BIOMARKERS
Detection of exercise-induced ischemia by changes in B-type natriuretic peptides
Robert S. Foote, MD*, ,*,
Justin D. Pearlman, MD, PhD, FACC*,, ,
Alan H. Siegel, MD, and
Kiang-Teck J. Yeo, PhD,
* Medicine (Cardiology)
Radiology
Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Dartmouth Medical School, Hanover, New Hampshire
Manuscript received January 29, 2004;
revised manuscript received July 23, 2004,
accepted August 2, 2004.
* Reprint requests and correspondence: Dr. Robert S. Foote, Section of Cardiology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756 (Email: rsf{at}hitchcock.org).
OBJECTIVES: The purpose of this study was to examine the effect of exercise-induced ischemia on levels of B-type natriuretic peptide (BNP) and its inactive N-terminal fragment (NT-pro-BNP)and to determine whether measurement of these peptides can improve the diagnostic accuracy of exercise testing.
BACKGROUND: The ability of exercise testing to detect coronary artery disease (CAD) is limited by modest sensitivity and specificity. B-type natriuretic peptides (NT-pro-BNP and BNP) are released by ventricular myocytes in response to wall stress. We hypothesized that exercise-induced ischemia results in increased wall stress and triggers release of NT-pro-BNP and BNP.
METHODS: A total of 74 patients with known CAD, normal left ventricular function, and normal resting levels of NT-pro-BNP and BNP who were referred for exercise testing with radionuclide imaging, and 21 healthy volunteers, were enrolled. Blood was drawn before and after maximal exercise and analyzed for NT-pro-BNP and BNP.
RESULTS: Of the patients with CAD, 40 had ischemia on perfusion images and 34 did not. Median post-exercise increases in NT-pro-BNP and BNP ( NT-pro-BNP and BNP) were approximately four-fold higher in the ischemic group than in the nonischemic group (NT-pro-BNP 14.5 vs. 4 pg/ml, p < 0.0001; BNP 36.5 vs. 7.5 pg/ml, p < 0.0001). In volunteers, median NT-pro-BNP was almost identical to that of the nonischemic patient group. At equal specificity to the electrocardiogram (ECG) (58.8%), the sensitivities of NT-pro-BNP and BNP for detecting ischemia were 90% and 80%, respectively; in contrast, the sensitivity of the exercise ECG was 37.5%.
CONCLUSIONS: Measurement of exercise-induced increases in BNPs more than doubles the sensitivity of the exercise test for detecting ischemia with no loss of specificity.
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Abbreviations and Acronyms
| | BNP = B-type natriuretic peptide | | CAD = coronary artery disease | | ECG = electrocardiogram/electrocardiographic | | NT-pro-BNP = N-terminal fragment of B-type natriuretic peptide pro-hormone | | SDS = summed difference score | | SPECT = single-photon emission computed tomography | | SRS = summed rest score | | SSS = summed stress score |
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