The SA Journal Diabetes & Vascular Disease Vol 13 No 1 (July 2016)

REVIEW

SA JOURNAL OF DIABETES & VASCULAR DISEASE

VOLUME 13 NUMBER 1 • JULY 2016

In another study that involved 72 patients on haemodialysis,

NT-pro-BNP level was not associated with heart failure, but was

dependent on factors associated with an increase in post-load.

An association between increased levels of NT-pro-BNP and

chronic renal failure was also demonstrated in patients without

left ventricular dysfunction.

17,18

Diabetes mellitus

In a study on 371 patients with heart failure, 81 of whom had

diabetes, the levels of 10 neurohormones from the plasma

(adrenaline, noradrenaline, dopamine, aldosterone, renin,

endothelin, ANP, NT-pro-ANP, BNP and NT-pro-BNP) were measured.

All patients were also part of the PRIME-II study that investigated

the effects of ibopamine on the causes of mortality in patients with

moderate or severe heart failure.

Most of the neurohormones were similar between the two

groups, but patients with diabetes had higher values of BNP and

NT-pro-BNP. The patients were monitored for five years, and during

this time, 195 died, of whom 51 had diabetes. For patients with

diabetes, noradrenaline, ANP, NT-pro-ANP, BNP and NT-pro-BNP

levels were significantly higher than in those who did not survive.

Therefore BNP and NT-pro-BNP proved the strongest predictors of

outcome for both groups of patients.

The most likely explanation for the increase in BNP and NT-pro-

BNP levels in these patients with diabetes was the presence of

diastolic dysfunction.

Another study showed normal values of

NT-pro-BNP for women with gestational type 2 diabetes mellitus,

and lower values for those with insulin-dependent gestational

diabetes.

Cirrhotic cardiomyopathy

Cirrhotic cardiomyopathy is an under-diagnosed condition. This is

most likely due to the fact that there is no single diagnostic test to

identify these patients.

Numerous recent studies demonstrated that patients with

hepatic cirrhosis had increased plasma concentrations of BNP and

NT-pro-BNP, representing markers of early ventricular dysfunction.

Henriksen

et al

showed that these markers were correlated with

the severity of hepatic cirrhosis, and with heart dysfunction. BNP

could therefore have prognostic value with regard to the evolution

of cirrhosis. In addition NT-pro-BNP represents a useful marker

to demonstrate the existence of diastolic dysfunction of the left

ventricle caused by a chronic hepatic disease.

A study conducted on 153 patients subjected to a liver transplant

determined their BNP levels post-transplant and on days 1 and 7. It

was observed that a BNP level higher than 391 pg/ml immediately

after the liver transplant appeared to be an early marker for heart

dysfunction related to the cirrhosis.

Conclusion

In patients with dyspnoea, overlapping or even conflicting history,

physical and radiographic findings often hinder the differentiation

between cardiac and non-cardiac aetiology. The primary value of

BNP and NT-pro-BNP testing in the emergency department is its

diagnostic value in the differential diagnosis of acute dyspnoea

and possible congestive heart failure.

Levels of natriuretic peptides may also assist the emergency

physician in appropriately triaging the patient with congestive

heart failure.

Studies have shown that measurements of BNP

or NT-pro-BNP in the emergency department can be used to

establish the diagnosis of congestive heart failure when clinical

presentation is ambiguous or when confounding co-morbidities

are present.

After multiple studies, the conclusion was reached that levels

of BNP < 100 pg/ml and > 500 pg/ml have a positive and negative

predictive value, respectively, of 90% for the diagnosis of congestive

heart failure for patients presenting with acute dyspnoea. For

values between 100 and 500 pg/ml, the physicians must consider

underlying left ventricular dysfunction, the effects of renal failure,

or right ventricular dysfunction secondary to chronic pulmonary

disease or acute pulmonary embolism.

The recommended thresholds of less than 100 pg/ml to rule

out heart failure and more than 500 pg/ml to rule in heart failure

have been estimated to have the following likelihood ratios (LRs):

LR-negative = 0.13 and LR-positive = 8.1. These different cut-off

values create an intermediate range of 100–500 pg/ml with an

LR-positive of only 1.9 pg/ml. Therefore, an intermediate BNP

result alone cannot be used to rule in or rule out heart failure.

Acknowledgements

Research done on the POSDRU/6/1.5/S/26 project was co-financed

by the European Social Funds by means of the Sectoral Operational

Programme for the Development of the Human Resources 2007–

2013.

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