Peptidos natriureticos en el diagnostico, manejo y tratamiento de la insuficiencia cardiaca Dr.Pablo Cesar Spada Sociedad de Cardiologia del Oeste Bonaerense Federacion Argentina de Cardiologia

INSUFICIENCIA CARDIACA

En USA afecta a 5 millones de pacientes

1 millon de hospitalizaciones y 300.000 muertes anuales Causa mas frecuente de hospitalizacion en ancianos Prevalencia 6-10% > 65 anos

Prevalencia de la insuficiencia cardiaca

Effect of the aging population on the prevalence of heart failure, based on data from the National Heart, Lung, and Blood Institute and the US Census Bureau (CHF = congestive heart failure) (from Braunwald's Heart Disease, 7th ed. 2005:604, Sanders, Figure 24-1).

Schematic of the cleavage of intracellular pro B-type natriuretic peptide (BNP) to release from the myocyte of the active hormone BNP and the biologically inert N-terminal pro-B-natriuretic peptide (NT-proBNP).

Diagnostic utility of N-terminal pro-B-natriuretic peptide (NT-proBNP)/B-type natriuretic peptide (BNP) levels in the breathless patient

Utilidades del BNP

Vasodilatacion arterial y venosa Modulador neurohumoral ( disminucion de hormonas vasoconstrictoras y retenedoras de sal )

Junto con ANP promueve diuresis y natriuresis

BNP con herramienta diagnostica

Aumenta su secrecion a medida que envejecemos

Las mujeres suelen tener valores levemente mas altos El valor normal es menor de 100 pg/ml Valor predictivo negativo del 96% Costo 25 dolares, duracion 15 minutos Ayuda a distinguir la disnea cardiaca de la de otras causas

Plasma BNP plotted against plasma amino terminal N-terminal pro-B-natriuretic peptide (NTproBNP) in 1049 patients with stable ischemic heart disease (from Journal of the American College of Cardiology. 2006;46:52-60, Elsevier Biomedical, Figure 1).

Kaplan-Meier curves demonstrating the survival rates of all subjects. "Diagnostic NT-proBNP" denotes either an N-terminal pro-B-natriuretic peptide (NT-proBNP) concentration < 300 ng/L in patients without heart failure (HF) or a result greater than the rule-in cutpoint for those with HF (from The American Journal of Cardiology. 2006;98:386-90, Figure 1, Excerpta Medica)

Estudio ICON.Puntos de corte para el NT-proBNP

Confirmatorio < 50 anos : 450 pg/ml 50-75 anos : 900 pg/ml >75 anos : 1800 pg/ml

Exclusion Todos los pacientes : 300 pg/ml

Total 1256 pacientes Eur Heart J. 2006;27:330-337.

Sindrome cardiorrenal

Survival curves of HF subjects in The International Collaborative of NT-proBNP (ICON) as a function of glomerular filtration rate and N-terminal pro-B-natriuretic peptide (NT-proBNP) concentration on admission (log-rank P < .001) (from Journal of the American College of Cardiology, 2006;48:1621-1627, Figure 1, Elsevier Biomedical).

Cumulative hospitalization-free survival according to patterns of response of N-terminal pro-B-natriuretic peptide (NT-proBNP) (decreased by ≥ 30% of baseline value, changed by < 30%, increased by ≥ 30%). Individual comparisons between pairs of the groups are as follows: decreased by ≥ 30% of baseline value vs changed by < 30%, P = .006; changed by < 30% vs increased by ≥ 30%, P = .0002; decreased by ≥ 30% of baseline value vs increased by ≥ 30%, P < .0001 (from Circulation. 2004;110:2168-2174, Figure 2, Lippincott Williams & Wilkins).

Los peptidos natriureticos tienen valor pronostico en pacientes con insuficiencia cardiaca y disnea aguda, en pacientes con miocardiopatias isquemicas y en aquellos con

disfuncion ventricular asintomatica

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Systolic Heart Failure Treatment Supported by BNP (STARS-BNP)

220 pac, Cf II-III estables Manejo clinico vs BNP < 100 pg/ml

Seguimiento a 15 meses Resultado a favor del BNP 38% vs 52%, ( P < .001) Solo el 33% de pac con BNP alcanzo las metas de