), 4-34 mm Hg (4-34%) and 3-16 mm Hg (4-94%), respectively. Table 3 summarizes the mean values of NT-proBNP and filling pressures in the group of 13 patients with serial measurements. In concordance with the single measurements at first follow-up visit, the patient means of NT-proBNP were not correlated (ns).


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  		Table 3 Mean values for NT-proBNP and haemodynamic parameters from serial measurements (n=13)

 
Importantly, when serial measurements in each patient were analyzed, there was a significant positive intra-patient correlation between NT-proBNP and the 24 h median of RVSP (p=0.006) and ePAD (p=0.001) as analyzed by the random coefficient model. A similar outcome for intra-patient correlations was observed when percent changes in 24 h haemodynamic variables and NT-proBNP were correlated (r=0.62 and 0.65 for RVSP and ePAD, respectively; p<0.01). However, due to the varying number of samples per patient, the random coefficient model was considered more appropriate to describe the results. Fig. 2 shows the relationship between NT-proBNP and "24 h" RVSP (panel A) and "24 h" ePAD (panel B). For the whole group, NT-proBNP values were spread over a wide range of pressures. However, regression lines for the serial measurements in each patient indicate a positive correlation on the individual patient level. This relationship was stronger during the "24 h" period as compared to "rest". During "24 h", 12/13 patients had a positive correlation between NT-proBNP and RVSP/ePAD resulting in a median correlation coefficient of 0.71 and 0.74, respectively. During rest, the corresponding number was 9/13 patients with a median correlation coefficient of 0.53 and 0.44, respectively (p<0.05 for comparisons between "24 h" and "rest"). Accordingly, expressed by the random coefficient model, intra-patient correlations between NT-proBNP and haemodynamics reached higher significance levels during 24 h (p=0.006 and p=0.001) as compared with rest (p=0.025 and p=0.013 for RVSP and ePAD, respectively). NT-proBNP and physical activity, measured by the piezoelectric crystal, were negatively correlated in 10/13 patients. However, intra-patient correlations between NT-proBNP and activity or heart rate showed no statistical significance.


Figure 2
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  		Fig. 2 Intra-patient correlations between serial measurements of NT-proBNP and the 24 h median of the right ventricular systolic pressure (RVSP, panel A, p=0.006) and the estimated pulmonary artery pressure (ePAD, panel B, p=0.001) in 13 patients with chronic severe heart failure. Regression lines are drawn for serial measurements of each patient. Symbols and patient numbers: 1{square} 3+ 4{triangleup} 5{lozenge} 6{circ} 9Figure 2 10Figure 2 11Figure 2 13Figure 2 14{blacksquare} 15{blacktriangleup} 17{diamondsuit} 18{blacksquare}.

 

   4. Discussion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
The present study assessed the relationship between serial measurements of NT-proBNP plasma levels and cardiac filling pressures derived from an implanted haemodynamic monitor in outpatients with chronic moderate to severe CHF. The main finding was that serial measurements of NT-proBNP in the individual patient yield a significant positive correlation with cardiac filling pressures obtained by the implanted haemodynamic monitor. In contrast, no significant correlation between NT-proBNP and filling pressures was found for single measurements in the total patient group. This implies that NT-proBNP may well reflect changes in cardiac filling pressures over time in the individual patient albeit neurohormonal activation patterns and haemodynamic profiles vary largely between subjects with chronic heart failure.

Repeated BNP measurements are related to changes in NYHA heart failure severity [8] and have been suggested to guide treatment in outpatients with CHF [5-7]. In agreement with these reports, our finding supports the usefulness of serial NT-proBNP measurements in CHF outpatient follow-up by providing a link to haemodynamics on the individual patient level. Notably, our investigation was conducted in the setting of outpatient visits. Thus, variations in the study variables reflected changes as intrinsic to the course of chronic heart failure. This is in contrast to previous studies, evaluating the value of BNP tests in the context of acute clinical events [4,21] and specific therapeutic interventions [22,23]. Under such circumstances, corresponding changes of BNP and haemodynamic variables are more likely to occur.

The lack of correspondence between single measurements of NT-proBNP and cardiac filling pressures in our patient group is well matched by recent reports in patients admitted to intensive care units [12,14] or with chronic severe heart failure [13]. In agreement with these observations, our data indicates that NT-proBNP has a low predictive power to estimate cardiac filling pressures in patients with chronic heart failure and does not provide information comparable with a "biochemical Swan Ganz catheter". Well known reasons for a substantial between-patient variability of BNP included age, sex and co-morbidities typically associated with heart failure, such as impaired renal function [24,25]. BNP concentrations may also be affected by standard heart failure drugs such as ACE inhibitors, spironolactone and β-receptor antagonists [5,26,27].

Central haemodynamic function is commonly assessed in the resting, supine patient. Nevertheless, the "haemodynamic reality" during daily living with transient changes of activity and posture is different. Accordingly, filling pressures at rest were 20% to 32% lower as compared with 24 h median values. In some patients, values measured at supine rest were even lower than the minimum range registered during daily living conditions. BNP is activated predominantly after prolonged ventricular overload [28], shows little circadian variation [29] and only minor changes with vigorous exercise [30]. Due to its longer half-life, NT-proBNP may be even less responsive to short-term haemodynamic changes than BNP. Therefore, we hypothesized that NT-proBNP plasma concentrations rather reflect the long-term median haemodynamic condition during 24 h of daily living activities than a haemodynamic "snap shot" at supine rest. The present finding of stronger intra-patient correlations between NT-proBNP and RVSP and ePAD during 24 h compared to rest may indicate support for this hypothesis.

In this study, the use of implantable monitoring technology provided a unique source of ambulatory haemodynamic data and was crucial to avoid the obstacles associated with repeated invasive procedures. In light of the proven long-term accuracy of the pressure sensor [17], we do not consider that device-related issues contributed to the variability of the NT-proBNP/pressure relationship. Adamson et al. demonstrated that the IHM may improve heart failure management by providing early warning of imminent volume overload [16,31]. In a recent controlled study, clinical use of remote IHM technology decreased the need of CHF-related hospitalisation by 21% [32]. Hence, continuous haemodynamic monitoring and serial NT-proBNP monitoring are both potentially valuable tools to improve patient management in chronic heart failure. Their impact on patient outcome, however, remains to be established in prospective clinical trials.

4.1. Limitations
Due to the use of implantable monitors, the sample size of this study is small and permits no general conclusions. Patients were seen at relatively short intervals (39±23 days), which may have reduced the potential for larger changes in study variables. The effect of continuous dobutamine infusions, which were used in two study subjects, on circulating NT-proBNP levels has not been studied in detail, but is likely to reflect the haemodynamic response to this drug. However, it is interesting to note that the only patient without a positive correlation between NT-proBNP and filling pressures was on continuous dopamine infusion. Concomitant treatment with cardiac resynchronization devices, used in 6 patient, is becoming a common option in CHF patients. The programmed back-up pacing rate may have affected HR analysis but the spontaneous median HR was higher than the programmed back-up HR in all patients during 24 h and in 5/6 patients at rest.


   5. Conclusion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
This study provides new insights into the use of NT-proBNP as marker of the haemodynamic state in outpatients with chronic heart failure. Serial measurements of NT-proBNP are positively correlated to right ventricular pressure parameters in the individual patient. This implies that repeated NT-proBNP measurements may serve as a useful tool to indicate gradual changes in cardiac filling pressures and thus heart failure state over time. However, NT-proBNP values vary substantially between patients with chronic heart failure and a single BNP measurement does not provide the same information as a "biochemical Swan Ganz catheter".


   Acknowledgements
 
Elisabeth Berg is gratefully acknowledged for statistical advice. We thank Pierre André Grandjean and Marc Harrison, Medtronic Bakken Research Center, Maastricht, The Netherlands, for expert technical assistance.


   Notes
Top
 Notes
Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
{star} Supported by Medtronic, Bakken Research Center, Maastricht, The Netherlands and the Swedish Heart and Lung Foundation, Stockholm, Sweden. Back


   References
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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