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CLINICAL RESEARCH: HEART FAILURE

Dynamic Cardiovascular Risk Assessment in Elderly People

The Role of Repeated N-Terminal Pro–B-Type Natriuretic Peptide Testing

Christopher R. deFilippi, MD^_*,_*, Robert H. Christenson, PhD, John S. Gottdiener, MD^_*, Willem J. Kop, PhD^_* and Stephen L. Seliger, MD, MS

^_* Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland
Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland

Manuscript received March 3, 2009; revised manuscript received June 3, 2009, accepted July 6, 2009.

^_* Reprint requests and correspondence: Dr. Christopher R. deFilippi, G3K63, Division of Cardiology, University of Maryland, 22 South Greene Street, Baltimore, Maryland 21201 (Email: cdefilip{at}medicine.umaryland.edu).

Objectives: This study sought to determine whether serial measurement of N-terminal pro–B-type natriuretic peptide (NT-proBNP) in community-dwelling elderly people would provide additional prognostic information to that from traditional risk factors.

Background: Accurate cardiovascular risk stratification is challenging in elderly people.

Methods: NT-proBNP was measured at baseline and 2 to 3 years later in 2,975 community-dwelling older adults free of heart failure in the longitudinal CHS (Cardiovascular Health Study). This investigation examined the risk of new-onset heart failure (HF) and death from cardiovascular causes associated with baseline NT-proBNP and changes in NT-proBNP levels, adjusting for potential confounders.

Results: NT-proBNP levels in the highest quintile (>267.7 pg/ml) were independently associated with greater risks of HF (hazard ratio [HR]: 3.05; 95% confidence interval [CI]: 2.46 to 3.78) and cardiovascular death (HR: 3.02; 95% CI: 2.36 to 3.86) compared with the lowest quintile (<47.5 pg/ml). The inflection point for elevated risk occurred at NT-proBNP 190 pg/ml. Among participants with initially low NT-proBNP (<190 pg/ml), those who developed a >25% increase on follow-up to >190 pg/ml (21%) were at greater adjusted risk of HF (HR: 2.13; 95% CI: 1.68 to 2.71) and cardiovascular death (HR: 1.91; 95% CI: 1.43 to 2.53) compared with those with sustained low levels. Among participants with initially high NT-proBNP, those who developed a >25% increase (40%) were at higher risk of HF (HR: 2.06; 95% CI: 1.56 to 2.72) and cardiovascular death (HR: 1.88; 95% CI: 1.37 to 2.57), whereas those who developed a >25% decrease to 190 pg/ml (15%) were at lower risk of HF (HR: 0.58; 95% CI: 0.36 to 0.93) and cardiovascular death (HR: 0.57; 95% CI: 0.32 to 1.01) compared with those with unchanged high values.

Conclusions: NT-proBNP levels independently predict heart failure and cardiovascular death in older adults. NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk.

Key Words: biomarkers • risk stratification • heart failure • elderly

Abbreviations and Acronyms   CI = confidence interval   ECG = electrocardiogram   HF = heart failure   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   NT-proBNP = N-terminal pro–B-type natriuretic peptide   ROC = receiver-operator characteristic

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