ABC | Volume 110, Nº3, March 2018

Original Article Natriuretic Peptide and Clinical Evaluation in the Diagnosis of Heart Failure Hemodynamic Profile: Comparison with Tissue Doppler Echocardiography Gustavo Luiz Gouvêa de Almeida Junior, 1 Nadine Clausell, 4 Marcelo Iorio Garcia, 2 Roberto Esporcatte, 2 Fernando Oswaldo Dias Rangel, 2 Ricardo Mourilhe Rocha, 2 Luis Beck-da-Silva, 4 Fabricio Braga da Silva, 1 Paula de Castro Carvalho Gorgulho, 1 Sergio Salles Xavier 3 Casa de Saúde São José, Rio de Janeiro, RJ – Brazil 1 Hospital Pro-Cardíaco, Rio de Janeiro, RJ – Brazil 2 Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brazil 3 Hospital de Clínicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS – Brazil 4 Mailing Address: Gustavo Luiz Gouvea de Almeida Junior • Rua Macedo Sobrinho, 21. Unidade Coronariana. CEP 22271-080, Botafogo, RJ – Brazil E-mail: gustavogouvea@cardiol.br , gustavogouvea@globo.com Manuscript received August 07, 2017, revised manuscript October 09, 2017, accepted October 18, 2017 DOI: 10.5935/abc.20180046 Abstract Background: Physical examination and B-type natriuretic peptide (BNP) have been used to estimate hemodynamics and tailor therapy of acute decompensated heart failure (ADHF) patients. However, correlation between these parameters and left ventricular filling pressures is controversial. Objective: This study was designed to evaluate the diagnostic accuracy of physical examination, chest radiography (CR) and BNP in estimating left atrial pressure (LAP) as assessed by tissue Doppler echocardiogram. Methods: Patients admitted with ADHF were prospectively assessed. Diagnostic characteristics of physical signs of heart failure, CR and BNP in predicting elevation (> 15 mm Hg) of LAP, alone or combined, were calculated. Spearman test was used to analyze the correlation between non-normal distribution variables. The level of significance was 5%. Results: Forty-three patients were included, with mean age of 69.9 ± 11.1years, left ventricular ejection fraction of 25 ± 8.0%, and BNP of 1057 ± 1024.21 pg/mL. Individually, all clinical, CR or BNP parameters had a poor performance in predicting LAP ≥ 15 mmHg. A clinical score of congestion had the poorest performance [area under the receiver operating characteristic curve (AUC) 0.53], followed by clinical score + CR (AUC 0.60), clinical score + CR + BNP > 400 pg/mL (AUC 0.62), and clinical score + CR + BNP > 1000 pg/mL (AUC 0.66). Conclusion: Physical examination, CR and BNP had a poor performance in predicting a LAP ≥ 15 mm Hg. Using these parameters alone or in combination may lead to inaccurate estimation of hemodynamics. (Arq Bras Cardiol. 2018; 110(3):270-277) Keywords: Heart Failure; Natriuretic Peptide, Brain; Hemodynamics; Ventricular Function, Left; Echocardiography, Doppler. Introduction Clinical evaluation of patients with acute decompensated heart failure (ADHF) based only on physical examination has proved to be inadequate for both assessment of left ventricular (LV) function (systolic versus diastolic dysfunction) 1,2 and estimation of patient’s hemodynamic status. 3 Precise determination of LV filling pressures is critical to the proper treatment of patients with ADHF, since congestion is the main determinant of symptoms, hospitalization, and prognosis. 4-7 Additional assessment using both invasive 8 and noninvasive tools may be useful, as it adds important information potentially contributing to tailored management. Echocardiography has proven its usefulness in assessing the hemodynamic status of patients with ADHF, especially after the advent of new techniques, such as tissue Doppler imaging. 9 The so-called “hemodynamic echocardiogram” may help physicians to detect congestion. 10 Several studies have shown that echocardiographic-derived hemodynamic parameters correlate significantly with those obtained by right heart catheterization. 11 Elevated levels of B-type natriuretic peptide (BNP) reflect increased LV filling pressures, secondary to myocyte stretch, due to volume or pressure overload. 12,13 Whether the association of BNP values adds diagnostic accuracy to the standard clinical assessment in estimating patient’s hemodynamic status remains unknown. In this study we tested the hypothesis that BNP values add diagnostic accuracy to physical examination in detecting congestion in patients with ADHF, using echocardiogram-derived hemodynamic assessment as a reference method for comparison. 270