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CLINICAL RESEARCH: HEART FAILURE

Relationship Between B-Type Natriuretic Peptides and Pulmonary Capillary Wedge Pressure in the Intensive Care Unit

Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland.

Manuscript received June 4, 2004; revised manuscript received October 7, 2004, accepted January 26, 2005.

^_* Reprint requests and correspondence: Dr. Edward P. Shapiro, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, Maryland 21224. (Email: eshapiro{at}jhmi.edu).

OBJECTIVES: We examined whether B-type natriuretic peptides (BNP) can serve as noninvasive markers of pulmonary capillary wedge pressure (PCWP) in the setting of critical illness.

BACKGROUND: The BNP and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are highly correlated with left ventricular (LV) filling pressures in patients with depressed LV systolic function. However, their relationship to PCWP in a heterogeneous intensive care unit (ICU) population has not been established.

METHODS: We prospectively studied 40 patients in the ICU requiring invasive hemodynamic monitoring. Hemodynamics were recorded simultaneously with blood sampling for BNP and NT-proBNP.

RESULTS: The BNP (median 420 pg/ml) and NT-proBNP (median 3,304 pg/ml) levels were markedly elevated, but weakly correlated with PCWP (BNP, r = 0.40, NT-proBNP, r = 0.32) and other cardiac parameters. Peptide levels were approximately four-fold greater in patients with impaired (estimated glomerular filtration rate [eGFR] <60 ml/min) versus normal (eGFR >60 ml/min) renal function, despite similar PCWP, cardiac index, and LV ejection fraction. In addition, both BNP and NT-proBNP showed stronger correlations with PCWP in patients with preserved (BNP, r = 0.58, NT-proBNP, r = 0.73) versus impaired renal function (BNP, r = 0.48, NT-proBNP, r = 0.34). Interaction terms between eGFR and BNP (p = 0.06) and NT-proBNP (p = 0.04) suggest that eGFR modulates the relationship of these peptides to filling pressures.

CONCLUSIONS: The BNPs are markedly elevated, yet show only weak correlations to PCWP in ICU patients requiring invasive hemodynamic monitoring. Thus, a single value for BNP or NT-proBNP may not be a clinically useful noninvasive marker of filling pressures in the critically ill patient. This appears to be especially true in patients with impaired renal function.

Abbreviations and Acronyms   BNP = B-type natriuretic peptide   CI = cardiac index   eGFR = estimated glomerular filtration rate   ICU = intensive care unit   IQR = interquartile range   LV = left ventricular   LVEF = left ventricular ejection fraction   NT-proBNP = N-terminal pro-B-type natriuretic peptide   PAC = pulmonary artery catheter   PCWP = pulmonary capillary wedge pressure

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