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European Journal of Echocardiography 2006 7(1):45-52; doi:10.1016/j.euje.2005.04.014
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Copyright © 2005, The European Society of Cardiology

Left ventricular cavity area reflects N-terminal pro-brain natriuretic peptide plasma levels in heart failure*

Raquel Taléns-Viscontia, Miguel Rivera Oteroa,*, Ma José Sancho-Tellob, Fernando García de Burgosc, Luis Martínez-Dolzb, Begoña Sevillad, Vicente Climente, Raquel Cortésa, Antonio Salvadord, Francisco Sogorbe, Vicente Mirob, Ricardo Valerof, Jose Luis Perez-Boscág, Vicente Bertomeuf, Manuel Portolésa and Rafael Payág

aResearch Center La Fe Hospital, Valencia, Spain
bLa Fe Hospital, Valencia, Spain
cElche Hospital, Elche, Spain
dDr. Peset Hospital, Valencia, Spain
eGeneral Hospital, Alicante, Spain
fSan Juan Hospital, Alicante, Spain
gGeneral Hospital, Valencia, Spain

Received 22 November 2004; received in revised form 14 April 2005; accepted after revision 20 April 2005.

* Corresponding author. José María Haro, 59, puerta 59, 46022 Valencia, Spain. Tel.: +34 96 371 61 98; fax: +34 96 1973018. rivera_jmi{at}gva.es


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Limitations of the study
 Conclusions
 Notes
 References
 
Aims N-terminal pro-brain natriuretic peptide (NT-proBNP) is useful in the diagnosis of heart failure (HF). LV two-dimensional cavity area from end-diastole (LVEDA) and end-systole (LVESA), and LV fractional area change (LVFAC) reflect changes in LV morphology and function without using geometric assumptions. In a multicenter study, we correlated LVEDA, LVESA and LVFAC with NT-proBNP, comparing patients with dilated and ischemic cardiomyopathy.

Methods and results We studied 106 HF patients. In the dilated group, NT-proBNP correlated with LVEDAI (r=0.6), LVESAI (r=0.7) and LVFAC (r=–0.6), all significant at p<0.001. In patients with ischemic cardiomyopathy we found LVESAI (r=0.3, p<0.05) and LVFAC (r=–0.4, p<0.01). After adjustment for age and BMI, LVFAC and LVESAI were associated in a multiple linear regression analysis with peptide levels (adjusted r2=0.5, p<0.001).

Conclusions In this study we found a good correlation of NT-proBNP with LV cavity areas and LVFAC. Multiple regression analysis showed that when adjusted for age and BMI, LVFAC and LVESAI are independent predictors of NT-proBNP levels in both dilated and ischemic etiologies. Patients with dilated cardiomyopathy showed better results than those with ischemic cardiomyopathy. We think LV areas are a useful and reproducible parameter, do not need geometric assumptions and reflect NT-proBNP plasma levels.

Keywords: Heart failure; NT-proBNP; Left ventricular two-dimensional cavity area


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Limitations of the study
 Conclusions
 Notes
 References
 
Heart failure (HF) is a complex syndrome, mediated among others by neurohumoral and inflammatory factors. The myocardium synthesizes and secretes a family of peptides with natriuretic, vasodilatory and antimitogenic properties, as a response to increased atrial and ventricular wall stress and tension.1,2 The C-terminal endocrinological active peptides, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and their N-terminal prohormone fragments are found in plasma. Therefore, circulating levels of these peptides are increased both in patients with left ventricular hypertrophy and in patients with left ventricular dysfunction,3,4 including congestive heart failure and acute myocardial infarction.5 Moreover, the natriuretic peptide system is also activated in hypertrophic cardiomyopathy, left ventricular hypertrophy, and left ventricular diastolic dysfunction.6–9 Consequently, their plasma concentration can be helpful in the diagnostic process, as they are independent markers for risk assessment.10–13 Recently, it has been established that age and sex influence plasma natriuretic peptide levels in healthy adults.14 Furthermore, it has just been published that obesity decreases BNP in plasma.15,16

On the other hand, the relationship of natriuretic peptides with function parameters in HF has also been established.6,17,18 In fact, NT-proBNP is a powerful marker for left ventricular (LV) remodeling and systolic function in patients with HF.6 Nevertheless, these well established function parameters, as LV end-systolic and end-diastolic volume indices, LV mass index and LV ejection fraction, are non-invasively calculated by use of methods employing geometric assumptions.19–21 In contrast, LV areas measured from two-dimensional echocardiography do not need geometric assumptions for calculations, as they are measured directly from planimetered ventricular images.

We hypothesized that LV areas could reflect NT-proBNP plasma levels better than the non-invasively calculated LV volumes and their derived indices. Therefore, the purpose of this study was to determine the relationship between the biochemical marker NT-proBNP and the two-dimensional LV areas and derived indices calculated in heart failure patients, comparing patients with dilated and ischemic cardiomyopathy.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Limitations of the study
 Conclusions
 Notes
 References
 
Patients
We have studied 106 patients, 78 males and 28 females from the Valencian Community, with a mean age of 64±13, diagnosed of HF, performed with basic medical history data: electrocardiogram, chest X-ray, treadmill exercise and echo-Doppler study.22 Patients were functionally defined according to the New York Heart Association. Subjects in atrial fibrillation, with acute coronary syndromes and those with acute and chronic liver or renal disease, chronic infections, pulmonary diseases or malignancy were excluded. The diagnosis of ischemic cardiomyopathy (n=48, 45%), dilated cardiomyopathy (n=41, 39%), hypertensive cardiomyopathy (n=14, 13%) and other diseases (n=3, 3%) was confirmed according to the report of the 1995 World Health Organization.22–24 All patients were on stable medical therapy, following the guidelines of the American Heart Association25 and the European Society of Cardiology,26 for at least one month before study enrollment, in order to avoid the possible effects changing cardiovascular interventions, and none were receiving anti-inflammatory drugs. In particular, patients were receiving treatment with diuretics 77.9%, ACE inhibitors 73.8%, β-blockers 49.5%, aldosterone antagonist 40.2%, digitalis 27.5%, ARBs 15.7% and calcium-channel blockers 14.7%. The clinical characteristics of these patients are shown in Table 1. The procedure was approved by the appropriate institutional review boards or ethics review committees of each study center, and the study was conducted in accordance with the guidelines of good clinical practice and with ethical standards for human experimentation established by the Declaration of Helsinki. Every patient signed a written informed consent for his/her inclusion in the study.


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  		Table 1 Clinical characteristics of study subjects (n=106)

 
Blood samples
After the patient had been seated for at least 30min, venous blood was collected by venipuncture. The sample was separated by centrifugation at 3000rpm for 10min at room temperature and the sample was stored in Eppendorf tubes congealed before transport to the laboratory for assay. The study was coordinated in a central laboratory, where assays for NT-proBNP were conducted in a blind manner.

Serum concentration of NT-proBNP was determined in duplicate by using an electrochemiluminescence immunoassay "ECLIA" (Elecsys® proBNP from Roche Diagnostics). The lower detection limit was 5pg/ml, and intra-assay variability was between the range 1.8% and 2.7%. The test does not show any significant cross-reactions with ANP, CNP and BNP, <0.001%.

Echo-Doppler study
The study was performed using the standard echocardiographic systems of the hospitals involved in the study equipped with 2.5-MHz transducers. The echocardiographic examinations were performed using the standard apical and parasternal views. Doppler echocardiogram images were stored on videotape and analyses of recordings were all performed in a central unit. Cardiologists assessing left ventricular function were blinded to the assay. Bidimensional images, Doppler spectrum and color Doppler were analyzed off-line, using a computerized system (Eco-dat; Software Medicina SA). For each patient, four consecutive beats were measured and averaged for each Doppler variable.

For ejection fraction (EF), the area-length method19 was used and calculated as, 100[(end-diastolic volume–end-systolic volume)/end-diastolic volume]. Mitral flow propagation velocity (Vp) was determined using the previously described method.27 LV areas were measured from two-dimensional echocardiography directly from planimetered apical four-chamber images,28 that could be measured in 93% of patients. LV fractional area changes were calculated as, 100[(end-diastolic area–end-systolic area)/end-diastolic area].

Intra-observer and inter-observer variabilities were evaluated in a series of 50 patients by two observers who examined each patient in a consecutive way. Variability is expressed as the absolute difference divided by mean value of measurements. Intra-observer and inter-observer variabilities for LV areas were 2.9±2.1% and 3.9±3.1%, respectively.

Statistical analysis
Data are presented as mean±SD. Because the NT-proBNP data were not normally distributed, its levels were subjected to logarithmic transformation before all statistical analysis. Correlation between LV areas and NT-proBNP was performed using Pearson's product–moment correlation. This procedure was used both in heart failure patients with dilated and ischemic cardiomyopathy.

Furthermore, a multivariable linear regression (MLR) analysis was used to test the independent predictive power of LV areas and derived indices and other variables on NT-proBNP levels in the HF patients with both ischemic and dilated cardiomyopathies.

A stepwise selection procedure of the different variables was applied. The discrimination of the best model was based on the principle of least mean square and higher r2. All p values <0.05 were referred to in the test as having statistical significance. Regression analysis included LV areas and derived indices, sex, age, Vp and body mass index (BMI, kg/m2) as independent variables for MLR analysis with NT-proBNP as the dependent variable.

All statistical analyses were obtained by use of the Statistical Package for Social Sciences (SPSS/PC 10.1) statistical software (SPSS Inc. Chicago, Illinois). Significant differences were said to exist at p<0.05 for all parameters.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Limitations of the study
 Conclusions
 Notes
 References
 
We have determined the relationships between the biochemical marker NT-proBNP and the two-dimensional LV areas calculated in heart failure patients, comparing patients with dilated and ischemic cardiomyopathy.

Results for NT-proBNP levels and LV areas in the whole population are shown in Table 1. When we correlated NT-proBNP with left ventricular end-diastolic area (LVEDA) and left ventricular end-systolic area (LVESA) we had r=0.2, p<0.05 and 0.4, p<0.001, respectively. When we normalized LVEDA and LVESA by body surface area and correlated the obtained indices with NT-proBNP, we found with left ventricular end-diastolic area index (LVEDAI) r=0.4, p<0.001, and with left ventricular end-systolic area index (LVESAI) r=0.5, p<0.001 (Fig. 1). When we also studied the correlation of the left ventricular fractional area change (LVFAC) with the NT-proBNP we found r=–0.5, p<0.001.


Figure 1
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  		Figure 1 Correlation of left ventricular end-diastolic area index (LVESAI) with NT-proBNP in heart failure patients.

 
On the other hand, in Table 2 the results obtained when comparing the LV areas of the HF patients with ischemic and dilated cardiomyopathy are shown. Values obtained in patients with dilated cardiomyopathy were higher than those for the ischemic group, but significant differences were only obtained with the LVEDAI, though with LVESAI there was a statistical trend (p=0.1). NT-proBNP levels were similar in both groups.


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  		Table 2 Two-dimensional LV areas in heart failure patients with ischemic and dilated cardiomyopathy

 
Pearson's correlation of the data between LV areas and NT-proBNP was calculated both in ischemic and in dilated cardiomyopathy. In the dilated group, NT-proBNP correlated with LVEDA (r=0.5), LVESA (r=0.6), LVEDAI (r=0.6), LVESAI (r=0.7), LVFAC (r=–0.6), all were significant at p<0.001. However, in the patients with ischemic cardiomyopathy, NT-proBNP levels exclusively correlated with LVESAI (r=0.3, p<0.05) and LVFAC (r=–0.4, p<0.01).

A multivariable linear regression analysis was used to test the independent predictive power of LVESAI, LVEDAI, LVFAC and other variables on the peptide levels, in the HF patients. The best model was found when, after adjustment for age, and BMI, LVFAC and LVESAI were associated with plasma natriuretic peptide levels (Table 3) (p<0.001).


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  		Table 3 Multivariate linear regression results of LV areas on NT-proBNP plasma levels in the all patients studied

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Limitations of the study
 Conclusions
 Notes
 References
 
Accurate determinations of LV volume and performance are important in the clinical management of patients with heart disease. Echocardiography is a convenient modality for this assessment, because it is non-invasive, portable and permits serial follow-up. Two-dimensional quantitative echocardiographic methods require image acquisition from standardized scanning planes. LV volume and ejection fraction are then calculated by assuming that LV shape can be represented by individual geometric figures or their combination.29 These assumptions may not be valid in distorted ventricles. Nevertheless, three-dimensional echocardiography allows quantification of ventricular volume without the limitations imposed on two-dimensional echocardiographic algorithms,30,31 but its applicability is not extensively available. Since many of the algorithms for calculating LV volume from two-dimensional echocardiograms may be inaccurate as ventricles develop asymmetrical shapes, particularly in the assessment of ventricular performance in patients with ischemic heart disease, two-dimensional LV areas measured directly from planimetered ventricular images could be an easy and reproducible way to reflect changes in size and function of the LV.

It is well established that NT-proBNP is a powerful marker for LV dimensions and systolic function in patients with heart failure and discriminates well between healthy subjects and subjects with impaired LV systolic function or increased LV volume. In this context, we have seen that LV areas reflect NT-proBNP plasma levels in heart failure patients showing a good relationship. In fact, NT-proBNP was significantly correlated with LV end-systolic and end-diastolic areas and with LV fractional area change. These correlations improved when we considered the body surface area of patients obtaining the LV end-systolic and end-diastolic area indices.

To investigate how variables like LV areas and derived indices, sex, age, Vp and BMI influence NT-proBNP plasma levels in HF, a multiple regression analysis was performed. Results showed that, in the population studied, the best model was found when after adjustment for age and BMI, LVFAC and LVESAI were associated with plasma natriuretic peptide levels, as no significant additional explicatory power was found when variable sex, LVEDAI or Vp was added as independent variables in the model with NT-proBNP as the dependent variable.

Concerning the relationships of LV areas and derived indices with NT-proBNP in patients with ischemic cardiomyopathy, we only found significant correlation with LVESAI (r=0.3, p<0.05) and LVFAC (r=–0.4, p<0.01). In contrast, in the group with dilated cardiomyopathy, NT-proBNP correlated with all parameters studied LVEDA (r=0.5), LVESA (r=0.6), LVEDAI (r=0.6), LVESAI (r=0.7), LVFAC (r=–0.6), with a signification <0.001. These findings indicate that the origin for the elevation of NT-proBNP plasma levels in ischemic heart disease is more complex than in the dilated etiology, as other factors apart from LV areas and their derived volumes are implicated in BNP production in this pathology. We have to consider that, especially after myocardial infarction, BNP production seems to be regulated to a greater degree by the local stretch mechanisms in the area surrounding the infarcted area.32 Therefore, despite LV area values and their derived indices being similar in our series, it is not odd that their correlation with NT-proBNP is not as strong in this group of patients as in those with dilated cardiomyopathy. Notwithstanding, the role of NT-proBNP, during acute coronary syndrome, has been demonstrated in recent reports33,34 elucidating its prognostic value. NT-proBNP elevation in patients with ischemic cardiomyopathy is related to the pathophysiological background of coronary artery disease. Therefore, the higher mean values and greater variability of NT-proBNP elevation described in patients with previous myocardial infarction compared to other diagnostic groups may be related to different locations and sizes of infarct, inhomogeneous wall stress because of localized asynergy, ventricular remodeling following myocardial infarction, and residual or recurrent ischemic insults.35 We also have to take into account that the restrictive filling pattern of transmitral flow velocity is associated with higher brain natriuretic peptide levels, irrespective of the increase in LV volumes.36,37 This situation would interfere with the lineal relationship between NT-proBNP and LV areas. Notwithstanding, the restrictive filling pattern is more frequent among patients with hypertensive heart disease38 and in our population studied, only 13% of subjects have this diagnosis.

In summary, our results with LV areas are at least the same as those previously calculated with LV volumes.6,9 On the other hand, LV areas determination, measured from two-dimensional echocardiography directly from planimetered ventricular images, improves accuracy and reproducibility with respect to LV volumes as the need for standardized imaging planes or geometric assumptions is not necessary.39,40 Therefore, correlation with peptide levels are more reproducible. Moreover, when we considered the major diagnostic groups in this cohort of patients, we have found that correlations of LV areas with NT-proBNP in the dilated cardiomyopathy are better than those obtained with the whole population. In contrast, in the group of patients with ischemic cardiomyopathy LV areas and their derived indices do not show a good relation with the peptide levels, as NT-proBNP elevation in this group of patients may be related to the pathophysiological background of coronary artery disease more than to the LV areas.


   Limitations of the study
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Limitations of the study
Conclusions
 Notes
 References
 
In regard to echo-Doppler equipment, we should highlight that the use of some of them could introduce variability when acquiring the images. Nevertheless, every physician of this study usually performs the echocardiographic studies in his/her hospital. On the other hand, a sample video was given to each participating hospital, and therefore the uniformity of acquired images was favored.

Another limitation of the study that should be mentioned is that it has just been published that obesity decreases BNP in plasma15,16 and it could interfere with LV areas and peptide levels correlation. This reduction in obese patients could be due to collection of the peptide by the adipose tissue.41 However, this mechanism does not occur with NT-proBNP,42 and therefore, its lower levels would be caused by a lower release by cardiac ventricles15 when compared with non-obese subjects. These considerations make us think that obesity could interfere with the lineal relationship between NT-proBNP and LV areas. Nevertheless, the mean value for body mass index (calculated as weight in kilograms divided by height in square meters) in our population was 28.3±5kg/m2. Out of the total, 79% of patients were over the cut-off value established for over-weight (BMI≥25kg/m2) and therefore, we can consider our population as a homogeneous BMI group.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Limitations of the study
 Conclusions
Notes
 References
 
In this multicenter study, we have found a good correlation of NT-proBNP plasma levels with LV two-dimensional cavity areas (LVEDA, LVESA) and LVFAC. This correlation is at least the same and more reproducible as that previously obtained when comparing with LV volumes. Furthermore, correlation improved when we normalized those values by body surface area. Results of the multiple regression analysis showed that after adjustment for age and BMI, LVFAC and LVESAI are independent predictors of NT-proBNP plasma levels in both dilated and ischemic etiologies. Patients with dilated cardiomyopathy showed better results than those with ischemic cardiomyopathy. We think LV areas are a useful and reproducible parameter, do not need geometric assumptions and reflect NT-proBNP plasma levels.


   Notes
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Limitations of the study
 Conclusions
 Notes
References
 
* The research support source was from the National Institute of Health Fondo de Investigaciones Sanitarias del Instituto de Salud Carlos III, FIS 01/0943 Project, Spain. Back


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Limitations of the study
 Conclusions
 Notes
 References
 

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