Skip to main content
SpringerLink
Log in

Heart failure with preserved ejection fraction, atrial fibrillation, and increased NT‑proBNP levels

An emergent clinical dilemma

Herzinsuffizienz mit erhaltener Ejektionsfraktion, Vorhofflimmern und erhöhten NT‑proBNP-Werten

Zeichen eines klinischen Dilemmas

  • Original articles
  • Published:
Herz Aims and scope Submit manuscript

Abstract

Background

The co-presence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) may cause some diagnostic difficulties, because AF itself is associated with elevated levels of N‑terminal pro-B-type natriuretic peptide (NT-proBNP). In the present study we aimed to investigate NT-proBNP levels of patients with HFpEF and AF.

Methods

This was a retrospective cohort study. Outpatient data were reviewed through the hospital data management system. Consecutive patients with the diagnosis of HFpEF and AF, who had at least one NT-proBNP measurement, were included in the study.

Results

The study population comprised 235 patients. Median NT-proBNP levels were 1242 pg/ml in the stable phase and 2321.5 pg/ml during decompensation. NT-proBNP was correlated positively with age, CHA2DS2 and CHA2DS2VASc scores, left atrial diameter (LAD), tricuspid annulus diameter, and systolic pulmonary artery pressure but negatively correlated with left ventricular ejection fraction (LVEF) and hemoglobin level. The change in NT-proBNP was positively correlated with heart rate and LAD.

Conclusion

Patients with HFpEF and AF have higher levels of NT-proBNP, which may exceed the upper limits defined in guidelines. This study underlines the importance of measuring NT-proBNP levels in the stable phase and proposes a rule-in level for the decompensated phase.

Zusammenfassung

Hintergrund

Wenn bei Patienten mit Herzinsuffizienz und erhaltener Ejektionsfraktion (HFpEF) gleichzeitig Vorhofflimmern (VF) vorliegt, kann das zu diagnostischen Schwierigkeiten führen, denn VF an sich geht mit erhöhten Werten des NT-proBNP („N-terminal pro-B-type natriuretic peptide“) einher. In der vorliegenden Studie war es das Ziel, die NT-proBNP-Werte bei Patienten mit HFpEF und VF zu untersuchen.

Methoden

Es handelte sich um eine retrospektive Kohortenstudie. Die Daten ambulanter Patienten wurden mithilfe des Datenmanagementsystems des Krankenhauses ausgewertet. Konsekutive Patienten mit den Diagnosen HFpEF und VF, bei denen mindestens eine Bestimmung des NT-proBNP-Werts vorlag, wurden in die Studie aufgenommen.

Ergebnisse

Die Studienpopulation umfasste 235 Patienten. Die medianen NT-proBNP-Werte betrugen 1242 pg/ml in der stabilen Phase und 2321,5 pg/ml während der Dekompensation. Es bestand eine positive Korrelation von NT-proBNP mit dem Alter, den Scores CHA2DS2 und CHA2DS2VASc, dem linksatrialen Durchmesser (LAD), dem Durchmesser des Trikuspidalklappenrings und dem systolischen pulmonalarteriellen Druck, aber eine negative Korrelation mit der linksventrikulären Ejektionsfraktion (LVEF) und dem Hämoglobinwert. Die Änderung des NT-proBNP-Werts war positiv mit der Herzfrequenz und dem LAD korreliert.

Schlussfolgerung

Patienten mit HFpEF und VF weisen höhere NT-proBNP-Werte auf, welche die in Leitlinien definierten Obergrenzen übersteigen können. In der vorliegenden Studie wird die Bedeutung der Bestimmung des NT-proBNP-Werts in der stabilen Phase unterstrichen und ein Vorschlag für einen Wert als Einschlusskriterium für die dekompensierte Phase unterbreitet.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 37:2129–2200. https://doi.org/10.1093/eurheartj/ehw128

    Article  PubMed  Google Scholar 

  2. Heart Failure Association of the European Society of Cardiology, Mueller C, McDonald K, de Boer RA, Maisel A, Cleland JGF, Kozhuharov N et al (2019) Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail 21:715–731. https://doi.org/10.1002/ejhf.1494

    Article  CAS  Google Scholar 

  3. Pfeffer MA, Shah AM, Borlaug BA (2019) Heart failure with preserved ejection fraction in percpectice. Circ Res 124:1598–1617. https://doi.org/10.1161/CIRCRESAHA.119.313572

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Ho JE, Enserro D, Brouwers FP, Kizer JR, Shah SJ, Psaty BM et al (2016) Predicting heart failure with pre-served and reduced ejection fraction: the International Collaboration on Heart Failure Subtypes. Circ Heart Fail 9:e3116

    Article  PubMed  Google Scholar 

  5. Borlaug BA, Jaber WA, Ommen SR, Lam CS, Redfield MM, Nishimura RA (2011) Diastolic relaxation and compliance reserve during dynamic exercise in heart failure with preserved ejection fraction. Heart 97:964–969. https://doi.org/10.1136/hrt.2010.212787

    Article  PubMed  Google Scholar 

  6. Westermann D, Kasner M, Steendijk P, Spillmann F, Riad A, Weitmann K et al (2008) Role of left ventricular stiffness in heart failure with normal ejection fraction. Circulation 117:2051–2060. https://doi.org/10.1161/CIRCULATIONAHA.107.716886

    Article  PubMed  Google Scholar 

  7. Cheng CP, Noda T, Nozawa T, Little WC (1993) Effect of heart failure on the mechanism of exercise-induced augmentation of mitral valve flow. Circ Res 72:795–806

    Article  CAS  PubMed  Google Scholar 

  8. Davie P, Francis CM, Caruana L, Sutherland GR, McMurray JJ (1997) Assessing diagnosis in heart failure: which features are any use? QJM 90:335–339

    Article  CAS  PubMed  Google Scholar 

  9. Mant J, Doust J, Roalfe A, Barton P, Cowie MR, Glasziou P et al (2009) Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess 13:1–207, iii

    Article  CAS  PubMed  Google Scholar 

  10. Oudejans I, Mosterd A, Bloemen JA, Valk MJ, Van Velzen E, Wielders JP et al (2011) Clinical evaluation of geriatric outpatients with suspected heart failure: value of symptoms, signs, and additional tests. Eur J Heart Fail 13:518–527

    Article  PubMed  Google Scholar 

  11. Fonseca C (2006) Diagnosis of heart failure in primary care. Heart Fail Rev 11:95–107

    Article  PubMed  Google Scholar 

  12. Kelder J, Cramer M, van Wijngaarden J, van Tooren R, Mosterd A, Moons KGM et al (2011) The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation 124:2865–2873

    Article  PubMed  Google Scholar 

  13. Boonman-de Winter LJM, Rutten FH, Cramer MJ, Landman MJ, Zuithoff NPA, Liem AH et al (2015) Efficiently screening heart failure in patients with type 2 diabetes. Eur J Heart Fail 17:187–195

    Article  PubMed  Google Scholar 

  14. Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA (2018) A simple evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction. Circulation 138:861–870. https://doi.org/10.1161/CIRCULATIONAHA.118.034646

    Article  PubMed  PubMed Central  Google Scholar 

  15. Rutten FH, Taylor CJ, Brouwer JR, Hobbs R, EPCCS Board (2016) Practical guidance on heart failure diagnosis and management in primary care. Eur J Prev Cardiol 23(5):460–473

    Article  PubMed  Google Scholar 

  16. Data established with the Elecsys proBNP assay (first generation, REF 03121640122). Elecsys proBNP II Cobas® Roche Diagnostics GmbH.

  17. Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA (2018) A simple evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction. Circulation 138:861–870. https://doi.org/10.1161/CIRCULATIONAHA.118.034646

    Article  PubMed  PubMed Central  Google Scholar 

  18. Morello A, Lloyd-Jones DM, Chae CU, van Kimmenade RRJ, Chen AC, Baggish AL et al (2007) Association of atrial fibrillation and amino-terminal pro-brain natriuretic peptide concentrations in dyspneic subjects with and without acute heart failure: results from the ProBNP investigation of dyspnea in the Emergency Department (PRIDE) study. Am Heart J 153:90–97

    Article  CAS  PubMed  Google Scholar 

  19. Gould PA, Gula LJ, Bhayana V, Subbiah RN, Bentley C, Yee R et al (2010) Characterization of cardiac brain natriuretic peptide release in patients with paroxysmal atrial fibrillation undergoing left atrial ablation. Circ Arrhythm Electrophysiol 3:18–23

    Article  CAS  PubMed  Google Scholar 

  20. Santema BT, Chan MM, Tromp J, Dokter M, van der Wal HH, Emmens JE et al (2019) The influence of atrial fibrillation on the levels of NT-proBNP versus GDF-15 in patients with heart failure. Clin Res Cardiol. https://doi.org/10.1007/s00392-019-01513-y

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lam CSP, Rienstra M, Tay WT, Liu LCY, Hummel YM, van der Meer P et al (2017) Atrial fibrillation in heart failure with preserved ejection fraction. Association with exercise capacity, left ventricular filling pressures, natriuretic peptides and left atrial volume. JACC Heart Fail 5(2):92–98. https://doi.org/10.1016/j.jchf.2016.10.005

    Article  PubMed  Google Scholar 

  22. Zakeri R, Borlaug BA, McNulty S, Mohammed SF, Lewis GD, Semigran MJ et al (2014) Impact of atrial fibrillation on exercise capacity in heart failure with preserved ejection fraction: a RELAX trial ancillary study. Circ Heart Fail 7:123–130. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000568

    Article  CAS  PubMed  Google Scholar 

  23. SOCRATES Investigators and Coordinators, Pieske B, Butler J, Filippatos G, Lam C, Maggioni AP, Ponikowski P et al (2014) Rationale and design of the SOluble guanylate Cyclase stimulatoR in heArT failurE Studies (SOCRATES). Eur J Heart Fail 16:1026–1038. https://doi.org/10.1002/ejhf.135

    Article  CAS  Google Scholar 

  24. Santema B, Kloosterman M, van Gelder IC, Mordi I, Lang CC, Lam CSP et al (2018) Comparing biomarker profiles of patients with heart failure: atrial fibrillation vs. sinus rhythm and reduced vs. preserved ejection fraction. Eur Heart J 39:3867–3875. https://doi.org/10.1093/eurheartj/ehy421

    Article  CAS  PubMed  Google Scholar 

  25. Voors AA, Anker SD, Cleland JG, Dickstein K, Filippatos G, van der Harst P et al (2016) BIOlogy Study to TAilored Treatment in Chronic Heart Failure: rationale, design and baseline characteristics of BIOSTAT-CHF. Eur J Heart Fail 18:716–726. https://doi.org/10.1002/ejhf.531

    Article  PubMed  Google Scholar 

Download references

Author Contributions

Concept: Ebru Ipek Turkoglu (EIT); Design: EIT, Emine Cigdem Kircicegi Cicekdag (ECKC); Definition of intellectual content: EIT, ECKC; Literature search: EIT; Clinical studies: EIT, ECKC; Data acquisition: EIT, ECKC; Statistical analysis: EIT, ECKC, Omer Kaplan. Manuscript preparation, editing, and review: EIT, ECKC. The manuscript has been read and approved by all authors. The dataset can be provided upon request.

Acknowledgements

We are thankful to Ömer Kaplan for his great help with the statistical analysis.

Author information

Authors and Affiliations

  1. Department of Cardiology, Izmir Kemalpasa State Hospital, 8 Eylul Mah, 35170, Izmir, Kırovası, Turkey

    Ebru Ipek Turkoglu MD, PhD

  2. Department of Anesthesiology, Izmir Kemalpasa State Hospital, Izmir, Turkey

    Emine Cigdem Kircicegi Cicekdag MD, PhD

  3. Department of Cardiology, İstanbul Aydin University, Istanbul, Turkey

    Ebru Ipek Turkoglu MD, PhD

Authors
  1. Ebru Ipek Turkoglu MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emine Cigdem Kircicegi Cicekdag MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ebru Ipek Turkoglu MD, PhD.

Ethics declarations

Conflict of interest

E.I. Turkoglu and E.C. Kircicegi Cicekdag declare that they have no competing interests.

The ethic approval is acquired from the Health Science University, Izmir Tepecik Research and Training Hospital, Ethical Board of Non-invasive Clinical Research on 14 November 2018 and the approval number was 2018/13-13. For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case. This retrospective study was performed after consultation with the institutional ethics committee and in accordance with national legal requirements.

Additional information

The present study has not been presented in any scientific congress previously. The present manuscript has not been published before and is not under consideration for publication anywhere else.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Turkoglu, E.I., Kircicegi Cicekdag, E.C. Heart failure with preserved ejection fraction, atrial fibrillation, and increased NT‑proBNP levels. Herz 46 (Suppl 2), 191–197 (2021). https://doi.org/10.1007/s00059-020-04981-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00059-020-04981-5

Keywords

Schlüsselwörter

Search

Navigation