Abstract
Aims
N‐terminal prohormone of brain natriuretic peptide (NT‐proBNP) plays an important role in diagnosis and management of heart failure. The aim of the present study was to assess haemodynamic response to exercise and to evaluate the relationship between NT‐proBNP, cardiac function, and exercise tolerance in chronic heart failure.
Methods and results
A single‐centre, cross‐sectional pilot study recruited 17 patients with chronic heart failure with reduced left ventricular ejection fraction (age 67 ± 7 years) and 20 healthy volunteers (age 65 ± 12 years). The NT‐proBNP was measured in the heart failure group. All participants completed maximal graded cardiopulmonary exercise stress testing coupled with gas exchange (using metabolic analyser for determination of exercise tolerance, i.e. peak O2 consumption) and continuous haemodynamic measurements (i.e. cardiac output and cardiac power output) using non‐invasive bioreactance technology. Heart failure patients demonstrated significantly lower peak exercise cardiac function and exercise tolerance than healthy controls, i.e. cardiac power output (5.0 ± 2.0 vs. 3.2 ± 1.2 W, P < 0.01), cardiac output (18.2 ± 6.3 vs. 13.5 ± 4.0 L/min, P < 0.01), heart rate (148 ± 23.7 vs. 111 ± 20.9 beats/min, P < 0.01), and oxygen consumption (24.3 ± 9.5 vs. 16.8 ± 3.8 mL/kg/min, P < 0.01). There was no significant relationship between NT‐proBNP and cardiac function at rest, i.e. cardiac power output (r = −0.28, P = 0.28), cardiac output (r = −0.18, P = 0.50), and oxygen consumption (r = −0.18, P = 0.50), or peak exercise, i.e. cardiac power output (r = 0.18, P = 0.49), cardiac output (r = 0.13, P = 0.63), and oxygen consumption (r = −0.05, P = 0.84).
Conclusions
Lack of a significant and strong relationship between the NT‐proBNP and measures of cardiac function and exercise tolerance may suggest that natriuretic peptides should be considered with caution in interpretation of the severity of cardiac dysfunction and functional capacity in chronic heart failure.
Keywords: Heart failure, NT‐proBNP, Cardiac power, Exercise
Introduction
Heart failure is a clinical syndrome associated with poor prognosis, characterized by reduced cardiac output at rest and/or stress.1 Natriuretic peptides are widely used in clinical practice to help the diagnosis of heart failure, but the low specificity limits their diagnostic utility.2 Daily clinical practice confirms limited accuracy of increased serum levels of natriuretic peptides to predict the presence of heart failure. Despite these limitations, natriuretic peptides continue to be used in heart failure diagnostic pathway.1 The literature report on the relationship between natriuretic peptides and cardiac function and performance in response to stress is limited. Better understanding of this relationship is important as it would allow for more accurate monitoring and risk stratification in heart failure. The aim of the present study was to assess haemodynamic response to exercise and to evaluate the relationship between N‐terminal prohormone of brain natriuretic peptide (NT‐proBNP), cardiac function, and exercise tolerance in chronic heart failure.
Methods
Study design
This was a single‐centre, cross‐sectional pilot study to assess the relationship between NT‐proBNP and cardiac function and exercise tolerance.
Participants
The study included 17 patients with chronic heart failure and 20 healthy individuals (Table 1). The study inclusion criteria for heart failure were adults (i) >50 years of age, (ii) diagnosed with stage II–III New York Heart Association functional class of chronic heart failure due to left ventricular systolic dysfunction (<40%), (iii) had NT‐proBNP >125 ng/L, (iv) were clinically stable for at least 6 weeks prior to screening, and (v) were optimally treated for chronic heart failure. The exclusion criteria were (i) inability to provide informed consent, (ii) inability to perform the exercise stress testing, (iii) serious co‐morbidities, i.e. severe aortic stenosis or uncontrolled arrhythmias, (iv) myocardial intervention/coronary artery bypass grafting in the past 3 months, (v) severe obesity (body mass index > 40 kg/m2), and (vi) patients in New York Heart Association class I or IV. The ‘healthy control’ group consisted of age‐matched healthy individuals.
Table 1.
Participants' demographics and physical characteristics
| Healthy controls (n = 20) | HF patients (n = 17) | P‐value | |
|---|---|---|---|
| Age (years) | 65 ± 12 | 67 ± 7 | 0.57 |
| Men/women (n) | 13/7 | 13/4 | — |
| Weight (kg) | 76 ± 13 | 84 ± 15 | 0.08 |
| Height (cm) | 165 ± 8.8 | 172 ± 5.8 | 0.01 |
| Body surface area (m2) | 1.83 ± 0.2 | 1.97 ± 0.2 | 0.02 |
| Body mass index (kg/m2) | 27.7 ± 3.3 | 28.2 ± 4.5 | 0.73 |
|
Aetiology Ischaemic heart disease/dilated cardiomyopathy |
— | 13/4 | — |
| Left ventricular ejection fraction (%) | — | 32 ± 7.5 | — |
| NT‐proBNP level (ng/L) | — | 420 ± 265 | — |
| Medication | — | — | |
| Beta‐blockers | — | 17 | — |
| Angiotensin‐converting enzyme inhibitors | — | 15 | — |
| Angiotensin receptor blockers | — | 2 | — |
| Diuretics | — | 13 | — |
| Warfarin | — | 6 | — |
| Anti‐arrhythmic | — | 3 | — |
HF, heart failure; NT‐proBNP, N‐terminal prohormone of brain natriuretic peptide.
Procedures
The patients in the ‘heart failure’ group underwent blood sampling for determination of plasma NT‐proBNP. Subsequently, all participants completed maximal graded cardiopulmonary exercise stress testing using a semi‐recumbent, electromagnetically controlled cycle ergometer (Corrival; Lode, Groningen, the Netherlands). Bioreactance method (NICOM, Cheetah Medical, USA) and gas exchange monitoring (Metalyzer 3B, Cortex, Leipzig, Germany) were used to non‐invasively assess cardiac output and gas exchange. Bioreactance has been validated against gold‐standard measures of cardiac function and has been shown to be a reliable and valid method of estimating cardiac output.3, 4, 5
Incremental exercise stress testing protocol was used, where patients were required to maintain cycling speed between 60 and 70 rpm, with work increasing by 10 W/min. Standardized Borg scale was used to assess the perceived exertion during exercise (6—no exertion at all and 20—maximal exertion).6 The test was terminated when (i) the respiratory exchange ratio showed the maximal level of exertion (respiratory exchange ratio > 1.15), (ii) a patient was unable to maintain required cycling cadence, or (iii) until patients reached volitional exertion and desired to stop. Cardiac power output, as an integrative and direct measure of overall function and pumping capability of the heart, was calculated as a product of simultaneously measured mean arterial blood pressure and cardiac output.7, 8
Statistical analysis
Data were analysed using SPSS version 24.0 (SPSS Inc., Chicago, IL, USA). All data were screened for univariate outliers using Z‐distribution cut‐off scores and Mahalanobis distance test for multivariate outliers. Independent samples T‐tests were used to assess the differences in physiological variables between patients with heart failure and healthy controls. The relationship between NT‐proBNP and measures of cardiac function and exercise tolerance was evaluated using Pearson's product moment correlation coefficient analysis (r). Coefficient of determination (R 2) was used to determine the goodness of fit within the correlation. Statistical significance level was set to P ≤ 0.05. All data are presented as mean ± standard deviation.
Results
Demographics and physical characteristics
Study participants' demographics and physical characteristics are presented in Table 1. Body mass index and age were not significantly different between the groups (P > 0.05). The mean left ventricular ejection fraction in patients with chronic heart failure was 32 ± 7%, and mean NT‐proBNP level was 420 ± 265 ng/L. Patients were treated with a recommended medical therapy including beta‐blockers, angiotensin‐converting enzyme inhibitors (or angiotensin receptor blockers), and diuretics as appropriate.
Difference in cardiac function at rest
Table 2 demonstrates haemodynamic and metabolic measures for heart failure patients and healthy controls, at rest. Systolic, diastolic, and mean arterial blood pressures were significantly higher in the healthy control group (P = 0.00). Nevertheless, there were no significant differences in heart rate (P = 0.27), cardiac output (P = 0.55), and cardiac index (P = 0.70) between the groups. In contrast to other haemodynamic measures of cardiac function, cardiac power output was significantly higher in the healthy controls (P = 0.02). Oxygen consumption was significantly higher in heart failure (P = 0.05), while arteriovenous oxygen difference showed no significant difference.
Table 2.
Resting haemodynamic and metabolic variables
| Healthy controls (n = 20) | HF patients (n = 17) | Percentage difference | P‐value | |
|---|---|---|---|---|
| Heart rate (beats/min) | 70.2 ± 8.5 | 67.5 ± 7.0 | 3.8 | 0.27 |
| Systolic blood pressure (mmHg) | 140 ± 15.4 | 117.8 ± 18.4 | 16.0 | <0.01 |
| Diastolic blood pressure (mmHg) | 85.9 ± 9.1 | 74.3 ± 7.6 | 13.5 | <0.01 |
| Mean arterial blood pressure (mmHg) | 104 ± 9.4 | 88.7 ± 8.0 | 14.7 | <0.01 |
| Cardiac output (L/min) | 5.90 ± 1.0 | 6.1 ± 1.0 | −3.3 | 0.55 |
| Cardiac power output (W) | 1.40 ± 0.2 | 1.20 ± 0.2 | 14.3 | 0.02 |
| Cardiac index (L/min/m2) | 3.20 ± 0.5 | 3.10 ± 0.5 | 3.1 | 0.70 |
| Arteriovenous oxygen difference (mL/100 mL) | 4.60 ± 0.5 | 5.30 ± 1.5 | −13.2 | 0.08 |
| Oxygen consumption (mL/kg/min) | 3.60 ± 0.5 | 3.80 ± 1.2 | −5.3 | 0.49 |
HF, heart failure.
Difference in cardiac function at peak exercise
Table 3 shows the difference in haemodynamic and metabolic measures at peak exercise. In contrast to the results obtained at rest, the difference in haemodynamic variables between heart failure and healthy controls is more pronounced at peak exercise. The average value of cardiac power output was 36% higher in the healthy control group (5.0 ± 2.0 vs. 3.2 ± 1.2 W, P = 0.00). Oxygen consumption at peak exercise was significantly higher in the healthy control group, indicating better exercise tolerance compared with patients with heart failure. No significant differences between the groups were found for arteriovenous oxygen difference.
Table 3.
Peak exercise haemodynamic and metabolic variables
| Healthy controls (n = 20) | HF patients (n = 17) | Percentage difference | P‐value | |
|---|---|---|---|---|
| Heart rate (beats/min) | 148 ± 23.7 | 111 ± 20.9 | 25.0 | <0.01 |
| Systolic blood pressure (mmHg) | 202 ± 16.2 | 155 ± 13.4 | 23.1 | <0.01 |
| Diastolic blood pressure (mmHg) | 94.4 ± 14.0 | 80.2 ± 8.5 | 15.0 | <0.01 |
| Mean arterial blood pressure (mmHg) | 130 ± 11.5 | 105 ± 13.4 | 19.3 | <0.01 |
| Cardiac output (L/min) | 18.2 ± 6.3 | 13.5 ± 4.0 | 25.8 | 0.01 |
| Cardiac power output (W) | 5.0 ± 2.0 | 3.2 ± 1.2 | 36.0 | 0.00 |
| Cardiac index (L/min/m2) | 9.8 ± 2.9 | 6.9 ± 1.7 | 29.6 | 0.00 |
| Arteriovenous oxygen difference (mL/100 mL) | 10.5 ± 2.3 | 10.8 ± 2.2 | −2.8 | 0.62 |
| Oxygen consumption (mL/kg/min) | 24.3 ± 9.5 | 16.8 ± 3.8 | 30.1 | <0.01 |
HF, heart failure.
Relationship between NT‐proBNP and measures of cardiac function and performance
Table 4 shows the relationship between NT‐proBNP and other variables of cardiac function and performance in patients with chronic heart failure. There is no significant relationship between NT‐proBNP and any haemodynamic and metabolic variables, neither at rest nor at peak exercise. Figure 1 shows the relationship between NT‐proBNP and peak exercise measures of cardiac performance.
Table 4.
Correlation between N‐terminal prohormone of brain natriuretic peptide and measures of cardiac function and performance
| Rest (n = 17) | Peak exercise (n = 17) | |||||
|---|---|---|---|---|---|---|
| r | R 2 | P | r | R 2 | P | |
| Left ventricular ejection fraction (%) | 0.07 | 0.01 | 0.79 | — | — | — |
| Heart rate (beats/min) | 0.45 | 0.21 | 0.07 | 0.45 | 0.21 | 0.07 |
| Systolic blood pressure (mmHg) | −0.44 | 0.19 | 0.08 | 0.24 | 0.06 | 0.35 |
| Diastolic blood pressure (mmHg) | 0.09 | 0.01 | 0.73 | 0.14 | 0.02 | 0.58 |
| Mean arterial blood pressure (mmHg) | −0.23 | 0.05 | 0.37 | 0.25 | 0.06 | 0.34 |
| Stroke volume (mL) | −0.43 | 0.19 | 0.08 | −0.15 | 0.02 | 0.58 |
| Cardiac output (L/min) | −0.18 | 0.03 | 0.50 | 0.13 | 0.02 | 0.63 |
| Cardiac power output (W) | −0.28 | 0.08 | 0.28 | 0.18 | 0.03 | 0.49 |
| Cardiac index (L/min/m2) | −0.15 | 0.02 | 0.55 | 0.18 | 0.03 | 0.50 |
| Arteriovenous oxygen difference (mL/100 mL) | 0.03 | 0.00 | 0.92 | −0.05 | 0.00 | 0.85 |
| Oxygen consumption (mL/kg/min) | −0.18 | 0.03 | 0.50 | −0.05 | 0.00 | 0.84 |
Figure 1.
Relationship between N‐terminal prohormone of brain natriuretic peptide (NT‐proBNP) and peak exercise: cardiac power output (A), mean arterial blood pressure (B), stroke volume (C), and oxygen consumption (D).
Conclusion
The aim of the present study was to assess haemodynamic response to exercise and to evaluate the relationship between NT‐proBNP, cardiac function, and exercise tolerance in chronic heart failure.
The major findings of the present study suggest that (i) heart failure patients demonstrate a significantly diminished cardiac function (cardiac power output) at rest and in response to exercise and diminished exercise tolerance (peak oxygen consumption) compared with healthy controls and (ii) there is no significant relationship between the NT‐proBNP and measures of cardiac function and performance. It appears that there is a consensus among physicians based on their experience that natriuretic peptides should be considered with caution as an indicator of overall patients' symptoms and cardiac function.
The present study corroborates the findings of Bain and colleagues who demonstrated that patients with heart failure have a significantly lower peak exercise cardiac power output compared with healthy controls.9 However, the lack of significant relationship between NT‐proBNP and cardiac power output contrasts the findings of Williams and colleagues who suggested a significant, moderate negative relationship between the two measures (r = −0.64).10 The discrepancy between the results may be explained by the methodological limitations of the Williams et al. study, which may affect homogeneity of data and their distribution, i.e. they included patients with heart failure with preserved ejection fraction, classes I–IV of heart failure, as well as healthy individuals, which is demonstrated with significantly differing values of NT‐proBNP. Furthermore, the present study finding, which suggests lack of a significant relationship between NT‐proBNP and peak O2 consumption, differs from that of Felker and colleagues,11 who revealed a significant, moderate, negative relationship between the two variables (r = −0.39). Despite large sample size (N = 1383), lower age of patients (59 years old), and statistical significance (P < 0.0001), it should be acknowledged that only moderate strength of the relationship (r = 0.4) between does not warrant conclusion that NT‐proBNP is a strong/excellent predictor (or marker) of functional capacity, i.e. peak O2 consumption in chronic heart failure.
The two major limitation of the present study are (i) a small sample size and (ii) functional capacity of patients was a relatively preserved and NT‐proBNP rather elevated than high. These limitations may affect generalizability of the major findings.
In conclusion, results from the present study suggest the lack of significant and strong relationship between the NT‐proBNP and measures of cardiac function and exercise tolerance. It is reasonable to suggest that natriuretic peptides should be considered with caution in interpretation of the severity of cardiac dysfunction and functional capacity in chronic heart failure.
Conflict of interest
None declared.
Funding
This study was funded by the UK NIHR Newcastle Biomedical Research Centre grant to D.G.J. (grant no. BH161161). D.G.J. is supported by the UK Research Councils' Newcastle Centre for Ageing and Vitality (grant no. L016354). The views expressed are those of the authors and not necessarily those of the funding bodies. N.O. is supported by the European Horizon 2020 research and innovation programme (grant agreement no. 777204). The funders of the study had no role in study design or in data collection, analysis, or interpretation.
Parovic, M. , Okwose, N. C. , Bailey, K. , Velicki, L. , Fras, Z. , Seferovic, P. M. , MacGowan, G. A. , and Jakovljevic, D. G. (2019) NT‐proBNP is a weak indicator of cardiac function and haemodynamic response to exercise in chronic heart failure. ESC Heart Failure, 6: 449–454. 10.1002/ehf2.12424.
References
- 1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González‐Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Rev Esp Cardiol (Engl Ed) 2016; 69: 1167. [DOI] [PubMed] [Google Scholar]
- 2. Roberts E, Ludman AJ, Dworzynski K, Al‐Mohammad A, Cowie MR, McMurray JJ, Mant J. The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta‐analysis in the acute care setting. BMJ 2015; 350: h910. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Jones TW, Houghton D, Cassidy S, MacGowan GA, Trenell MI, Jakovljevic DG. Bioreactance is a reliable method for estimating cardiac output at rest and during exercise. Br J Anaesth 2015; 115: 386–391. [DOI] [PubMed] [Google Scholar]
- 4. Jakovljevic DG, Trenell MI, MacGowan GA. Bioimpedance and bioreactance methods for monitoring cardiac output. Best Pract Res Clin Anaesthesiol 2014; 28: 381–394. [DOI] [PubMed] [Google Scholar]
- 5. Keren H, Burkhoff D, Squara P. Evaluation of a noninvasive continuous cardiac output monitoring system based on thoracic bioreactance. Am J Physiol Heart Circ Physiol 2007; 293: H583–H589. [DOI] [PubMed] [Google Scholar]
- 6. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14: 377–381. [PubMed] [Google Scholar]
- 7. Jakovljevic DG, George RS, Donovan G, Nunan D, Henderson K, Bougard RS, Yacoub MH, Birks EJ, Brodie DA. Comparison of cardiac power output and exercise performance in patients with left ventricular assist devices, explanted (recovered) patients, and those with moderate to severe heart failure. Am J Cardiol 2010; 105: 1780–1785. [DOI] [PubMed] [Google Scholar]
- 8. Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG, LeJemtel TH, Cotter G. Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. J Am Coll Cardiol 2004; 44: 340–348. [DOI] [PubMed] [Google Scholar]
- 9. Bain RJ, Tan LB, Murray RG, Davies MK, Littler WA. The correlation of cardiac power output to exercise capacity in chronic heart failure. Eur J Appl Physiol Occup Physiol 1990; 61: 112–118. [DOI] [PubMed] [Google Scholar]
- 10. Williams SG, Ng LL, O'Brien RJ, Taylor S, Wright DJ, Tan LB. Is plasma N‐BNP a good indicator of the functional reserve of failing hearts? The FRESH‐BNP study. Eur J Heart Fail 2004; 6: 891–900. [DOI] [PubMed] [Google Scholar]
- 11. Felker GM, Whellan D, Kraus WE, Clare R, Zannad F, Donahue M, Adams K, McKelvie R, Piña IL, O'Connor CM, HF‐ACTION Investigators . N‐terminal pro‐brain natriuretic peptide and exercise capacity in chronic heart failure: data from the Heart Failure and a Controlled Trial Investigating Outcomes of Exercise Training (HF‐ACTION) study. Am Heart J 2009; 158: S37–S44. [DOI] [PMC free article] [PubMed] [Google Scholar]