Submit Manuscripts
Author Information
Subscribe/Renew
Email Alerts
Feedback
RSS Feed

About the Journal
Editorial Board & Staff

Interventions Homepage Imaging Homepage Interventions Homepage Imaging Homepage

ACC.org
Cardiosmart
Cardiosource
CVN
Imaging Library
JACC Imaging
JACC Interventions


ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease
cardiology careers collections past issues search home
     

J Am Coll Cardiol, 2006; 47:85-90, doi:10.1016/j.jacc.2005.08.050 (Published online 12 December 2005).
© 2006 by the American College of Cardiology Foundation
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
j.jacc.2005.08.050v1
47/1/85    most recent
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (22)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Horwich, T. B.
Right arrow Articles by Fonarow, G. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Horwich, T. B.
Right arrow Articles by Fonarow, G. C.

CLINICAL RESEARCH: HEART FAILURE

B-Type Natriuretic Peptide Levels in Obese Patients With Advanced Heart Failure

Tamara B. Horwich, MD, Michele A. Hamilton, MD, FACC and Gregg C. Fonarow, MD, FACC*

Ahmanson-UCLA Cardiomyopathy Center, UCLA Division of Cardiology, Los Angeles, California

Manuscript received May 22, 2005; revised manuscript received July 9, 2005, accepted August 1, 2005.

* Reprint requests and correspondence: Dr. Gregg C. Fonarow, Ahmanson-UCLA Cardiomyopathy Center, UCLA Division of Cardiology CHS 47-123, 10833 Le Conte Avenue, Los Angeles, California 90095-1679. (Email: gfonarow{at}mednet.ucla.edu).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusions
 References
 
OBJECTIVES: This study aimed to examine the influence of obesity on the predictive value of the B-type natriuretic peptide (BNP) assay in heart failure (HF).

BACKGROUND: Recent studies show that obesity, or elevated body mass index (BMI), is associated with lower circulating levels of BNP both in the general population and in patients with HF.

METHODS: We analyzed data from 316 systolic HF (left ventricular ejection fraction [LVEF] ≤40%) patients [age, 53 ± 13 years; mean LVEF, 24 ± 7%; 48% ischemic] followed up at a university HF center. Patients were divided into categories of BMI: lean (BMI <25 kg/m2), overweight (BMI = 25 to 29.9 kg/m2), and obese (BMI ≥30 kg/m2).

RESULTS: The BNP levels were significantly lower in overweight and obese compared with lean patients (p = 0.0001); median BNP (interquartile range) for the lean (n = 131), overweight (n = 99), and obese (n = 86) groups was 747 (272 to 1,300), 380 (143 to 856), and 332 (118 to 617) pg/ml, respectively. In each BMI category, elevated BNP was significantly associated with worse symptoms and higher pulmonary capillary wedge pressure. Higher BNP was also a significant independent predictor of survival independent of BMI. Optimal BNP cutoff for prediction of death or urgent transplant in lean, overweight, and obese HF patients was 590, 471, and 342 pg/ml, respectively.

CONCLUSIONS: Although BNP levels are relatively lower in overweight and obese HF patients, BNP predicts worse symptoms, impaired hemodynamics, and higher mortality at all levels of BMI.

Abbreviations and Acronyms
  BMI = body mass index
  BNP = B-type natriuretic peptide
  CI = confidence interval
  HF = heart failure
  LVEF = left ventricular ejection fraction
  OR = odds ratio

B-type natriuretic peptide (BNP) facilitates the diagnosis of heart failure (HF) (1) and in patients with pre-existing HF, BNP correlates with HF severity, ventricular filling pressures (2,3), and HF outcomes (4). The BNP levels are affected by demographic variables such as age, gender, and ethnicity, and clinical characteristics such as hypertension, atrial fibrillation, and renal function (5–7).

Recent reports suggest that obesity, as indexed by elevated body mass index (BMI), also affects BNP levels, with lower circulating levels in those with a higher BMI. The inverse relationship between BNP and BMI has been observed in diverse populations, including healthy individuals, patients presenting to emergency departments with dyspnea, and chronic HF patients (6,8,9).

Obesity, an increasingly prevalent condition in the U.S., contributes to the development of HF (10). In patients with established HF, overweight and obesity are common, occurring in approximately 30% of patients (11), and thus further elucidation of the relationship between BNP and BMI is critical. Our study aimed to further explore the association between elevated BMI and BNP in advanced HF, focusing on the influence of co-existing factors such as gender, age, hypertension, and diabetes. We also address a clinically relevant, as yet unanswered question: does the presence of obesity affect the prognostic value of BNP in advanced HF?


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 Conclusions
 References
 
Patient population.   The study population consisted of 316 consecutive HF patients seen at a single university medical center for HF management and/or heart transplantation evaluation between July 2000 and June 2004. Subjects with left ventricular ejection fraction (LVEF) >40%, creatinine >2.5 mg/dl, or a clinical diagnosis of acute coronary syndrome or myocarditis at time of referral were excluded. The BNP was measured in all patients within one month of initial referral date through the use of an industry-standard analytical platform (Triage, Biosite, San Diego, California). Medical record review was approved by the Medical Institutional Review Board of the University of California, Los Angeles.

Statistical analysis.   Patients were divided into three BMI categories based on World Health Organization/National Institutes of Health guidelines: lean (BMI <25.0 kg/m2), overweight (BMI 25.0 to 29.9 kg/m2), and obese (BMI ≥30.0 kg/m2) (12). Differences in baseline characteristics between groups were analyzed using independent samples t test, analysis of variance, chi-square, Kruskal-Wallis, and Mann-Whitney tests, as appropriate. The p values for analysis of variance test the hypothesis that several means are equal. Multivariate logistic regression analysis was used to estimate odds ratios (OR) for low BNP (BNP <100 pg/ml) in overweight and obese patients. Receiver operator curves for prediction of one-year outcomes by BNP were generated in each BMI category; optimal cutoff points were defined by maximization of the sum of sensitivity and specificity. Product-moment survival estimates were calculated using the Kaplan-Meier method. Cox regression models estimated the one- and two-year hazard ratios and 95% confidence intervals of BNP levels in predicting mortality. The primary end points analyzed were: 1) all-cause mortality, with censoring at the time of any heart transplantation, and 2) survival free from death or urgent transplantation (status Ia), with censoring at time of non-urgent transplantation (status Ib or II). All statistics were calculated with Statistical Package for Social Sciences version 12.0 for Windows (SPSS Inc., Chicago, Illinois).


   Results
Top
 Abstract
 Methods
 Results
Discussion
 Conclusions
 References
 
Obesity and baseline patient characteristics.   Mean age of the cohort was 53 ± 13 years, mean LVEF was 24 ± 7%, and 74% of the cohort was male. Baseline characteristics of the population according to BMI category are shown in Table 1. The HF medications were similar among the three BMI groups, with the exception of slighter higher rates of beta-blocker and statin usage in overweight and obese subjects.


View this table:
[in this window]
[in a new window]
  		Table 1. Baseline Characteristics of the Cohort in Lean, Overweight, and Obese Patients
 
Relationship between BMI and BNP levels.   Circulating BNP levels were significantly lower in overweight and obese HF patients compared with lean HF patients. Median (interquartile ranges) values for the lean, overweight, and obese groups were 747 (272 to 1,300), 380 (143 to 856), and 332 (113 to 617) pg/ml, respectively (Fig. 1). The BNP levels in patients with a very low BMI (<20.0 kg/m2) compared with patients with a normal BMI (20.0 to 24.9 kg/m2) were 839 (77 to 1,300) pg/ml versus 734 (317 to 1,300) pg/ml (p = 0.40). The proportion of patients with BNP above 1,000 pg/ml was progressively lower with increases in BMI across a broad range (Fig. 2). Furthermore, the association between high BMI and low BNP was consistent in clinically significant subgroups, with the exception of diabetic patients (Fig. 3).


Figure 1
View larger version (19K):
[in this window]
[in a new window]
  		Figure 1 Box plots showing median circulating levels of B-type natriuretic peptide (BNP) in lean, overweight, and obese heart failure patients. The lines represent the median, the boxes represent the interquartile range, and the I bars represent the 5th and 95th percentiles. BMI = body mass index.

 

Figure 2
View larger version (16K):
[in this window]
[in a new window]
  		Figure 2 The proportion of patients with B-type natriuretic peptide (BNP) ≥1,000 pg/ml by body mass index (BMI). In parentheses: n = patients with BNP ≥1,000 pg/ml, n = total patients in BMI subcategory.

 

Figure 3
View larger version (19K):
[in this window]
[in a new window]
  		Figure 3 B-type natriuretic peptide (BNP) levels (median) in lean, overweight, and obese patients stratified by gender, diabetes (DM), and hypertension (HTN).

 
A multivariate logistic regression analysis was performed to determine independent predictors of low BNP (<100 pg/ml, n = 52), adjusting for age, gender, race, hypertension, diabetes, LVEF, coronary artery disease, New York Heart Association functional class, creatinine, and medications (angiotensin converting enzyme inhibitor, angiotensin receptor antagonist, beta-blocker, and aldosterone antagonist). Obesity was associated with a greater than six-fold increase in the odds of having low BNP (OR, 6.7; 95% confidence interval [CI], 1.2 to 40.4). Per unit increase in BMI, the odds of having a low BNP increased by 13% (OR, 1.1; 95% CI, 1.0 to 1.3). After excluding underweight patients (BMI < 20), higher BMI was still an independent predictor of low BNP, with 23% increased odds of low BNP per unit increase in BMI (OR, 1.2; 95% CI, 1.1 to 1.4).

BNP, HF severity, and hemodynamics.   In each BMI category, higher BNP was associated with more severe functional impairment as well as elevated filling pressures (Figs. 4A and 4B).


Figure 4
View larger version (19K):
[in this window]
[in a new window]
  		Figure 4 B-type natriuretic peptide (BNP) predicts New York Heart Association (NYHA) functional class (A) and pulmonary capillary wedge pressure (PCW) (B) independent of body mass index (BMI). Median BNP levels in subjects with NYHA functional class III versus IV (A) and high versus low PCW (B) are depicted.

 
BNP, obesity, and survival.   The mean follow-up time was 456 days (15.2 months). There were 93 heart transplantations (67 urgent, status Ia, and 26 non-urgent, status Ib or II), 37 deaths, and 6 patients lost to follow-up during the first year. Progressive HF death accounted for 20 deaths, where as 6 were sudden, 2 were secondary to myocardial infarction, and 9 were other or unknown. One-year unadjusted survival estimates in the lean, overweight, and obese patients were 80%, 93%, and 88%, respectively (p < 0.02).

The BNP predicted outcomes independent of BMI. A BNP above the cohort median (452 pg/ml) was associated with impaired survival in lean, overweight, and obese subjects (Table 2). On multivariate analysis, BNP remained an independent predictor of one-year mortality in each BMI category (Table 3).


View this table:
[in this window]
[in a new window]
  		Table 2. One-Year Outcomes for the Lean, Overweight, and Obese Categories Stratified by Median BNP (452 pg/ml)
 

View this table:
[in this window]
[in a new window]
  		Table 3. B-Type Natriuretic Peptide (BNP) as a Determinant of One-Year Mortality in Lean, Overweight, and Obese Patients With Advanced Heart Failure
 
The receiver operator curve analysis to assess BNP as a predictor of one-year mortality or urgent heart transplantation showed that the area under the curve was >0.7 in each BMI category (Fig. 5A). Any BNP levels above the receiver operator curve-determined cut point predicted markedly increased all-cause mortality in each BMI category (Fig. 5B).


Figure 5
View larger version (37K):
[in this window]
[in a new window]
  		Figure 5 (A) Receiver-operator curves for prediction of death or urgent heart transplantation at one-year follow-up in lean, overweight, and obese subgroups. Arrows indicate best cutoff B-type natriuretic peptide (BNP). (B) Survival curves using the receiver-operator curve-determined best cutoff BNP level for each category of body mass index. p values, log rank test. AUC = area under the curve.

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusions
 References
 
In light of the increasing prevalence of both HF and obesity, understanding the relationship between BMI and BNP levels is integral to the successful diagnosis and management of HF. This study shows that overweight and obese HF patients (BMI ≥25.0 kg/m2) have significantly lower BNP levels compared with lean HF patients (BMI <25.0 kg/m2), confirming reports from previous investigators (6,8,9). The inverse relationship between BMI and BNP in this cohort was independent of factors known to affect circulating BNP levels, including age, race, gender, hypertension, renal function, and HF medications (5–7,9,13,14).

This study adds to the growing body of knowledge regarding natriuretic peptide levels and obesity (6,8,9). However, this is the first study to show that despite relatively less circulating BNP in HF patients who are overweight and obese, BNP retains its prognostic capacity in this cohort. The BNP not only predicted ventricular filling pressures and functional class, but also correlated with mortality at each level of BMI.

Mechanisms of low BNP in obesity.   Given the association of obesity with multiple cardiovascular risk factors, the relationship between elevation of BMI and reduction in BNP is counterintuitive. Several potential mechanistic explanations deserve consideration. It is possible that the low natriuretic peptide levels in overweight and obese patients reflect less advanced stages of HF compared with lean patients. Elevated BMI was associated with improved outcomes in this cohort and has been reported previously (11). However, ventricular filling pressures were no different in obese and non-obese patients, arguing against differential ventricular wall stretch/stress as an explanation for differential BNP production and release in obese and non-obese HF patients.

Cardiac cachexia, a state characterized by weight loss and neurohumoral/cytokine activation (15,16), is another potential explanation for a low BMI-high BNP association. However, BNP was statistically similar in underweight (BMI <20.0 kg/m2) and normal-weight patients (BMI = 20.0 to 24.9 kg/m2). There is evidence that inflammatory cytokines such as tumor necrosis factor-alpha, which may elicit release of BNP from cardiomyocytes (17), are less active in states of obesity. However, an initial investigation found tumor necrosis factor-alpha and interleukin-6 to be similar in obese and non-obese HF patients (8).

Recent evidence suggests that there may be increased clearance of circulating BNP in obesity. Natriuretic peptide clearance receptors are abundant on human adipocytes (18). Additionally, the vascularity of adipose tissue may allow for increased degradation of BNP by neutral endopeptidase (19). Conversely, it is also possible that overweight and obesity are associated with less robust synthesis and/or release of BNP from the myocardium. Decreased N terminal pro-BNP and pro-atrial natriuretic peptide have been observed in obesity (6,20), which may be suggestive of decreased natriuretic peptide production.

Alternatively, decreased circulating BNP levels may not be a consequence of increased body weight or excess adiposity, but rather may be a causative factor in the genotype or phenotype that leads to development of obesity. Both ANP and BNP are now recognized to be involved in fat metabolism as stimulators of lipolysis in adipose tissue (21).

Study limitations.   We acknowledge potential limitations to our study. Our cohort is a selected population with advanced HF referred to a tertiary center for disease management and transplantation evaluation. The number of events per BMI category was relatively low. The upper limit of detectable BNP increased from 1,300 to 5,000 pg/ml during the study period, although this adjustment likely affected all BMI categories to a similar extent. Both BMI and BNP may not have been assessed on the same day, although maximal delay was one month. We do not we have data on weight loss or measures of percent body fat, and also we did not measure additional neurohormones, cytokines, or adipokines for correlation with BNP or BMI.


   Conclusions
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions
References
 
In this advanced systolic HF cohort, overweight and obese patients had significantly lower circulating BNP levels compared with lean patients, and this relationship was independent of demographics, medications, or severity of HF. Despite the dampening of BNP levels in overweight and obese HF patients, BNP retained its prognostic capacity in this population, correlating not only with HF severity and hemodynamic status, but also predicting survival. These data suggest that the BNP assay is a useful tool for the management of chronic systolic heart failure at all levels of BMI, although increased risk may be seen at relatively lower levels of BNP in the obese.


   Footnotes
 
This research was supported by the Ahmanson Foundation, Los Angeles, California. Dr. Horwich was funded by NIH training grant 401357JI30608. Dr. Fonarow holds the Eliot Corday Chair in Cardiovascular Medicine and Science.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions
 References
 

  1. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure N Engl J Med 2002;347:161-167.[Abstract/Free Full Text]
  2. Kazanegra R, Cheng V, Garcia A, Krishnaswamy P, Gardetto N, Clopton P, Maisel A. A rapid test for B-type natriuretic peptide correlates with falling wedge pressures in patients treated for decompensated heart failurea pilot study. J Card Fail 2001;7:21-29.[CrossRef][ISI][Medline]
  3. Koglin J, Pehlivanli S, Schwaiblmair M, Vogeser M, Cremer P, vonScheidt W. Role of brain natriuretic peptide in risk stratification of patients with congestive heart failure J Am Coll Cardiol 2001;38:1934-1941.[Abstract/Free Full Text]
  4. Anand IS, Fisher LD, Chiang YT, et al. Changes in brain natriuretic peptide and norepinephrine over time and mortality and morbidity in the Valsartan Heart Failure Trial (Val-HeFT) Circulation 2003;107:1278-1283.[Abstract/Free Full Text]
  5. Maisel AS, Clopton P, Krishnaswamy P, et al. Impact of age, race, and sex on the ability of B-type natriuretic peptide to aid in the emergency diagnosis of heart failureresults from the Breathing Not Properly (BNP) multinational study. Am Heart J 2004;147:1078-1084.[CrossRef][ISI][Medline]
  6. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Wilson PW, Vasan RS. Impact of obesity on plasma natriuretic peptide levels Circulation 2004;109:594-600.[Abstract/Free Full Text]
  7. Tang WH, Girod JP, Lee MJ, Starling RC, Young JB, Van Lente F, Francis GS. Plasma B-type natriuretic peptide levels in ambulatory patients with established chronic symptomatic systolic heart failure Circulation 2003;108:2964-2966.[Abstract/Free Full Text]
  8. Mehra MR, Uber PA, Park MH, Scott RL, Ventura HO, Harris BC, Frohlich ED. Obesity and suppressed B-type natriuretic peptide levels in heart failure J Am Coll Cardiol 2004;43:1590-1595.[Abstract/Free Full Text]
  9. McCord J, Mundy BJ, Hudson MP, et al. Relationship between obesity and B-type natriuretic peptide levels Arch Intern Med 2004;164:2247-2252.[Abstract/Free Full Text]
  10. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure N Engl J Med 2002;347:305-313.[Abstract/Free Full Text]
  11. Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Woo MA, Tillisch JH. The relationship between obesity and mortality in patients with heart failure J Am Coll Cardiol 2001;38:789-795.[Abstract/Free Full Text]
  12. Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transitionbackground and recommendations for the United States. Am J Clin Nutr 2000;72:1074-1081.[Abstract/Free Full Text]
  13. Brunner-La Rocca HP, Weilenmann D, Kiowski W, Maly FE, Candinas R, Follath F. Within-patient comparison of effects of different dosages of enalapril on functional capacity and neurohormone levels in patients with chronic heart failure Am Heart J 1999;138:654-662.[CrossRef][ISI][Medline]
  14. Takeda Y, Fukutomi T, Suzuki S, et al. Effects of carvedilol on plasma B-type natriuretic peptide concentration and symptoms in patients with heart failure and preserved ejection fraction Am J Cardiol 2004;94:448-453.[CrossRef][ISI][Medline]
  15. Levine B, Kalman J, Mayer L, Fillit HM, Packer M. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure N Engl J Med 1990;323:236-241.[Abstract]
  16. Anker SD, Ponikowski P, Varney S, et al. Wasting as independent risk factor for mortality in chronic heart failure Lancet 1997;349:1050-1053.[CrossRef][ISI][Medline]
  17. Ma KK, Ogawa T, de Bold AJ. Selective upregulation of cardiac brain natriuretic peptide at the transcriptional and translational levels by pro-inflammatory cytokines and by conditioned medium derived from mixed lymphocyte reactions via p38 MAP kinase J Mol Cell Cardiol 2004;36:505-513.[CrossRef][ISI][Medline]
  18. Sarzani R, Dessi-Fulgheri P, Paci VM, Espinosa E, Rappelli A. Expression of natriuretic peptide receptors in human adipose and other tissues J Endocrinol Invest 1996;19:581-585.[ISI][Medline]
  19. McCullough PA, Sandberg KR. Sorting out the evidence on natriuretic peptides Rev Cardiovasc Med 2003;4(Suppl 4):S13-S19.
  20. James SK, Lindahl B, Siegbahn A, et al. N-terminal pro-brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery diseasea Global Utilization of Strategies To Open occluded arteries (GUSTO)-IV substudy. Circulation 2003;108:275-281.[Abstract/Free Full Text]
  21. Engeli S, Sharma AM. The renin-angiotensin system and natriuretic peptides in obesity-associated hypertension J Mol Med 2001;79:21-29.[CrossRef][ISI][Medline]



This article has been cited by other articles:


Home page
 CirculationHome page
H. Ashrafian, C. W. le Roux, A. Darzi, and T. Athanasiou
Effects of Bariatric Surgery on Cardiovascular Function
Circulation, November 11, 2008; 118(20): 2091 - 2102.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
L. Frankenstein, A. Remppis, M. Nelles, B. Schaelling, D. Schellberg, H. Katus, and C. Zugck
Relation of N-terminal pro-brain natriuretic peptide levels and their prognostic power in chronic stable heart failure to obesity status
Eur. Heart J., November 1, 2008; 29(21): 2634 - 2640.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
L Ingle, J G F Cleland, and A L Clark
Perception of symptoms is out of proportion to cardiac pathology in patients with "diastolic heart failure"
Heart, June 1, 2008; 94(6): 748 - 753.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
S. W. Waldo, J. Beede, S. Isakson, S. Villard-Saussine, J. Fareh, P. Clopton, R. L. Fitzgerald, and A. S. Maisel
Pro-B-Type Natriuretic Peptide Levels in Acute Decompensated Heart Failure
J. Am. Coll. Cardiol., May 13, 2008; 51(19): 1874 - 1882.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
L. B. Daniels and A. S. Maisel
Natriuretic Peptides
J. Am. Coll. Cardiol., December 18, 2007; 50(25): 2357 - 2368.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
W. J. Paulus, C. Tschope, J. E. Sanderson, C. Rusconi, F. A. Flachskampf, F. E. Rademakers, P. Marino, O. A. Smiseth, G. De Keulenaer, A. F. Leite-Moreira, et al.
How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology
Eur. Heart J., October 2, 2007; 28(20): 2539 - 2550.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
T. Tsutamoto, T. Tanaka, H. Sakai, C. Ishikawa, M. Fujii, T. Yamamoto, and M. Horie
Total and high molecular weight adiponectin, haemodynamics, and mortality in patients with chronic heart failure
Eur. Heart J., July 2, 2007; 28(14): 1723 - 1730.
[Abstract] [Full Text] [PDF]

Home page
 Emerg. Med. J.Home page
S. Choi, D. Park, S. Lee, Y. Hong, S. Kim, and J. Lee
Cut-off values of B-type natriuretic peptide for the diagnosis of congestive heart failure in patients with dyspnoea visiting emergency departments: a study on Korean patients visiting emergency departments
Emerg. Med. J., May 1, 2007; 24(5): 343 - 347.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
M. B. McEntegart, B. Awede, M. C. Petrie, N. Sattar, F. G. Dunn, N. G. MacFarlane, and J. J.V. McMurray
Increase in serum adiponectin concentration in patients with heart failure and cachexia: relationship with leptin, other cytokines, and B-type natriuretic peptide
Eur. Heart J., April 2, 2007; (2007) ehm033v1.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
A. Bayes-Genis, D. M. Lloyd-Jones, R. R. J. van Kimmenade, J. G. Lainchbury, A. M. Richards, J. Ordonez-Llanos, M. Santalo, Y. M. Pinto, and J. L. Januzzi Jr
Effect of Body Mass Index on Diagnostic and Prognostic Usefulness of Amino-Terminal Pro-Brain Natriuretic Peptide in Patients With Acute Dyspnea
Arch Intern Med, February 26, 2007; 167(4): 400 - 407.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
j.jacc.2005.08.050v1
47/1/85    most recent
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (22)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Horwich, T. B.
Right arrow Articles by Fonarow, G. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Horwich, T. B.
Right arrow Articles by Fonarow, G. C.

 
  cardiology careers collections past issues search home