Europace Advance Access originally published online on January 16, 2007
Europace 2007 9(2):148; doi:10.1093/europace/eul148
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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: reply
Department of Cardiology
University Medical Center Groningen
Groningen
The Netherlands
Department of Cardiology
University Medical Center Groningen
Groningen
The Netherlands
Tel: +00 31 50 361 2355
Fax: +00 31 50 361 4391
E-mail address: i.c.van.gelder{at}thorax.umcg.nl
Department of Cardiology
University Medical Center Groningen
Groningen
The Netherlands
Department of Cardiology
University Medical Center Groningen
University of Groningen
Groningen
The Netherlands
We appreciate the interest of Shelton RJ, Goode K, and Cleland JG in our study.1
In contrast to our main finding, they found an independent association between AF and NT-proBNP levels.2 The authors propose several interesting reasons that could explain this discrepancy.
Their first remark concerned the fact that in the PRIME II study patients with advanced CHF were included.3 The patients had to have symptoms at rest, or a hospital admission within the previous 2 months, but those who could not be discharged were not eligible. Indeed, in advanced CHF the decompensation of cardiac function might be the main factor of elevation of BNP and NT-proBNP levels.
Second, in the present neurohormonal substudy of PRIME II only patients with systolic left ventricular dysfunction were included. The diagnosis was not based on the finding of cardiomegaly on chest X-ray alone. In all except one patient, the diagnosis of heart failure was based on left ventricular ejection fraction. We did not study the effects of AF in patients with CHF and preserved left ventricular systolic function, in contrast to the study of Shelton et al.2
Finally, we adjusted for several confounders by multivariate linear regression analysis: age, gender, left ventricular ejection fraction, ischaemic heart disease, non-ischaemic heart disease, hypertension, valvular disease, NYHA functional class, diabetes, blood pressure, creatinine, and concomitant medication. All confounders with a P value <0.1 were included in a stepwise multivariate model. The final model of determinants of BNP consisted of left ventricular ejection fraction, systolic blood pressure, creatinine, and diabetes. The final model of NT-proBNP consisted of left ventricular ejection fraction, systolic blood pressure, and creatinine. Atrial fibrillation was not independently related to BNP and NT-proBNP.
In conclusion, the fact that BNP levels are increased in the presence of AF, has been shown in several studies.4–9 Shelton et al. demonstrated this in out-patients with suspected heart failure.2 In contrast, the PRIME II study deals with patients with much more advanced CHF.3 In contrast to the situation in mild-to-moderate CHF, in severe CHF, the atrial contribution is often limited due to severe diastolic dysfunction (due to restrictive physiology).10 Loss of the atrial kick, therefore, seems of less haemodynamic importance in severe CHF. This is supported by the fact that in patients with severe CHF, AF does not have any impact on prognosis anymore.11 Moreover, the influence of the irregularity of the ventricular response in AF may be limited.12–14 As such, the haemodynamic consequences of AF may be less important in patients with severe CHF. Atrial fibrillation may, therefore, not influence BNP and NT-proBNP levels.
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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 JG. 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.
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