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. 1999 Feb;81(2):114–120. doi: 10.1136/hrt.81.2.114

Neuroendocrine prediction of left ventricular function and heart failure after acute myocardial infarction

A Richards 1, M Nicholls 1, T Yandle 1, H Ikram 1, E Espiner 1, J Turner 1, R Buttimore 1, J Lainchbury 1, J Elliott 1, C Frampton 1, I Crozier 1, D Smyth 1
PMCID: PMC1728940  PMID: 9922344

Abstract

Objective—To determine the relations of plasma levels of brain natriuretic peptide (BNP), atrial natriuretic factor (ANF), N-terminal ANF (N-ANF), cyclic guanosine monophosphate (cGMP; the cardiac peptide second messenger), and plasma catecholamines to left ventricular function and to prognosis in patients admitted with acute myocardial infarction.
Design—Plasma hormones and ventricular function (radionuclide ventriculography) were measured 1-4 days after myocardial infarction in 220 patients admitted to a single coronary care unit. Radionuclide scanning was repeated 3-5 months after infarction. Clinical events were recorded over a mean period of 14 months.
Results—Both early and late left ventricular ejection fraction (LVEF) were most closely related to plasma BNP (r = −0.60, n = 220, p < 0.001; and r = −0.53, n = 192, p < 0.001, respectively), followed by ANF, N-ANF, cGMP, and the plasma catecholamines. Early plasma BNP concentrations less than twofold the upper limit of normal (20 pmol/l) had 100% negative predictive value for LVEF < 40% at 3-5 months after infarction. In multivariate analysis incorporating all the neurohormonal factors, only BNP remained independently predictive of LVEF < 40% (p < 0.005). Survival analysis by median levels of candidate predictors identified BNP as the most powerful discriminator for death (p < 0.0001). No early deaths (within 4 months) occurred in patients with plasma BNP concentrations below the group median (27 pmol/l), and over follow up only three of 26 deaths occurred in this subgroup. Of all episodes of left ventricular failure, 85% occurred in patients with plasma BNP above the median (p < 0.001). In multivariate analyses, BNP alone gave additional predictive information beyond sex, age, clinical history, LVEF, and plasma noradrenaline for both subsequent onset of LVF and death.
Conclusions—Plasma BNP measured within 1-4 days of acute myocardial infarction is a powerful independent predictor of left ventricular function, heart failure, or death over the subsequent 14 months, and superior to ANF, N-ANF, cGMP, and plasma catecholamines.

 Keywords: cardiac natriuretic peptides; noradrenaline; myocardial infarction; heart failure

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Figure 1  .

Figure 1  

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Individual early postinfarction plasma concentrations of brain natriuretic peptide (BNP; log scale) plotted against corresponding early (left; "admission") and late (right; "4 months") postinfarction radionuclide scan left ventricular ejection fraction (LVEF) (regression lines with 95% confidence intervals) for 220 patients with myocardial infarction. Vertical dashed lines are marked at 40% ejection fraction. BNP concentrations < 20 pmol/l (that is, less than twice the upper limit of normal) correspond to a late ejection fraction greater than 40%.

Figure 2  .

Figure 2  

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Kaplan-Meier survival curves for subgroups with early postinfarction plasma peptides (ANF, N-ANF, BNP) and cGMP concentrations above (solid line) and below (dashed line) the group median in 220 patients with myocardial infarction. ANF, atrial natriuretic factor; BNP, brain natriuretic peptide; cGMP, cyclic guanosine monophosphate; N-ANF, N-terminal ANF.

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