Title: Dynamic Cardiovascular Risk Assessment in Elderly People: The Role of Repeated N-Terminal Pro–B-Type Natriuretic Peptide Testing
Topic: Heart Failure/Transplant
Date Posted: 1/25/2010 5:00:00 PM
Author(s): deFilippi CR, Christenson RH, Gottdiener JS, Kop WJ, Seliger SL.
Citation: J Am Coll Cardiol 2010;55:441-450.
Clinical Trial: No
Study Question: Does serial measurement of N-terminal pro–B-type natriuretic peptide (NT-proBNP) in community-dwelling elderly people provide additional prognostic information to that from traditional risk factors?
Methods: The study cohort was comprised of 2,975 community-dwelling older adults free of heart failure (HF) in the longitudinal Cardiovascular Health Study. NT-proBNP was measured at baseline and 2-3 years later in the cohort. The risk of new-onset HF and mortality from cardiovascular causes was associated with baseline NT-proBNP and changes in NT-proBNP levels, adjusting for potential confounders.
Results: The study investigators found that NT-proBNP levels in the highest quintile (>267.7 pg/ml) were independently associated with greater risks of HF (hazard ratio [HR], 3.05; 95% confidence interval [CI], 2.46-3.78) and cardiovascular mortality (HR, 3.02; 95% CI, 2.36-3.86) compared with the lowest quintile (<47.5 pg/ml). Another important finding was that the inflection point for elevated risk occurred at NT-proBNP 190 pg/ml. Among subjects with initially low NT-proBNP (<190 pg/ml), those who developed a >25% increase on follow-up to >190 pg/ml (21%) were at greater adjusted risk of HF (HR, 2.13; 95% CI, 1.68-2.71) and cardiovascular mortality (HR, 1.91; 95% CI, 1.43-2.53) compared with those with sustained low levels. Among participants with initially high NT-proBNP, those who developed a >25% increase (40%) were at higher risk of HF (HR, 2.06; 95% CI, 1.56-2.72) and cardiovascular mortality (HR, 1.88; 95% CI, 1.37-2.57), whereas those who developed a <25% decrease to ≤190 pg/ml (15%) were at lower risk of HF (HR, 0.58; 95% CI, 0.36-0.93) and cardiovascular mortality (HR, 0.57; 95% CI, 0.32-1.01) compared with those with unchanged high values.
Conclusions: The authors concluded that NT-proBNP levels independently predict HF and cardiovascular mortality in older adults. NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk.
Perspective: This is an important study because it suggests NT-proBNP is an important long-term predictor of HF in the elderly and possibly an indicator of ‘subclinical’ heart failure. Another important take-away is that a level of 190 pg/ml may possibly be a cut-off point in patients without a ‘dry’ BNP (i.e., BNP at euvolemia). Further studies are required to validate these results. From a mechanistic perspective, I would be interested to know whether NT-proBNP level fluctuations reflect changes in left ventricular function such as E/E’ on tissue Doppler and other indicators of left ventricular diastolic function. Also, more data are needed to determine whether a single marker or a panel of biomarkers is superior in accurately predicting cardiovascular risk (Braunwald E. Heart Fail Clin 2009;4:xiii-xiv). Ragavendra R. Baliga, M.B.B.S.
Title: Supported High-Risk Percutaneous Coronary Intervention With the Impella 2.5 Device: The Europella Registry
Topic: Interventional Cardiology
Date Posted: 1/22/2010
Author(s): Sjauw KD, Konorza T, Erbel R, et al.
Citation: J Am Coll Cardiol 2009;54:2430-2434.
Clinical Trial: No
Study Question: What is the safety and feasibility of left ventricular (LV) support with the Impella 2.5 device during high-risk percutaneous coronary intervention (PCI)?
Methods: The Europella registry was comprised of patients from 10 tertiary PCI centers across Europe. It was designed to evaluate the safety and feasibility of all patients undergoing elective high-risk PCI with prophylactic mechanical cardiac support with the Impella 2.5. The Impella 2.5 (Abiomed, Inc.) is a novel catheter-mounted (9-F) micro-axial rotary blood pump (12-F), designed for short-term circulatory support. The registry was supported by Abiomed Europe GmbH. Safety and feasibility endpoints included incidence of 30-day adverse events and successful device function.
Results: Patients were older (62% were >70 years of age), 54% had an LV ejection fraction ≤30%, and the prevalence of comorbid conditions was high. Mean European System for Cardiac Operative Risk Evaluation score was 8.2 (standard deviation 3.4), and 43% of the patients were refused for coronary artery bypass grafting. A PCI was considered high-risk due to left main disease, last remaining vessel disease, multivessel coronary artery disease, and low LV function in 53%, 17%, 81%, and 35% of the cases, respectively. Mortality at 30 days was 5.5%. Rates of myocardial infarction, stroke, bleeding requiring transfusion/surgery, and vascular complications at 30 days were 0%, 0.7%, 6.2%, and 4.0%, respectively.
Conclusions: The authors concluded that this registry supports the safety, feasibility, and potential usefulness of hemodynamic support with Impella 2.5 in high-risk PCI.
Perspective: The present study shows that periprocedural support with the Impella 2.5 for elective high-risk PCI is safe and feasible and extends prior observations from three smaller case series. It should be noted that all adverse events were based on clinical diagnoses assigned by the patient's physician. Overall, this multicenter registry supports the safety, feasibility, and potential usefulness of hemodynamic support with Impella 2.5 in high-risk PCI, but needs to be evaluated in prospective randomized clinical trials. Debabrata Mukherjee, M.D., F.A.C.C.