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Heart failure in primary health care: special emphasis on natriuretic peptides in the elderly
Linköping University, Department of Medicine and Care, Cardiology. Linköping University, Faculty of Health Sciences.
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: This thesis focuses on heart failure among elderly patients in the community who usually are not included in studies on heart failure. The heart failure syndrome is an increasing problem in Western society. Severe heart failure is often easy to diagnose compared with light to moderate heart failure, which is more frequent in patients in the community,

Doppler echocardiography is the most commonly used method to objectively verify an abnormal cardiac function, mostly the systolic function. One goal of this thesis was to evaluate both the systolic and diastolic functions. Another goal was a study of the possible utility of the B-type natriuretic peptide, BNP (brain natriuretic peptide), and the amino terminal fragment of its precursor, proBNP (N-terminal proBNP) as tools in the diagnosis of heart failure in elderly patients.

Methods: In a primary health care setting, 510 elderly patients (age range 65-82 years) with symptoms and signs possibly associated with heart failure were examined concerning patient history, ongoing pharmacological treatment, clinical examination, chest x-ray, electrocardiogram, Doppler echo cardiography, and selected biochemical measurements of blood samples. Additionally, the natriuretic peptide BNP and the aminoterminal fragment of proBNP were analyzed for a possible influence of gender, age, impaired cardiac function assessed using Doppler echocardiography, other diseases, and phannacological treatment. We followed our study population for six years, carefully registering mortality with death certificates. This information was used in analyzing the risk of cardiovascular death based on Cox proportional hazard regression. We present a model for estimating the risk of cardiovascular death in the individual patient.

Results: Almost half of our study population [mean age 73 (SD 6) years] with symptoms of possible heart failure had signs of impaired cardiac function on Doppler echocardiography. Half of these individuals had isolated impairment of the diastolic function. Almost two thirds of the elderly patients who had an ejection fraction of less than 40% did not receive treatment with ACE inhibitors, one of the cornerstones in the treatment of heart failure.

BNP and N-terminal proBNP were equally effective in detecting impaired cardiac function. As a response to increased filling pressure they probably provide earlier information on the haemodynamic situation than Doppler echocardiography does.

In these elderly patients, functional class (NYHA class III: 7 times increased risk), in vivo examination by Doppler echo cardiography (EF<30%: 8 times increased risk) and the in vitro measurement of plasma BNP (>27.8 pmol/L: 11 times increased risk) and N-terminal proBNP (>109 pmol/L: 7 times increased risk) could be used as prognostic determinants in assessing the risk of cardiovascular death.

Conclusion: The results indicate that a focused patient history and clinical examination provides important information that is often sufficient for the prognostic evaluation of a patient with heart failure symptoms. Additional information may be obtained with Doppler echo cardiographic examination and measurement of plasma BNP or N-terminal proBNP. The relationship between BNPIN-terminal proBNP concentration and risk of cardiovascular death may be analysed to define decision limits for the concentrations of these peptides as regards further diagnostic procedures and/or phannaceutical treatment.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2003. , 111 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 819
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-27454Local ID: 12107ISBN: 91-7373-508-6 (print)OAI: oai:DiVA.org:liu-27454DiVA: diva2:248006
Public defence
2003-11-06, Hälsans Hus, Hälsouniversitetet, Campus US, Linköpings Universitet, Linköping, 13:00 (English)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-17Bibliographically approved
List of papers
1. Heart failure in the elderly: characteristics of a Swedish primary health care population
Open this publication in new window or tab >>Heart failure in the elderly: characteristics of a Swedish primary health care population
2002 (English)In: Heart Drug, ISSN 1422-9528, E-ISSN 1424-0556, Vol. 2, no 5, 211-220 p.Article in journal (Refereed) Published
Abstract [en]

Background: Heart failure (HF) is a challenge to diagnose and treat according to guidelines. Few studies have been performed in elderly subjects with symptoms that might be associated with HF in primary health care.

Objective: To study elderly patients presenting with symptoms possibly associated with HF, with respect to systolic and diastolic function, B-type natriuretic peptide (BNP) levels and treatment.

Methods: A cardiologist examined 415 elderly (65–82 years) patients with symptoms of dyspnoea, fatigue and/or peripheral oedema. All patients underwent echocardiography and plasma BNP determination. Systolic function was determined semiquantitatively, and ejection fraction (EF) <40% was considered to be reduced. Abnormal diastolic function was defined as a reduced ratio of peak early diastolic filling velocity to peak filling velocity at atrial contraction (E/A ratio; age adjusted) or an abnormal pattern of pulmonary venous flow.

Results: Forty-eight percent of the patients showed abnormal systolic (26%) or diastolic function (22%). A majority of the patients with diastolic HF had relaxation abnormalities and neither pseudonormal nor restrictive filling patterns. Increased levels of BNP were found in the group with impaired systolic function. More than half of those with EF <40% were not receiving angiotensin-converting enzyme inhibitions at all, or were on a suboptimal dose, whereas others were on treatment for an HF diagnosis despite normal cardiac function.

Conclusion: Diagnostic tools that are more objective than clinical examination are needed for the diagnosis of HF.

Keyword
Elderly patients, Heart failure, Primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-46849 (URN)10.1159/000067723 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved
2. Utility of the amino-terminal fragment of pro-brain natriuretic peptide in plasma for the evaluation of cardiac dysfunction in elderly patients in primary health care
Open this publication in new window or tab >>Utility of the amino-terminal fragment of pro-brain natriuretic peptide in plasma for the evaluation of cardiac dysfunction in elderly patients in primary health care
2003 (English)In: Clinical Chemistry, ISSN 0009-9147, E-ISSN 1530-8561, Vol. 49, no 8, 1337-1346 p.Article in journal (Refereed) Published
Abstract [en]

Background: The aims of this study were to measure the N-terminal fragment of pro-brain natriuretic peptide (proBNP) in plasma in medical conditions commonly found in primary care and to evaluate the utility of these measurements in identifying impaired cardiac function in elderly patients with symptoms associated with heart failure.

Methods: We studied 415 patients (221 men and 194 women; mean age, 72 years) who had contacted a primary healthcare center for dyspnea, fatigue, and/or peripheral edema. One cardiologist evaluated the patients in terms of history, physical examination, functional capacity, electrocardiography, and suspicion of heart failure. Plasma N-terminal proBNP was measured by an in-house RIA. An ejection fraction ≤40% by Doppler echocardiography was regarded as reduced cardiac function. Abnormal diastolic function was defined as an abnormal mitral inflow defined as reduced ratio of peak early diastolic filling velocity to peak filling velocity at atrial contraction (E/A ratio), or as abnormal pulmonary venous flow pattern.

Results: Patients with impaired functional capacity, impaired systolic function, and/or impaired renal function had significantly increased N-terminal proBNP concentrations. By multiple regression analysis, N-terminal proBNP concentrations were also influenced by ischemic heart disease, cardiac enlargement, and certain medications but not by increased creatinine. No gender differences were observed. Patients with isolated diastolic dysfunction attributable to relaxation abnormali-ties had lower concentrations than those with normal cardiac function, whereas those with pseudonormal E/A ratios or restrictive filling patterns had higher concentrations.

Conclusions: Plasma N-terminal proBNP concentrations increase as a result of impaired systolic function, age, impaired renal function, cardiac ischemia and enlargement, and certain medications. Values are high in diastolic dysfunction with pseudonormal patterns, but not in patients with relaxation abnormalities. An increase in plasma N-terminal proBNP might be an earlier sign of abnormal cardiac function than abnormalities identified by currently used echocardiographic measurements.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26758 (URN)10.1373/49.8.1337 (DOI)11356 (Local ID)11356 (Archive number)11356 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. The risk of cardiovascular death in elderly patients with possible heart failure: results from a 6-year follow-up of a Swedish primary care population
Open this publication in new window or tab >>The risk of cardiovascular death in elderly patients with possible heart failure: results from a 6-year follow-up of a Swedish primary care population
2005 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 100, no 1, 17-27 p.Article in journal (Refereed) Published
Abstract [en]

Little is known about the prognosis and clinical variables influencing the prognosis among elderly patients in primary health care with mild to moderate heart failure.

Aim: To evaluate the risk of cardiovascular mortality in elderly patients with symptoms of heart failure with respect to systolic and diastolic function, and functional impairment. To evaluate prognostic determinants and to risk-stratify the patients.

Methods: A cardiologist examined 510 patients, out of 548 invited, attending primary care for symptoms of dyspnoea, fatigue and/or peripheral oedema and assessed New York Heart Association (NYHA) functional class. Examination by Doppler echocardiography was done in 454 patients, 56 patients being excluded because of, e.g., atrial fibrillation. Abnormal systolic function was defined as ejection fraction <40%. The diastolic function was evaluated using the mitral inflow and pulmonary venous flow variables. Different clinical and echocardiographic variables were analysed using a Cox regression analysis to identify those most influencing the risk of cardiovascular mortality.

Conclusion: Abnormal systolic and/or diastolic function was found in 219 patients (48% of the 454 patients who could be echocardiographically completely investigated). The follow-up period was 6 years. Total mortality was 20%, and cardiovascular mortality was 14% (70% of total mortality). Cardiovascular mortality was high in patients with severely impaired functional capacity and ejection fraction <40% at the start of the study. Risk variables identified were male gender, diabetes mellitus, impaired functional capacity and abnormal cardiac function by echocardiography. A prognostic score model using simple clinical variables (gender, NYHA class, cardiac function) was developed to assess the risk of cardiovascular death in order to identify patients with high, moderate or low risk. In a ROC curve analysis, the AUC for clinical variables was only 0.75, whereas the AUC for clinical variables and echocardiography was 0.78, indicating that the additional prognostic information obtained by Doppler echocardiography was rather small.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-33737 (URN)10.1016/j.ijcard.2004.03.031 (DOI)19779 (Local ID)19779 (Archive number)19779 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
4. Results from a 6-year follow-up of a Swedish population in primary care regarding b-type natriuretic peptide (bnp) and the aminoterminal fragment of proBNP (n-terminal proBNP) and risk for cardiovascular death in elderly patients with possible heart failure.
Open this publication in new window or tab >>Results from a 6-year follow-up of a Swedish population in primary care regarding b-type natriuretic peptide (bnp) and the aminoterminal fragment of proBNP (n-terminal proBNP) and risk for cardiovascular death in elderly patients with possible heart failure.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Abstract

Heart failure is common in the elderly population and carries a serious prognosis. Identification of risk factors for cardiovascular mortality among primary care patients is important.

Aim

To evaluate EDTA-plasma brain natriuretic peptide (BNP) and the aminoterminal fragment of proBNP (N-terminal proBNP) as prognostic markers in elderly with symptoms of mild to moderate heart failure.

Methods

From 474 patients attending primary care for symptoms of dyspnoea, fatigue and/or peripheral oedema blood was sampled in plastic tubes containing EDTA in order to measure BNP by non-extraction immunoradiometric assay and of N-terminal proBNP by non-extraction radioimmunoassay. Patients were evaluated with respect to history and clinical- and laboratory examinations with particular reference to cardiac structure and function. Follow-up time was 6 years. A Cox regression analysis was performed to identify the weight of risk variables.

Conclusion

During the follow-up period of 6 years the total mortality was 16 % (75 patients out of 474), and cardiovascular mortality was 11% (52 patients). Cardiovascular mortality increased with increased plasma concentration of BNP or N-terminal proBNP. Both pep tides were useful prognostic markers for cardiovascular mortality in patients with heart failure. In those with the highest quartile of plasma concentration of BNP and N=terminal proBNP, 9.9 times and 5.0 times increased risk for CV death were identified respectively.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84703 (URN)
Available from: 2012-10-17 Created: 2012-10-17 Last updated: 2013-09-26Bibliographically approved

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