Heart failure (HF) is, after cirrhosis, the second-most common cause of ascites. Serum B-type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. Therefore, we hypothesized that BNP would be useful in the differential diagnosis of ascites. Consecutive patients with new onset ascites were prospectively enrolled in this crosssectional study. All patients had measurements of serum-ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum, and ascites BNP. We enrolled 218 consecutive patients with ascites resulting from HF (n 5 44), cirrhosis (n 5 162), peritoneal disease (n 5 10), and constrictive pericarditis (n 5 2). Compared to SAAG and/or total protein concentration in ascites, the test that best discriminated HF-related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, and diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1); that is, it was the best to rule in HF-related ascites. Conversely, a cutoff £ 182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule out HF-related ascites. These findings were confirmed in a 60-patient validation cohort. Conclusions: Serum BNP is more accurate than ascites analyses in the diagnosis of HFrelated ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test and could forego the need for diagnostic paracentesis, particularly in cases where the cause of ascites is uncertain and/or could be the result of HF. (HEPATOLOGY 2014;59:1043-1051 See Editorial on Page 751A scites secondary to heart failure (HF) is, after cirrhosis, the second-most common cause of ascites. 1 The pathophysiology of ascites in both HF and cirrhosis is hepatic sinusoidal hypertension, and therefore the serum-ascites albumin gradient (SAAG) is greater than 1.1 g/dL in both conditions. 2 Because the hepatic sinusoids are normal (leaky, i.e., without significant collagen deposition in the space of Disse) in HF and are abnormal in cirrhosis (less leaky as a result of capillarization of sinusoids), 3 ascites total protein content is higher in HF-related ascites than in cirrhotic ascites and has been used to help in the differential diagnosis between these two entities, with a ascites protein level of >2.5 mg/dL suggesting the presence of ascites related to HF. However, a significant number of cases are still misclassified. 2,4 Even the Abbreviations: ASE, American Society of Echocardiography; BNP, B-type natriuretic peptide; CLD, chronic liver disease; HF, heart failure; HVPG, hepatic venous pressure gradient; INR, international normalized ratio; IQR, interquartile range; LR, likelihood ratio; NPV, negative predictive value; NT-proBNP, N-terminal proBNP; PH, portal hypertension; PPV, positive predictive value; SAAG, serum-ascites albumin gradient; STARD, Standards for reporting Studies of Diagnostic Accuracy; US, ultrasound.From the

Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.

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