N-terminal brain natriuretic peptide is a more powerful predictor of mortality than endothelin-1, adrenomedullin and tumour necrosis factor-α in patients referred for consideration of cardiac transplantation

Abstract

Background: The selection of patients for cardiac transplantation is notoriously difficult. We have demonstrated that N-terminal brain natriuretic peptide (NT-proBNP) is a powerful predictor of mortality in advanced heart failure and is superior to the traditional markers of chronic heart failure (CHF) severity. However, the comparative prognostic power of endothelin-1 (Et-1), adrenomedullin (Adm) and tumour necrosis factor-alpha (TNF-a) in this patient group is unknown. Methods and results: We prospectively studied 150 consecutive patients with advanced CHF referred for consideration of cardiac transplantation. Blood samples for NT-proBNP, Et-1, Adm and TNF-a analysis were taken at recruitment and patients followed up for a median of 666 days. The primary endpoint of all-cause mortality was reached in 25 patients and the secondary endpoint of all-cause mortality or urgent cardiac transplantation in 29 patients. The median values for NT-proBNP, Et-1, Adm and TNF-a were 1494 pg/ml [interquartile range 530-3930], 0.39 fmol/ml [0.10-1.24], 94 pg/ml and 2.0 pg/ml [0-18.5] respectively. The only univariate and multivariate predictor of all-cause mortality (v 2 =26.95, pb0.0001), or the secondary endpoint of all-cause mortality or urgent transplantation (v 2 =31.23, pb0.0001), was an NT-proBNP concentration above the median value. Conclusion: A single measurement of NT-proBNP in patients with advanced CHF can help identify patients at the highest risk of death, and is a better prognostic marker than Et-1, Adm and TNF-a.

Biomarkers in heart failure: a clinical review

“…ET emerged as the best predictor of cardiac death. This seems in stark contrast to more contemporary studies such as those undertaken by Gardner and colleagues where the superiority of NT-proBNP in patients with advanced heart failure was incontrovertible, albeit in a small and highly selected patient group [49].…”

“…Carvedilol improved outcome in both those with ADM levels above median and those with ADM levels below median, and to a similar extent in terms of relative risk reduction. In patients with advanced heart failure, Gardner and colleagues have convincingly demonstrated the superiority of NT-proBNP over ADM [49]. These conflicting results may relate to the heterogeneous populations studied (e.g.…”

“…In patients with advanced heart failure referred for consideration of cardiac transplantation, NT-proBNP (or a change in NT-proBNP) was the only independent predictor of all-cause mortality or need for transplantation and out-performed conventional prognostic indicators including left ventricular ejection fraction (LVEF), peak maximum oxygen uptake, Heart Failure Survival Score and plasma neurohormones [49][50][51]. The selection of patients for such expensive and finite resources is difficult.…”

B‐Type Natriuretic Peptide: Application in the Community

“…[20][21][22] Of particular note is that an isolated reading has been shown to be superior to well-established predictors of outcome including peak VO 2 , ventricular function, the heart failure survival score, and levels of plasma norepinephrine. 23,24 In addition, changes in natriuretic peptide levels are also predictive of outcome in both patients with stable heart failure as well as those with advanced heart failure. 25,26 Assessment of Clinical Deterioration.…”

B-type Natriuretic Peptides in Heart Failure

“…However, these variables vary in their success at predicting outcome owing to the heterogeneous nature of heart failure, together with the availability and reproducibility of investigatory tools. Our group has shown that NT-proBNP appears superior to traditional markers of outcome (e.g., the LV ejection fraction, peak O 2 uptake and Heart Failure Survival Score) as well as other neurohormones in patients with advanced heart failure [13][14][15].…”