B-Type Natriuretic Peptides Lose Prognostic Value in Cardiogenic Shock

B-type natriuretic peptide levels have long been used to diagnose and predict heart failure. Physician-scientists at the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, on the other hand, have discovered that BNP levels may not be an efficient predictive tool in heart failure patients with ventricular assist devices. According to their study, which was published in the American Journal of Cardiology, BNP levels were high in end-stage heart failure patients with cardiogenic shock but lost their predictive value in VAD recipients.

Blood BNP levels represent the severity of cardiac dysfunction. Higher BNP levels have been linked to worse clinical outcomes. This study looked at people with end-stage heart failure who had cardiogenic shock 34, a disease in which the heart is unable to pump enough blood to the body’s essential organs. However, due to a dearth of data on patients with end-stage heart failure, BNP levels and their prognostic significance, or ability to predict clinical outcomes, have not previously been defined.

“Heart failure is a progressive disease wherein the pumping function of the heart gradually decreases,” said Naman S. Shetty, M.D., first author of the study and a clinical research fellow in the UAB Division of Cardiovascular Disease. “End-stage heart failure represents the end of the clinical spectrum of heart failure where patients require a heart transplant or a device like a VAD that assists with the pumping function of the heart. Considering that there is a shortage of hearts for transplantation, there is a significant increase in the number of patients being implanted with a VAD.”

According to Shetty, predicting results following VAD implantation is critical for effectively allocating resources and delivering the best treatment for patients. Typically, a mix of clinical, imaging, and biomarker data is used to assess patient candidacy and predict results following VAD implantation. As a result, a gold standard biomarker that can help guide health care decisions for patients with end-stage heart failure is required.

Shetty and his colleagues examined data from roughly 7,000 VAD users who were enrolled in the INTERMACS database, which is maintained at UAB and comprises clinical information on VAD recipients from across the United States. Shetty observed that BNP levels in individuals with end-stage heart failure and cardiogenic shock were comparable to those in patients in the preceding stage of heart failure.

“It was previously hypothesized that, in end-stage heart failure, the heart’s ability to produce and release these hormones may become impaired due to the weakening of the heart muscle and the overall dysfunction of the cardiovascular system,” Shetty said.

“Considering that the heart releases BNP, it was thought that BNP levels would be relatively lower in end-stage heart failure patients compared to the patients in the beginning stages of heart failure. Our study provides evidence refuting this belief,” said Pankaj Arora, M.D., the senior author of the manuscript and an associate professor in the UAB Division of Cardiovascular Disease. “Furthermore, the study showed that factors influencing BNP levels in healthy individuals continued to act even in patients with end-stage heart failure with cardiogenic shock. Previously, we have shown that BNP was lower in males and Black individuals compared with their counterparts. We noted a similar pattern even in end-stage heart failure with cardiogenic shock.”

According to Arora, BNP is a commonly utilized measure that predicts the probability of death across the spectrum of heart failure. However, BNP loses its predictive significance in end-stage heart failure patients with cardiogenic shock. The study also found that BNP levels did not predict other clinical outcomes such arrhythmias, right heart failure, or cardiovascular mortality. Arora notes that future research should focus on examining the prognostic value of biomarkers representing other pathophysiological pathways such as fibrosis to help guide clinical decisions in end-stage heart failure.

“Currently, BNP levels are being routinely measured in patients with end-stage heart failure,” Arora said. “Given the lack of prognostic value of this marker, the study questions the need for this practice. Machine learning models that incorporate several factors to estimate the risk of mortality may be developed and implemented in this patient population to guide clinical decision-making.”

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