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Serial Measurement of Amino-Terminal Pro-B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Outcome in Children With Primary Myocardial Dysfunction and Acute Decompensated Heart Failure

Medar, Shivanand Shankar MD1; Hsu, Daphne T. MD2; Ushay, H. Michael MD, PhD1; Lamour, Jacqueline M. MD2; Cohen, Hillel W. DrPH, MPH3; Killinger, James S. MD1

Pediatric Critical Care Medicine: July 2015 - Volume 16 - Issue 6 - p 529–534
doi: 10.1097/PCC.0000000000000408
Cardiac Intensive Care

Objectives: In children, elevated amino-terminal pro-B-type natriuretic peptide levels are associated with impaired heart function. The predictive value of serial monitoring of amino-terminal pro-B-type natriuretic peptide levels in acute decompensated heart failure is unclear.

Design: Prospective observational study.

Setting: Single, tertiary referral pediatric critical care unit.

Patients: Patients aged 0-21 years with primary myocardial dysfunction and acute decompensated heart failure.

Interventions: Amino-terminal pro-B-type natriuretic peptide levels were obtained on enrollment, day 2, and day 7. Clinical, laboratory, and imaging data were collected on enrollment. Adverse cardiovascular outcome was defined as heart transplant, ventricular assist device placement, extracorporeal membrane oxygenation, or death at 1 year after admission. Aminoterminal pro-B-type natriuretic peptide levels and the percent change from day 0 to day 2 and day 0 to day 7 were calculated and compared between those with and without adverse cardiovascular outcome.

Measurements and Main Results: Sixteen consecutive patients were enrolled. Adverse cardiovascular outcome occurred in six patients (37.5%, four heart transplant and two ventricular assist device). In patients with an adverse cardiovascular outcome, median amino-terminal pro-B-type natriuretic peptide levels at day 7 were significantly higher (7,365 vs 1,196 pg/mL; p = 0.02) and the percent decline in amino-terminal pro-B-type natriuretic peptide was significantly smaller (28% vs 73%; p = 0.02) compared with those without an adverse cardiovascular outcome. Receiver operating curve analysis revealed that a less than 55% decline in amino-terminal pro-B-type natriuretic peptide levels at day 7 had a sensitivity and specificity of 83% and 90%, respectively, in predicting an adverse cardiovascular (area under the curve, 0.86; 95% CI, 0.68–1.0; p = 0.02).

Conclusions: In conclusion, children with primary myocardial dysfunction and acute decompensated heart failure, a persistently elevated amino-terminal pro-B-type natriuretic peptide, and/or a lesser degree of decline in amino-terminal pro-B-type natriuretic peptide during the first week of presentation were strongly associated with adverse cardiovascular outcome. Serial amino-terminal pro-B-type natriuretic peptide monitoring may allow the early identification of children at risk for worse outcome.

1Division of Pediatric Critical Care Medicine, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY.

2Division of Pediatric Cardiology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY.

3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.

Supported, in part, by the Clinical and Translational Service Awards grant 1 UL1 TR001073-01, 1 TL1 TR001072-01, and 1 KL2 TR001071-01 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health.

Dr. Hsu consulted for Novartis and Bayer. Her institution received grant support from the National Institutes of Health (NIH). Dr. Cohen received support for article research from the NIH and consulted for the American Journal of Hypertension (Coexecutive Editor of a nonprofit medical journal). His institution received grant support from the NIH (Clinical and Translational Science Award grant for core support) and various federal grants (support for salary from the Medical School). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: smedar@montefiore.org

©2015The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies