Europace Advance Access originally published online on January 16, 2007
Europace 2007 9(2):147; doi:10.1093/europace/eul147
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LETTERS TO THE EDITOR
Natriuretic peptides in patients with atrial fibrillation and advanced chronic heart failure: determinants and prognostic value of (NT-)ANP and (NT-pro) BNP
Department of Academic Cardiology
Castle Hill Hospital
Cottingham
Kingston-upon-Hull
East Yorkshire
UK
Tel: +44 1482624073
Fax: +44 7902840055
E-mail address: rhidianshelton{at}btopenworld.com
Department of Academic Cardiology
Castle Hill Hospital
Cottingham
Kingston-upon-Hull
East Yorkshire
UK
Department of Academic Cardiology
Castle Hill Hospital
Cottingham
Kingston-upon-Hull
East Yorkshire
UK
The PRIME II investigators have to be congratulated for not only highlighting the deleterious effects of ibopamine but subsequent analyses have provided many other interesting insights into the natural history of heart failure.
We read with interest the latest publication regarding the influence of atrial fibrillation (AF) upon natriuretic peptides by Rienstra et al.1
They demonstrate that natriuretic peptide concentrations are higher in patients with heart failure and AF but, did not find an independent association between AF and elevated BNP/NT-BNP levels. However, in a large population of out-patients with suspected heart failure, we have found otherwise.2 There may be several explanations for the observed difference.
Firstly, the PRIME II study3 included patients with a recent hospital admission and as such the major driving force responsible for the elevation in natriuretic peptide (particularly those with a longer half-life) may be the resolving decompensation in cardiac function rather than atrial fibrillation per se. The effect therefore of AF on natriuretic peptides may have been diluted. To clarify further the effect of AF on natriuretic peptides analysis of ‘convalescent’ samples may be more appropriate. In addition, decompensation of cardiac failure may be due to unrecognized paroxysms of AF rather than persistent AF.
Second, it is possible in some cases that the diagnosis of heart failure may have been based on the finding of cardiomegaly by chest x-ray alone. Patients with heart failure and preserved LV systolic function are more likely to have AF.4 In these cases, AF rather than ventricular dysfunction may be the cause of symptoms and peptide elevation. However, such patients may have a better prognosis.
Third, heart failure is the common result of a variety of structural and functional cardiac disorders (e.g. systolic dysfunction, diastolic dysfunction, valvular heart disease, pulmonary hypertension, and left ventricular hypertrophy). Most, if not all, are associated with varying increases in natriuretic peptides, which require explanation and specific therapy.
Finally, adjustment is necessary for confounding factors apart from cardiac disease including age, sex, renal function, body mass index, and cardiac pacemakers. Despite differences in baseline characteristics, it is unclear as to whether the authors have taken these factors into account with regard to determinants and prognostic value.
In conclusion, we believe AF may be independently associated with elevated natriuretic peptide levels in patients with and without cardiac failure if careful attention is given to confounding factors.
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[1] Rienstra M, Van Gelder IC, Van den Berg MP, Boomsma F, Van Veldhuisen DJ. Natriuretic peptides in patients with atrial fibrillation and advanced chronic heart failure: determinants and prognostic value of (NT-)ANP and (NT-pro) BNP. Europace 2006; 8: 482–7.
[2] Shelton RJ, Clark AL, Goode K, Rigby AS, Cleland JGF. The diagnostic utility of N-terminal pro-b-type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation. Eur Heart J 2006 27: 2353–61.
[3] Hampton JR, van Veldhuisen DJ, Kleber FX, Cowley AJ, et al. Randomised study of effect of ibopamine on survival in patients with advanced severe heart failure. Second prospective randomised study of ibopamine on mortality and efficacy (PRIME II) Investigators. Lancet 1997; 349: 971–7.[CrossRef][Web of Science][Medline]
[4] Hogg K, Swedberg K, McMurray J. Heart failure with preserved left ventricular systolic function; epidemiology, clinical characteristics, and prognosis. J Am Coll Cardiol 2004; 43: 317–27.
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