Background: Whole-body water immersion leads to a significant shift of blood from the periphery to the intrathoracic circulation, followed by an increase in central venous pressure and heart volume. ...In patients with severely reduced left ventricular function, this hydrostatically induced volume shift might overstrain the cardiovascular adaptive mechanisms and lead to cardiac decompensation. Aim: To assess the haemodynamic response to water immersion, gymnastics and swimming in patients with chronic heart failure (CHF). Methods: 10 patients with compensated CHF (62.9 (6.3) years, ejection fraction 31.5% (4.1%), peak oxygen consumption (V̇o2) 19.4 (2.8) ml/kg/min), 10 patients with coronary artery disease (CAD) but preserved left ventricular function (57.2 (5.6) years, ejection fraction 63.9% (5.5%), peak V̇o2 28 (6.3) ml/kg/min), and 10 healthy controls (32.8 (7.2) years, peak V̇o2 45.6 (6) ml/kg/min) were examined. Haemodynamic response to thermoneutral (32°C) water immersion and exercise was measured using a non-invasive foreign gas rebreathing method during stepwise water immersion, water gymnastics and swimming. Results: Water immersion up to the chest increased cardiac index by 19% in controls, by 21% in patients with CAD and by 16% in patients with CHF. Although some patients with CHF showed a decrease of stroke volume during immersion, all subjects were able to increase cardiac index (by 87% in healthy subjects, by 77% in patients with CAD and by 53% in patients with CHF). V̇o2 during swimming was 9.7 (3.3) ml/kg/min in patients with CHF, 12.4 (3.5) ml/kg/min in patients with CAD and 13.9 (4) ml/kg/min in controls. Conclusions: Patients with severely reduced left ventricular function but stable clinical conditions and a minimal peak V̇o2 of at least 15 ml/kg/min during a symptom-limited exercise stress test tolerate water immersion and swimming in thermoneutral water well. Although cardiac index and V̇o2 are lower than in patients with CAD with preserved left ventricular function and controls, these patients are able to increase cardiac index adequately during water immersion and swimming.
The identification of patients at highest risk for adverse outcome who are presenting with acute dyspnea to the emergency department remains a challenge. This study investigates the prognostic value ...of the newly described midregional fragment of the pro-Adrenomedullin molecule (MR-proADM) alone and combined to B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) in patients with acute dyspnea.
We conducted a prospective, observational cohort study in the emergency department of a University Hospital and enrolled 287 unselected, consecutive patients (48% women, median age 77 (range 68 to 83) years) with acute dyspnea.
MR-proADM levels were elevated in non-survivors (n = 77) compared to survivors (median 1.9 (1.2 to 3.2) nmol/L vs. 1.1 (0.8 to 1.6) nmol/L; P < 0.001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.81 (95% CI 0.73 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for MR-proADM, NT-proBNP and BNP, respectively (MRproADM vs. NTproBNP P = 0.38; MRproADM vs. BNP P = 0.009). For one-year mortality the AUC were 0.75 (95% CI 0.69 to 0.81), 0.75 (95% CI 0.68 to 0.81), 0.69 (95% CI 0.62 to 0.76) for MR-proADM, NT-proBNP and BNP, respectively without any significant difference. Using multivariate linear regression analysis, MR-proADM strongly predicted one-year all-cause mortality independently of NT-proBNP and BNP levels (OR = 10.46 (1.36 to 80.50), P = 0.02 and OR = 24.86 (3.87 to 159.80) P = 0.001, respectively). Using quartile approaches, Kaplan-Meier curve analyses demonstrated a stepwise increase in one-year all-cause mortality with increasing plasma levels (P < 0.0001). Combined levels of MR-proADM and NT-proBNP did risk stratify acute dyspneic patients into a low (90% one-year survival rate), intermediate (72 to 82% one-year survival rate) or high risk group (52% one-year survival rate).
MR-proADM alone or combined to NT-proBNP has a potential to assist clinicians in risk stratifying patients presenting with acute dyspnea regardless of the underlying disease.
Abstract Objectives This study aimed to examine the influence of history of heart failure (HF) on circulating levels, diagnostic accuracy and prognostic value of B-type natriuretic peptide (BNP) in ...patients presenting with all cause dyspnea at the emergency department. Background BNP has been shown to be very helpful in diagnosis and prognosis of HF. Due to chronically elevated cardiac filling pressures, patients with a history of HF might have higher BNP levels and therefore diagnostic and prognostic properties of BNP may be affected. Methods We analyzed circulating levels, diagnostic accuracy and prognostic value of BNP in 388 patients without a previous history of HF and compared these to data to 64 patients with a history of HF included in the B-type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) Study. Results Baseline BNP levels were higher in patients with a history of HF (median 814 pg/ml 353–1300 pg/ml vs. 216 pg/ml 45–801 pg/ml, p < 0.001). Diagnostic accuracy of BNP to identify HF was comparable in patients with (AUC = 0.804; 95% CI 0.628–0.980) and in patients without history of HF (AUC = 0.883; 95% CI 0.848–0.919, p = 0.389). Prognostic ability of BNP to predict one-year mortality was lower in overall patients with history of HF (AUC = 0.458; 95%CI 0.294–0.622) compared to patients without history of HF (AUC = 0.710; 95% CI 0.653–0.768, p < 0.05). Conclusions In patients with history of HF, BNP levels retain diagnostic accuracy. Ability to predict one-year mortality was decreased in unselected patients, but not in patients with acute HF-induced dyspnea.
The role of the arginine–vasopressin (AVP) system in the response to myocardial ischemia is unclear. Copeptin, the C-terminal part of the AVP prohormone is secreted stoichiometrically with AVP.
A ...total of 253 consecutive patients with suspected myocardial ischemia referred for rest/ergometry myocardial perfusion single-photon emission computed tomography (SPECT) were enrolled. We evaluated the response of copeptin during exercise and determined whether measurement of copeptin may be helpful in the detection of myocardial ischemia.
Myocardial ischemia on perfusion images was detected in 127 patients (50%). Median copeptin levels increased significantly with exercise in patients with ischemia as well as in patients without ischemia (from 3.8 IQR 2.8–6.6 to 12.3 IQR 5.2–39.6 pmol/l,
P
<
0.001; and from 3.6 IQR 2.6–5.7 to 10.8 IQR 5.0–24.5 pmol/l,
P
<
0.001). Median exercise-induced changes in copeptin (Δcopeptin) were similar in both groups (7.7 versus 5.1 pmol/l,
P
=
0.150). The area under the ROC curve for the ability of Δcopeptin to detect myocardial ischemia was 0.552.
Copeptin levels increased threefold with exercise, irrespective of the presence or absence of myocardial ischemia. Therefore, myocardial ischemia does not seem to be a major trigger of the AVP system. Measurement of copeptin does not seem helpful in the detection of exercise-induced myocardial ischemia.
Objectives: To quantify the prognostic utility of QRS and QTc interval prolongation in patients presenting with acute destabilised heart failure (ADHF) to the emergency department (ED). Design: ...Prospective cohort study among patients enrolled in the B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study. QRS and QT intervals were measured in 173 consecutive patients with ADHF. QT interval was corrected using the Bazett formula. The primary end point was all-cause mortality during the 720-day follow-up. Results: QRS interval was prolonged (⩾120 ms) in 27% of patients, and QTc interval was prolonged (⩾440 ms) in 72% of patients. Baseline demographic and clinical characteristics were comparable in patients with normal and prolonged QRS or QTc intervals. A total of 78 patients died during follow-up. Interestingly, the 720-day mortality was similar in patients with prolonged and normal QTc (44% vs 42%, p = 0.546), but was significantly higher in patients with prolonged QRS interval than in those with normal QRS (59% vs 37%, p = 0.004). In Cox proportional hazards analysis, prolonged QRS interval was associated with a nearly twofold increase in mortality (HR 1.94, 95% CI 1.22 to 3.07; p = 0.005). This association persisted after adjustment for variables routinely available in the ED. Conclusions: Prolonged QRS interval, but not prolonged QTc interval, is associated with increased long-term mortality in patients with ADHF.
Aims
To investigate the relationship between central venous pressure (CVP) at presentation to the emergency room (ER) and the risk of cardiac rehospitalization and mortality in patients with ...decompensated heart failure (DHF).
Methods and results
Central venous pressure was determined non‐invasively using high‐resolution compression sonography at presentation in 100 patients with DHF. Cardiac hospitalizations and cardiac and all‐cause mortality were assessed as a function of continuous CVP levels and predefined CVP categories (low <6 cm H2O, intermediate 6–23 cm H2O, and high >23 cm H2O). Endpoints were adjudicated blinded to CVP. At presentation, mean age was 78 ± 11 years, 60% of patients were male, mean B‐type natriuretic peptide level was 1904 ± 1592 pg/mL, and mean CVP was 13.7 ± 7.0 cm H2O (range 0–33). During follow‐up (median 12 months), 25 cardiac rehospitalizations, 26 cardiac deaths, and 7 non‐cardiac deaths occurred. Univariate and stepwise multivariate Cox regression analysis revealed an independent relationship between CVP and cardiac rehospitalization (HR 1.09, 95% CI 1.01–1.18, P = 0.034). Kaplan–Meier analyses confirmed a stepwise increase in cardiac rehospitalization for low‐to‐high CVP (log‐rank test P = 0.015). No association between CVP and (cardiac) mortality was detectable.
Conclusion
Central venous pressure at ER presentation in patients with DHF is an independent predictor of cardiac rehospitalization but not of cardiac and all‐cause mortality.
Aims
Data on moderately cold water immersion and occurrence of arrhythmias in chronic heart failure (CHF) patients are scarce.
Methods and results
We examined 22 male patients, 12 with CHF mean age ...59 years, ejection fraction (EF) 32%, NYHA class II and 10 patients with stable coronary artery disease (CAD) without CHF (mean age 65 years, EF 52%). Haemodynamic effects of water immersion and swimming in warm (32°C) and moderately cold (22°C) water were measured using an inert gas rebreathing method. The occurrence of arrhythmias during water activities was compared with those measured during a 24 h ECG recording. Rate pressure product during water immersion up to the chest was significantly higher in moderately cold (P = 0.043 in CHF, P = 0.028 in CAD patients) compared with warm water, but not during swimming. Rate pressure product reached 14200 in CAD and 12 400 in CHF patients during swimming. Changes in cardiac index (increase by 5-15%) and oxygen consumption (increase up to 20%) were of similar magnitude in moderately cold and warm water. Premature ventricular contractions (PVCs) increased significantly in moderately cold water from 15 ± 41 to 76 ± 163 beats per 30 min in CHF (P = 0.013) but not in CAD patients (20 ± 33 vs. 42 ± 125 beats per 30 min, P = 0.480). No ventricular tachycardia was noted.
Conclusion
Patients with compensated CHF tolerate water immersion and swimming in moderately cold water well. However, the increase in PVCs raises concerns about the potential danger of high-grade ventricular arrhythmias.
Aims
Evaluation and management of patients with hypoxaemic respiratory failure in the intensive care unit (ICU) are difficult. The use of B‐type natriuretic peptide (BNP), a quantitative marker of ...cardiac stress and heart failure (HF), may be helpful. The purpose of this study is to describe the prevalence of causative disorders of hypoxaemic respiratory failure in the ICU and to determine the impact of a BNP‐guided diagnostic strategy.
Methods and results
This prospective, multi‐centre, randomized, single‐blind, controlled trial included 314 ICU patients with hypoxaemic respiratory failure: 159 patients were randomly assigned to a diagnostic strategy involving the measurement of BNP and 155 were assessed in a standard manner. The time to discharge and the total cost of treatment were the primary endpoints. Hypoxaemic respiratory failure was multi‐causal in 27% of the patients. Heart failure was the most common diagnosis in both groups. The use of BNP levels, in conjunction with other clinical information, significantly increased the detection of HF in combination with an additional diagnosis (32 vs. 16%, P = 0.001) and also increased the application of HF‐specific medical therapy (nitrates: 32 vs. 23%, P < 0.05 and diuretics: 65 vs. 50%, P < 0.01). Time to discharge (median, 13 vs.14 days, P = 0.50) and total cost of treatment (median, US‐$6190 vs. 7155, P = 0.24) were comparable in both groups.
Conclusion
Hypoxaemic respiratory failure in the ICU is often a multi‐causal disorder. The use of BNP increased the detection of HF, but did not significantly improve patient management as quantified by time to discharge or treatment cost. ClinicalTrials.gov Identifier: NCT00130559.
Abstract Background Exercise is associated with changes in circulating B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP). However, the biological relevance of this phenomenon is ...poorly examined. We sought to assess determinants of absolute (Δ) and relative (Δ%) exercise-induced changes in BNP and NT-proBNP. Methods BNP ( n = 418) and NT-proBNP ( n = 478) at rest and peak exercise were measured in patients undergoing symptom-limited cycle ergometer tests. Multivariate logistic regression was performed to identify predictors of high Δ BNP/ Δ NT-proBNP and high Δ BNP/ Δ %NT-proBNP defined as their highest quartiles (Q4). Results The median (interquartile range) Δ BNP and Δ NT-proBNP was 12 (0–28) pg/ml and 7 (2–21) pg/ml respectively, and Δ %BNP and Δ %NT-proBNP was 21 (0–46) % and 7 (3–12) % respectively. Higher BNP odds ratio (OR) 3.92 per ln unit; p < 0.001 or NT-proBNP OR 4.88 per ln unit; p < 0.001 at rest was the strongest predictor of Δ BNP in Q4 (≥ 28 pg/ml) or Δ NT-proBNP in Q4 (≥ 21 pg/ml). In contrast, higher maximal work rate expressed as the percentage of the predicted value (OR 1.015 per %; p = 0.007) was the only independent predictor of Δ %BNP in Q4 (≥ 46%), and lower resting heart rate (OR 0.97 per bpm; p = 0.001) and lower age (OR 0.95 per year; p = 0.001) were the only independent predictors of Δ %NT-proBNP in Q4 (≥ 12%). Conclusions Higher ΔBNP and ΔNT-proBNP primarily reflected higher BNP and NT-proBNP plasma levels at rest. In contrast, higher Δ%BNP and Δ%NT-proBNP were associated with several prognostically favorable features, indicating that higher Δ%BNP and Δ%NT-proBNP may be markers of health rather than disease.
Abstract The utility of B-type natriuretic peptide (BNP) testing in patients with atrial fibrillation (AF) is poorly defined. We analyzed patients ( n = 452) included in the BNP for Acute Shortness ...of Breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with or without the use of BNP. Ninety-nine patients presented with AF ( n = 48 BNP group; n = 51 control group). Although comparable with respect to gender and cardiopulmonary comorbidity, patients with AF were older and more often had heart failure as the cause of dyspnea. In addition, patients with AF had higher in-hospital mortality (13% versus 6%, P = 0.012). The use of BNP significantly reduced time to discharge (BNP group median 8 days 1–16 versus 12 days IQR 4–21 control group; P = 0.046) in patients with AF. Initial total treatment costs (median) were $4239 769–7422 in the BNP group and $5940 4024–10848 in the control group ( P = 0.041). These benefits were maintained after 90 days: patients in the BNP group had spent fewer days in hospital (10 days 2–21 versus 15 days IQR 9–27; P = 0.022) and induced lower total treatment costs ($4790 1260–9387 versus $7179 4311–13173; P = 0.016). In conclusion, the use of BNP seems to improve the management of patients with AF presenting with dyspnea.
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