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Interpretation of BNP

Interpretation of BNP. Peter A. McCullough, MD, MPH, FACC, FACP William Beaumont Hospital, Royal Oak, MI. Outline. Differentiating BNP and NT ProBNP Nuances of BNP Testing Obese patients and BNP Interpretation BNP and Cardiorenal Syndrome BNP in Preserved Systolic Dysfunction BNP in ACS

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Interpretation of BNP

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  1. Interpretation of BNP Peter A. McCullough, MD, MPH, FACC, FACPWilliam Beaumont Hospital, Royal Oak, MI

  2. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  3. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  4. 1 98 99 126 1 77 78 107 ProANP ProBNP Mechanical and Neurohumeral Signals Wall Stress ANP BNP Biosite Beckman Abbott Bayer N-BNP N-ANP High Variability Inferior Dx/Prognostic Test Roche NT-pro-BNP ProBNP Natriuretic Peptides — Storage and Secretion Made Constitutively Briefly Stored in Granules Stored Longer in Granules Corin Corin 120 min 3 min 20 min Small Quantities in Blood 120 min Adapted from McCullough PA, Omland T, Maisel AS. B-type natriuretic peptides: a diagnostic breakthrough for clinicians. Rev Cardiovasc Med. 2003 Spring;4(2):72-80.

  5. NT-proBNP Symptomatic CHF Normal NT-proBNP BNP LV Systolic/Diastolic Dysfunction Women Men Normal BNP Lifetime BNP/NT-proBNP Trajectory 5000 100 50 NT-ProBNP/BNP (pg/ml) Log Scale 20 30 60 90 Age (years) McCullough PA, Sandberg KR. Sorting out the Evidence on the Natriuretic Peptides, Rev Cardiovasc Med, 2003, 4 (Suppl 4), S13-19

  6. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  7. BNP and Body Weight in Normals Framingham participants without CVD (N = 3389) 25 Normal Overweight Obese 20 21.4 21.1 15 16.3 15.5 BNP (pg/mL) 13.1 12.7 10 5 0 Men Women Wang TJ et al. Circulation. 2004;109:594–600.

  8. Obesity and the Heart • Fatty steatosis of myocardium • Inflammatory factors • Cytokines Enhanced Clearance of BNP Impaired Cardiac Production of BNP

  9. BNP and Body Weight in Decompensated CHF Patients McCord J, et al, Arch Int Med 2004

  10. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  11. Estimated Glomerular Filtration and Normal Aging McCullough PA. Beyond serum creatinine: defining the patient with renal insufficiency and why? Rev Cardiovasc Med 2003;4(suppl 1):S2-S6. NLM CIT. ID 12556731

  12. Mean BNP by eGFR P < 0.0001 for all pairwise comparisons McCullough PA, Duc P, Omland T, McCord J, Nowak RM, Hollander JE, Herrmann HC, Steg PG, Westheim A, Knudsen CW, Storrow AB, Abraham WT, Lamba S, Wu AH, Perez A, Clopton P, Krishnaswamy P, Kazanegra R, Maisel AS; Breathing Not Properly Multinational Study Investigators. B-type natriuretic peptide and renal function in the diagnosis of heart failure: an analysis from the Breathing Not Properly Multinational Study. Am J Kidney Dis. 2003 Mar;41(3):571-9. NLM CIT. ID 12612980

  13. Optimal Cutpoints for Biosite BNP by Renal Function eGFR(ml/min/1.73 m2) ≥90 89–60 59–30 <30 N 540 480 358 74 Creatinine (mg/dL) 0.7 1.0 1.5 2.9 Optimum Cutpoint (pg/mL) 70.7 104.3 201.2 225.0 AUC 0.91 0.90 0.81 0.86 eGFR = estimated glomerular filtration rate ~ CrCl McCullough PA, Duc P, Omland T, McCord J, Nowak RM, Hollander JE, Herrmann HC, Steg PG, Westheim A, Knudsen CW, Storrow AB, Abraham WT, Lamba S, Wu AH, Perez A, Clopton P, Krishnaswamy P, Kazanegra R, Maisel AS; Breathing Not Properly Multinational Study Investigators. B-type natriuretic peptide and renal function in the diagnosis of heart failure: an analysis from the Breathing Not Properly Multinational Study. Am J Kidney Dis. 2003 Mar;41(3):571-9. NLM CIT. ID 12612980

  14. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  15. 402 ± 66 P < 0.001 294 ± 82 203 ± 30 33 ± 3 Normal Impaired Relaxation Pseudonormal Restrictive BNP levels in stable patients with diastolic dysfunction BNP (pg/ml) Lubien R, et al, Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002 Feb 5;105(5):595-601

  16. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  17. ACS Survival by BNP Quartile Analysis 10 Quartile 4 (BNP > 80 pg/ml) 8 6 Quartile 3 Mortality, Percent 4 Quartile 2 2 Quartile 1 0 0 50 100 150 200 250 300 Time (days) Braunwald, N Engl J Med, Vol 345, No. 14, 2001

  18. Kaplan-Meier Survival Curves Regarding Probability of Death During 1 Year for Patient Strata, According to Quartiles of NT-proBNP P<0.001, log rank >1869 ng/L Cumulative Probability of Death 669-1869 ng/L 238-669 ng/L <=237 ng/L Days James S. et al., Circulation 2003; 108:275-81.

  19. Mortality at 1-Year Follow-Up Among Strata of Patients, According to Quartiles of NT-proBNP and Quartiles of Creatinine Clearance Death 1 year, % NT-proBNP, quartiles pg/mL >1869 669-1869 238-668 <=237 Creatinine clearance, ml/min James S. et al., Circulation 2003; 108:275-81.

  20. Outline • Differentiating BNP and NT ProBNP • Nuances of BNP Testing • Obese patients and BNP Interpretation • BNP and Cardiorenal Syndrome • BNP in Preserved Systolic Dysfunction • BNP in ACS • BNP and Nesiritide Treatment

  21. Blood Levels of BNP and NT-proBNP with Nesiritide Infusion N=27 with CHF Fitzgerald, et al, J Card Fail, October 2004: 10(4, Supplement) (Abstract #129)

  22. Conclusions • BNP and NT-proBNP have fundamental differences • Adiposity ↓ BNP 30-50% • Renal insufficiency ↑ BNP 100-500 pg/ml range • BNP in diastolic dysfunction • Elevated but not as high as systolic dysfunction • Related to severity of diastolic impairment • BNP in ACS • Elevated in only 25% of UA or ACS • Is a risk marker for mortality • BNP is dynamic through a nesiritide infusion

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