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Clinical Articles, Lead Article

AF disrupts peptide use in heart failure diagnosis

The diagnostic performance of plasma natriuretic peptides is impaired by atrial fibrillation (AF), which is associated with increased peptide levels in the absence of heart failure (HF), according to a study1 published recently in JACC: Heart Failure.

The purpose of this study was to assess the impact of AF on the performance of mid-region amino terminal pro-atrial natriuretic peptide (MR-proANP) in comparison with the B-type peptides (BNP and NT-proBNP) for diagnosis of acute HF in dyspneic patients.

A total of 1,445 patients attending the emergency department with acute dyspnea had measurements taken of MR-proANP, BNP, and NT-proBNP values on enrollment to the BACH (Biomarkers in ACute Heart Failure) trial and were grouped according to presence or absence of AF and HF.

AF was present in 242 patients. Plasma concentrations of all three peptides were lowest in those with neither AF nor HF and AF without HF was associated with markedly increased levels (p<0.00001). HF with or without AF was associated with a significant further increment (p<0.00001 for all three markers). Areas under receiver operator characteristic curves (AUCs) for discrimination of acute HF were similar and powerful for all peptides without AF (0.893 to 0.912; all p<0.001) with substantial and similar reductions (0.701 to 0.757) in the presence of AF. All three peptides were independently prognostic but there was no interaction between any peptide and AF for prediction of all-cause mortality.

Mark Richards

Professor Mark Richards (University of Otago)

These findings warrant consideration of adjusted peptide thresholds for diagnostic use in AF and mandates the continued search for markers free of confounding by AF, say the authors.

Lead author, Professor Mark Richards (University of Otago, Christchurch, New Zealand) spoke to BJC Arrhythmia Watch on the search for other heart failure biomarkers, which might not be interfered with in AF patients: “We are hunting markers that are not confounded by cardiac rhythm, so we are investigating circulating proteins and peptides which are disturbed in heart failure but are derived predominantly from non-cardiac tissue (e.g. white cells, vasculature, etc…) and so not generated or disturbed as directly by intra-cardiac mechanical  stresses as the natriuretic peptides,” said Professor Richards.

“Candidates include Galectin 3 and Growth Differentiation Factor 15 (GDF15) and NT pro urocortin 2 (new assay unique to our group), among others. It is too soon to indicate any outcome at this stage,” he added.

References

1. Richards M, Di Somma S, Mueller C, et al. Atrial fibrillation impairs the diagnostic performance of cardiac natriuretic peptides in dyspneic patients results from the BACH study (Biomarkers in ACute Heart Failure). JACC: Heart Failure 2013;1:192–9. http://dx.doi.org/10.1016/j.jchf.2013.02.004

Published on: June 20, 2013

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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