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Prognostic role of B-type natriuretic peptide levels in patients with type 2 diabetes mellitus

Meenakshi A. Bhalla, MD^*, Audrey Chiang, MD^*, Victoria A. Epshteyn, MD^*, Radmila Kazanegra, MD^*, Vikas Bhalla, MD^*, Paul Clopton, MS^*, Padma Krishnaswamy, MD^*, L.K. Morrison, BS^*, Albert Chiu, BS^*, Nancy Gardetto, NPN^*, Sunder Mudaliar, MD, Steven V. Edelman, MD, Robert R. Henry, MD and Alan S. Maisel, MD^,*

^* Division of Cardiology, San Diego, San Diego, California, USA
Division of Endocrinology, San Diego, San Diego, California, USA
Division of Department of Medicine Veteran’s Affairs Medical Center and University of California, San Diego, San Diego, California, USA

Manuscript received April 2, 2004; revised manuscript received May 6, 2004, accepted May 6, 2004.

^* Reprint requests and correspondence: Dr. Alan S. Maisel, VAMC Cardiology 111-A, 3350 La Jolla Village Drive, San Diego, California 92161 (Email: amaisel{at}ucsd.edu).

OBJECTIVES: We hypothesized that B-type natriuretic peptide (BNP) levels can predict cardiac mortality in diabetic patients.

BACKGROUND: Detection of cardiovascular disease in diabetics can be difficult until overt events occur.

METHODS: A total of 482 diabetics (majority male with type 2 diabetes) at the Veterans Affairs Medical Center San Diego were divided into two groups: 1) referred patients for echocardiogram on the basis of clinical suspicion of cardiac dysfunction (referred [R], n = 180); 2) patients randomly selected from the diabetic clinic without any suspicion of cardiac dysfunction (not referred [N-R], n = 302). We examined cardiac events and all-cause mortality in relation to initial BNP levels during the follow-up.

RESULTS: A total of 71 (14.7%) patients died during this period: 52 of 180 (29%) in the R group (30 of 52 [58%] cardiac, 10 of 52 [19%] non-cardiac, 2 of 52 [4%] renal, 10 of 52 [19%] unknown cause) and 19 of 302 (6%) in N-R group (6 of 19 [32%] cardiac). The median BNP level in the R and N-R groups who died of cardiac, non-cardiac, and unknown cause was 537 and 87, 80 and 53, and 343 and 38 pg/ml, respectively. The receiver-operating characteristic (ROC) values for mortality in two groups in relation to BNP revealed the area under the curve to be 0.720 and 0.691, respectively (p < 0.01 in both). Among commonly used prognostic indicators in diabetics, only the ROC for triglycerides was significant. The most accurate cut-point in both the N-R group (87%) and R group (61%) was 120 pg/ml of BNP. Cox regression analysis showed BNP to be the most significant predictor of all-cause mortality in the R group. There was a marked decrease in survival in the patient group with BNP >120 pg/ml.

CONCLUSIONS: B-type natriuretic peptide appears to be a reliable predictor of future cardiac and all-cause mortality in diabetic patients.

Abbreviations and Acronyms   BNP = B-type natriuretic peptide   EF = ejection fraction   HF = heart failure   LV = left ventricular   ROC = receiver-operating characteristic

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