Cardiac biomarkers such as BNP and NT-proBNP are useful for diagnosing and monitoring heart failure. The document discusses several studies that found BNP-guided treatment of heart failure reduced mortality rates compared to symptom-guided treatment. Measurement of BNP levels can aid clinical decision making in both acute and ambulatory heart failure patients. While useful, biomarkers have limitations and should be interpreted in the clinical context of each patient.
Role of plasma N-terminal proB-type natriuretic peptide (NT-proBNP) level in ...Apollo Hospitals
Cardioembolic stroke generally results in more severe disability, since it typically has a larger ischemic area than the other types of ischemic stroke. The correct identification of a stroke etiology as cardioembolic is important as it has been shown that these patients benefit from anticoagulation. However, it is difficult to differentiate cardioembolic strokes from non-cardioembolic strokes (atherothrombotic stroke and lacunar stroke). NT-proBNP is a well recognized biochemical marker of congestive heart failure. Recent studies suggest that NT-proBNP may be used as a marker of cardioembolic stroke.
Role of plasma N-terminal proB-type natriuretic peptide (NT-proBNP) level in ...Apollo Hospitals
Cardioembolic stroke generally results in more severe disability, since it typically has a larger ischemic area than the other types of ischemic stroke. The correct identification of a stroke etiology as cardioembolic is important as it has been shown that these patients benefit from anticoagulation. However, it is difficult to differentiate cardioembolic strokes from non-cardioembolic strokes (atherothrombotic stroke and lacunar stroke). NT-proBNP is a well recognized biochemical marker of congestive heart failure. Recent studies suggest that NT-proBNP may be used as a marker of cardioembolic stroke.
cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
Beta Blockers in current cardiovascular practice Praveen Nagula
betablockers are the drug of choice for prevention of progression of heart failure with mortality benefit, after the evolution of neurohormonal regulation as pathogenesis of heart failure
http://www.theheart.org/web_slides/1425587.do
A randomized to placebo or ivabradine study on Systolic Heart Failure Treatment with the If Inhibitor Ivabradine (SHIFT) with patients on standard HF medications according to guidelines
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Advanced Heart Failure Therapies: Cardiac Transplantation and Mechanical Circ...Allina Health
By Michael A. Samara, MD. A discussion about the growing population of patients with heart failure, advances in heart failure therapies, and the role of ECMO and LVAD implants in improving outcomes. "ECMO is an older therapy that is undergoing a renaissance. We've learned that poorer outcomes were a consequence of resorting to ECMO too late after multiple system failure. Now we're starting ECMO in the cath lab, even during active CPR."
cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
Beta Blockers in current cardiovascular practice Praveen Nagula
betablockers are the drug of choice for prevention of progression of heart failure with mortality benefit, after the evolution of neurohormonal regulation as pathogenesis of heart failure
http://www.theheart.org/web_slides/1425587.do
A randomized to placebo or ivabradine study on Systolic Heart Failure Treatment with the If Inhibitor Ivabradine (SHIFT) with patients on standard HF medications according to guidelines
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
http://www.theheart.org/web_slides/1283563.do
A study on Anglo-Scandinavian Cardiac Outcomes--Lipid Lowering Arm (ASCOT-LLA) designed to assess the effect on risk of normal MI and fatal CHD of two treatment strategies.
Advanced Heart Failure Therapies: Cardiac Transplantation and Mechanical Circ...Allina Health
By Michael A. Samara, MD. A discussion about the growing population of patients with heart failure, advances in heart failure therapies, and the role of ECMO and LVAD implants in improving outcomes. "ECMO is an older therapy that is undergoing a renaissance. We've learned that poorer outcomes were a consequence of resorting to ECMO too late after multiple system failure. Now we're starting ECMO in the cath lab, even during active CPR."
Utility of Cardiac Biomarkers in Clinical Heart Failure CareMd. Shahidul Islam
The talk describes the utility and limitations of Brain Natriuretic peptide (BNP) and N-terminal proBNP (NT-pBNP) in the clinical management of heart failure
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. Cardiac biomarkers in heart
failure : where are we now?
Dr Arun Kochar
MD;DM;DNB
Senior consultant, interventional cardiology
Fortis hospital, Mohali.
2. Heart Failure- Clinical syndrome
… can result from any structural
or functional cardiac disorder that
impairs ability of ventricle to fill
with or eject blood
•5 million Americans- have heart
failure
•500,000 new cases every year
• 30 billion dollars a year spent on heart
failure treatment
• 6,500,000 hospital days / year and
300,000 deaths/year
•Heart failure in India has been
conservatively estimated to affect up to
4.6 million people, with up to 1.8 million
new diagnoses made each year
3. What exactly is the term biomarker?
• The National Institutes of
Health define a biomarker
as a “characteristic that is
objectively measured and
evaluated as an indicator
of normal biologic processes,
pathogenic processes, or
pharmacologic
responses to a therapeutic intervention”
These are substances detectable in blood, urine,
or other bodily fluids. Tests measuring them
should be readily available, be quantitative,
reproducible and generally inexpensive,
6. Accurate, reproducible measurements must
be available to clinicians at reasonable cost with
short turn-around time
Biomarker must provide information that is not
already available from a careful clinical
assessment
Measured level should aid in clinical decision
making
10. What exactly are BNP
and NT-proBNP…..
• BNP is a hormone produced in r in
response to ventricular overload, and NT-
proBNP is the fragment produced from the
cleavage of proBNP.
• BNP and NT-proBNP levels are elevated in
patients with HF and correlate with functional
and morphological left ventricular parameters
and they independently predict prognosis
• The BNP gene natriuretic peptide B (NPPB)
is the precursor molecule for both
12. Punch lines….( BNP)
-BNP concentration increases, when there
is an abnormal cardiac dilatation.
-Factors as age, BMI, renal function can
alter levels resulting in “grey-zone” values.
- 100-400 ng/l = grey zone
- < 100 = to exclude HF
- Lower cutoff <50 to exclude HF = BMI>35
- the optimal times to assess BNP levels at
admission, 24 hours after admission and
at discharge.
- Dry and wet BNP
13. NT-proBNP
• Adding NT-proBNP levels to the
differential resulted in increase of 24.4%
with a diagnosis of HF and 47.5% with
lung failure. It helped diagnose 18% of
patients presenting with acute dyspnea.
• NT-proBNP had shown superior
prognostic power for all cause mortality
when compared with BNP.
20. Study Population Intervention Comparison Implication
Beck-da-Silva, 20058 (LVEF) of 40% or less
Symptomatic HF (New
York Heart Association
class II–IV) for at least 3
months or previous
hospital admission due
to HF
Age (mean): 65 years.
< 50% males
•-
•β-blocker dosage up-
titrated according to
plasma BNP levels plus
standard care
•-
•β-blocker dosage up-
titrated according
standard care
A trend toward better
quality of life was seen
in the BNP group as
compared to the
clinically guided group
Jourdain, 2007
STARS-BNP9
Symptomatic (New York
Heart Association
functional class II–III)
systolic HF defined by
left ventricular ejection
fraction (LVEF) <45%
Age (mean): 65 years
<50% females
•-
•Medical therapy was
increasingly used with
the aim of lowering
plasma BNP levels
(target <100 pg/ml)
•-
•Each class of therapy
modified according to
the judgment of the
investigator
•-
•Medical therapy was
adjusted on the basis
of the physical
examination and usual
para clinical and
biological parameters
BNP guided strategy
reduced the risk of
CHF-related death or
hospital stay for CHF
Pfisterer, 2009
TIME-CHF10
Dyspnea (New York
Heart Association class
≥II with current
therapy), a history of
hospitalization for HF
within the last year
Age (mean): 76 years
<50% females
Age subgroups: <75
years; ≥75 years)
•-
•BNP guided plus
symptom guided
medical therapy
•-
•Medical therapy to
reduce BNP levels to 2
times or less than the
upper limit of normal
(<400 pg/ml in patients
<75 years and
<800 pg/ml in patients
≥75 years) and
symptoms to NYHA
•-
•Symptom guided
medical therapy
•-
•Medical therapy to
reduce symptoms to
NYHA class of II or less
HF therapy guided by
N-terminal BNP did not
improve overall clinical
outcomes or quality of
life compared with
symptom guided
treatment
HF therapy guided by
N-terminal BNP
improved outcomes in
patients aged 60–75
years but not in those
aged 75 years or older
21. Effect of B-type natriuretic peptide-
guided treatment of chronic heart
failure on total mortality and
hospitalization: an individual
patient meta-analysis
• Richard W. Troughton1, et al.
• Eur Heart
J (2014)doi: 10.1093/eurheartj/ehu090First
published online: March 6, 2014
• Of 11 eligible studies, 2000 patients were
included, 994 randomized to clinically guided
care and 1006 to NP-guided care
23. Kaplan–Meier survival curves for the primary endpoint, overall mortality: (A) total group, (B)
below age 75 years (n = 982), (C) 75 years and above (n = 1018).
Natriuretic peptide-
guided treatment of
heart failure reduces
all-cause mortality in
patients aged <75
years and overall
reduces heart failure
and cardiovascular
hospitalization
24. Survival curve for all-cause
mortality in NP-guided or clinically
guided treatment of CHF
0.0 0.5 1.51.0 2.0
0.0
0.2
0.4
0.6
0.8
1.0
Proportionsurviving
Total group: HR: 0.62, 95%CI: 0.45-0.86, P=0.004
Age < 75 years: HR: 0.62, 95%CI: 0.45-0.85, P=0.004
Age > 75 years: HR: 0.98, 95%CI: 0.75-1.3, P=0.96
Throughton et al., Eur Heart J 2014
NP-guided
clinically-guided
25. most useful in the evaluation of pts with
dyspnea presenting to the ED where they may
provide the advantages of convenience and
rapid turnaround times facilitating clinical
management
Maisel et al showed in the Breathing Not
Properly study that BNP levels greatly
increased the accuracy of the diagnosis of HF in
pts presenting to ED with dyspnea;
level > 100 pg/ml HF unlikely but level >400
pg/ml makes the diagnosis likely.
26.
27. Systolic Heart Failure Treatment Supported by
BNP (STARS–BNP) trial by Jourdain et al
randomly assigned outpatients with NYHA cl II/III HF to
current clinical guidelines (control group) or to goal of
decreasing BNP < 100 pg/ml
primary end point (HF death or hosp admission for HF)
occurred in 24% of patients in whom the BNP level was
lowered vs 52% of the control group (p < 0.001)
28. predischarge level of BNP was a strong,
independent predictor of postdischarge
outcomes
patients with HF whose BNP level does not
decline to < 600 pg/ml should receive
intensified treatment before discharge
useful in screening asymptomatic subjects at
risk of HF such as elderly and those with HPN,
DM & asymptomatic CAD
may also be used to screen for acute or late
cardiotoxic effects associated with cancer
chemotherapy
29.
30. HFPEF…
• Patients with HFPEF overall have lower levels of
BNP than do HF patients with reduced LVEF, but
for a given BNP level, the associated risk of all-
cause mortality and HF hospitalization is at least
as high in patients with HFPEF as it is in those with
low LVEF.
• Use of cardiac peptides (BNP or NT-proBNP) to
guide pharmacologic therapy in patients with
HFPEF is associated with a significant reduction
of mortality and HF-related hospitalization,
especially in patients younger than 75 years.
31. In chronic HF…
• 90-day combined event rate with BNP
<200 pg/mL was 9% versus 29% for >200.
• A reduction of 25% (24 hours ) 46%( at
discharge) compared with the admission,with
the absolute value of less than 300 pg/mL is
very strong favorable prognosis.
• Val-HeFT trial reported them strongest
mortality and hospitalization predictors.
• 35% increase in risk of mortality with an
increase of 100 pg/mL from baseline.
• BNP level >189 pg/mL at 2 months with >15%
change from baseline had worst survival
despite being stable after discharge for HF
32. ACC 2013 recommendations
Ambulatory/Outpatient
BNP- or NT-proBNP guided HF therapy can be useful to
achieve optimal dosing of GDMT in select clinically
euvolemic patients followed in a well-structured HF
disease management program.
The usefulness of serial measurement of BNP or NT-
proBNP to reduce hospitalization or mortality in patients
with HF is not well established.
Measurement of other clinically available tests such as
biomarkers of myocardial injury or fibrosis may be
considered for additive risk stratification in patients with
chronic HF.
I IIa IIb III
I IIa IIb III
I IIa IIb III
33. Causes for Elevated Natriuretic
Peptide Levels
Cardiac Noncardiac
Heart failure, including RV
syndromes
Acute coronary syndrome
Heart muscle disease, including
LVH
Valvular heart disease
Pericardial disease
Atrial fibrillation
Myocarditis
Cardiac surgery
Cardioversion
Advancing age
Anemia
Renal failure
Pulmonary causes: obstructive
sleep apnea, severe pneumonia,
pulmonary hypertension
Critical illness
Bacterial sepsis
Severe burns
Toxic-metabolic insults, including
cancer chemotherapy and
envenomation
34. Recommendations for Biomarkers in HF
Biomarker, Application Setting COR LOE
Natriuretic peptides
Diagnosis or exclusion of HF
Ambulatory,
Acute
I A
Prognosis of HF
Ambulatory,
Acute
I A
Achieve GDMT Ambulatory IIa B
Guidance of acutely decompensated
HF therapy
Acute IIb C
Biomarkers of myocardial injury
Additive risk stratification
Acute,
Ambulatory I A
Biomarkers of myocardial fibrosis
Additive risk stratification
Ambulatory
IIb B
Acute
IIb A
35. Ambulatory/Outpatient
In ambulatory patients with dyspnea, measurement of
BNP or N-terminal pro-B-type natriuretic peptide (NT-
proBNP) is useful to support clinical decision making
regarding the diagnosis of HF, especially in the setting of
clinical uncertainty.
Measurement of BNP or NT-proBNP is useful for
establishing prognosis or disease severity in chronic HF.
I IIa IIb III
I IIa IIb III
37. Galectin-3
• Inflammatory and fibrotic processes are
central to cardiac remodeling and the
development of HF
• Galectin-3, secreted by activated
macrophages, causes cardiac fibrosis
• Increasingly being used as a s surrogate
indicator of cardiac remodeling and
fibrosis
• PROVE IT-TIMI22 , higher galectin-3 levels
in ACS showed a positive relationship with
the development of HF.
• “remodeling” and “non-remodeling” HF
38. High sensitivity troponin
- When comparing hs cTnI and NT-proBNP
to cardiac troponins measured using
conventional assay in 258 HF pts. hs cTnI
was single best independent prognostic
predictor
- hs c Tnl is independently predictive of
higher risk of death and 1-year mortality
and provide additional prognostic
information in patients with ADHF
39. Modest elevations of cT I levels are also found in
patients with HF without ischemia.
Horwich et al – cT I was detectable (≥0.04 ng /ml)
in approx half of 240 patients with advanced,
chronic heart failure without ischemia.
cT I remained an independent predictor of death.
cT T levels > 0.02 ng /ml chronic HF associated
with a hazard ratio for death of more than 4
40. An ideal HF bio marker
should …
-Be measurable at a reasonable
cost on short notice;
-Add new information to the clinical workup;
-Aid in the management of patients with HF.
-Identify possible underlying/reversible causes
of HF;
-Confirm the presence or absence of the HF
syndrome;
-Estimate the severity of HF and risk of disease
progression
41. Expectations of the ideal
biomarker
• Patient acceptability
• In vivo and in vitro stability
• Adequate analytical (functional) sensitivity
• Reproducibility and accuracy
• Feasibility
• Complete assay automation
• International standardization
• Low cost
• Low biological variation
• Reference range and cut-off values tested for gender, age,
and ethnicity dependence
• Good diagnostic and prognostic accuracy
• Cost-effectiveness
44. Selected Biochemical Markers Currently Available for Heart Failure
Standard laboratory markers
Uric acid
Red blood cell distribution width
Neurohormones
Catecholamines (norepinephrine, epinephrine)
Renin, ACE activity, angiotensin II, and aldosterone
Natriuretic peptides
Endothelin-1
Vasopressin/copeptin
Cardiotrophin-1
Novel vasodilators (adrenomedullin and mid-regional pro-adrenomedullin,
urotensin-II, urocortin)
Inflammatory biomarkers
High-sensitivity C-reactive protein
Myeloperoxidase
Galectin-3
Metabolic biomarkers
Leptin
Adiponectin
Insulin-like growth factor-1 (IGF-1)
Other miscellaneous biomarkers
G-protein coupled receptor kinase-2 (GRK-2)
Cardiac troponin I or troponin T and Myotrophin