Prognostic Implications of NT

For patients with heart failure with preserved ejection fraction, levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) can be used as a prognostic measure to determine risk outcome based on the presence or absence of atrial fibrillation (AF), according to a study published in Circulation: Heart Failure.

Using data from the Irbesartan in Heart Failure With Preserved Systolic Function trial (NCT00095238) and the Treatment of Preserved Cardiac Function in Heart Failure With an Aldosterone Antagonist (NCT00094302), researchers evaluated the prognostic value N-terminal pro-B-type natriuretic peptide levels have on outcomes in patients with heart failure (HF) with preserved ejection fraction. The trials included in this study evaluated the impact of angiotensin II receptor antagonist or aldosterone antagonist on morbidity and mortality. Based on baseline NT-proBNP levels, patients were categorized into subgroups of <200, 200 to 399, 400 to 999, 1000 to 1999, and ≥2000 pg/mL. Outcomes of interest were cardiovascular (CV) death or HF hospitalization.

Of the 3835 patients included in this study, 3479 came from the Irbesartan in Heart Failure With Preserved Systolic Function trial, and 356 came from the Treatment of Preserved Cardiac Function in Heart Failure With an Aldosterone Antagonist trial. When comparing the cohort of patients with AF (n=719) with those without, patients were older (74 vs 71 years), more likely men (47% vs 39%), more likely to have been hospitalized for HF (57% vs 40%), and less likely to have experienced a myocardial infarction (17% vs 26%; all P <.001).

Patients with higher levels of NT-proBNP were more likely to have lower systolic blood pressure, lower body mass index, worse kidney function, been hospitalized for HF, experienced a myocardial infarction, and be treated with β-blockers and diuretics.

When analyzing the NT-proBNP categories, patients with AF made up 3% of the <200 pg/mL category, 6% of the 200 to 399 pg/mL category, 28% of the 400 to 999 pg/mL category, 36% of the 1000 to 1999 pg/mL category, and 27% of the ≥2000 pg/mL category.

At NT-proBNP levels <400 pg/mL, CV death or HF hospitalization was higher in patients with AF but at NT-proBNP levels >1000 pg/mL, CV death or HF hospitalization was lower in patients with AF.

After analysis, a greater risk for mortality was found in patients without AF at the higher level of NT-proBNP categories.

Limitations of this study include using patients enrolled for trials to pragmatically determine NT-proBNP categories and the limited external validity of findings for extrapolating to a community-based setting.

The researchers concluded "[a]mong patients with NT-proBNP ≥400 pg/mL, the relationship between NT-proBNP and outcomes differs between individuals with and without AF, with lower absolute risk in patients with a high NT-proBNP have AF compared with those who do not have AF

The Irbesartan in Heart Failure With Preserved Systolic Function trial was supported by Bristol-Myers Squibb and Sanofi. Several authors report affiliation with pharmaceutical companies, please refer to original reference for a complete list of authors’ disclosures.

Reference

Kristensen SL, Mogensen UM, Jhund PS, et al. N-terminal pro-B-type natriuretic peptide levels for risk prediction in patients with heart failure and preserved ejection fraction according to atrial fibrillation status.Circ Heart Fail. 2019;12(3):e005766.