Original articlePrognostic utility of NT-proBNP in acute exacerbations of chronic pulmonary diseases
Introduction
B-type natriuretic peptides (BNP and NT-proBNP) are released by the heart to the bloodstream in response to increased ventricular volume or pressure [1], [2]. B-type natriuretic peptides concentration correlates clearly with pulmonary capillary pressure [3], telediastolic intraventricular pressure and left ventricular ejection fraction [4], [5]. There is also a weak-positive correlation between BNP concentration and main pulmonary arterial pressure, as assessed by echocardiography [6]. B-type natriuretic peptides have been used in clinical practice in the screening of patients with dyspnoea [7], [8], [9], asymptomatic ventricular dysfunction, and in the management of patients particularly those with cardiac diseases [10]. Moreover, B-type natriuretic peptides possess prognostic value for general and cardiovascular morbidity, even in patients without heart failure [11], [12].
NT-proBNP levels have been less extensively studied in pulmonary diseases. Raised NT-proBNP levels have been found in patients with chronic pulmonary diseases (CPD) [13], cor pulmonare [6], [14], and pulmonary embolism [15] as a consequence of pulmonary hypertension [13]. As well as this, B-type natriuretic peptide is a short-term independent predictor of mortality in patients with CPD [13] and primary pulmonary hypertension [16].
We hypothesize that elevated NT-proBNP levels could help to stratify patients with acute exacerbations of CPD before they develop symptomatic right heart failure. The aim of the study was to determine the prognostic utility of NT-proBNP in that scenario.
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Patients and setting
Consecutive patients admitted to the hospital due to acute exacerbation of chronic pulmonary diseases and interviewed within 72 h of admission were included in the study. Eligible chronic pulmonary diseases were chronic bronchitis, emphysema, chronic asthma, pulmonary fibrosis, pleural fibrosis, and pneumoconiosis. Eligible patients had basal functional statuses II–IV (using the NYHA scale as a reference) and no previous history of symptoms related to pulmonary hypertension or right heart
Results
One-hundred ninety two patients were included in the study. Table 1 shows the baseline demographic and clinical characteristics of these patients. Most of them (78.6%) were male and median age was 75 years. Smoking-related chronic obstructive pulmonary disease and chronic asthma accounted for 92% of the underlying pulmonary diseases. Acute deterioration was due to acute exacerbation without chest X-ray infiltrates or pneumonia in 95% of the cases. Atrial flutter or fibrillation was present in
Discussion
The prognostic value of NT-proBNP levels in unselected populations is well known [11], [19]. Our study found that NT-proBNP levels are significantly raised during acute exacerbations of CPD, in the absence of clinically apparent heart failure. Also, NT-proBNP levels associated with adverse outcomes were within the non-diagnostic range for heart failure. NT-proBNP levels above 587.9 pg/ml on admission showed a significant association with any cause mortality, and above 780 pg/ml due to
Learning points
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NT-proBNP levels below 600 pg/ml on presentation have a high negative predictive value for adverse outcomes in patients with acute exacerbations of chronic pulmonary diseases.
Acknowledgements
Supported in part by the Project 06061-00, Junta de Comunidades de Castilla La-Mancha, Spain. We are grateful to Uta M. Klepzig for helping in the preparation of the manuscript.
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Both authors have made equal contributions to all the parts of the study.