Do Elevated BNP Levels Predict Hemodynamically Significant PDAs

Diagnostic Prediction Value of B Type Natriuretic Peptide (BNP) Levels in Hemodynamically Significant Patent Ductus Arteriosus (hsPDA) in Premature Infants.

The purpose of this study is to determine if B type natriuretic peptide (BNP) levels can be used to predict a hemodynamically significant patent ductus arteriosus (PDA). This peptide is produced by the ventricles in the heart when they are under stress, such as when a ductus remains open. If we can use a simple and inexpensive blood test to determine whether a PDA needs to be treated, we can potentially treat infants sooner than if they needed to wait for the availability of a cardiologist to perform an echocardiogram. This might decrease some of the deleterious effects of PDAs on the preterm infant such as bronchopulmonary dysplasia, necrotizing enterocolitis, renal hypoperfusion, and pulmonary hemorrhage. In a situation where follow up echocardiogram after a course of medical therapy shows persistent PDA, this test may help to decide whether this baby needs further treatment, either medical or surgical.

Study Overview

• Status: Completed
• Conditions: Patent Ductus Arteriosus

Detailed Description

B type natriuretic peptide (BNP) is mainly synthesized in the ventricles of the heart and released in response to volume and pressure loading and ventricular stress and, therefore, plays an important role in regulation of extracellular fluid volume. BNP causes diuresis, natriuresis, arterial and venous vasodilation and antagonizes the renin-angiotensin system resulting in a reduction in intravascular volume and decreased ventricular preload and afterload.

In adults, BNP levels have been routinely used to diagnose and measure the degree of congestive heart failure. In healthy term infants, BNP levels are initially elevated in the first few days of life but then decline over the ensuing week after birth to near adult levels by 3 months of age. However, in premature newborn infants there are still no normative values for BNP and, therefore, no agreed-upon cut off points to diagnose ventricular overload without confirmatory echocardiography. Patent ductus arteriosus (PDA) is the most common cause of ventricular overload and congestive heart failure in premature neonates and can be a cause of significant morbidity. Excessive pulmonary blood flow due to the aortopulmonary shunting can result in increased ventilatory dependency and thereby contribute to chronic lung disease. Other possible sequelae from a PDA include renal hypoperfusion, necrotizing entercolitis, and pulmonary hemorrhage. Early closure of a PDA has been shown to reduce these risks.

Delayed ductal closure is inversely related to GA at birth with the incidence varying from 20% in babies greater than 32 weeks gestation and up to 60% in babies less than 28 weeks gestation. Currently, infants are screened for a PDA by echocardiography. This requires that centers have access to cardiologists to perform and analyze these studies. A simple blood test that could help diagnose a hemodynamically significant PDA would be extremely helpful in low birth weight infants, especially in more remote centers that do not have routine access to cardiology services. To date, there is no accepted blood test although numerous studies are emerging suggesting that BNP might be such a test. It has been shown that the magnitude of shunting through a PDA is a major determinant of BNP level, however, the levels published in various studies for what is hemodynamically significant varies greatly. In addition, the studies that have been done previously are on small sample sizes (less than 70 patients, with one retrospective study that had 88 patients) and on various gestational ages and, therefore, it is difficult to extrapolate normative data.

It is already known that BNP levels are elevated in neonates with a hsPDA, however, there is little agreement on how high a BNP level needs to get to imply a hsPDA. We propose a study to measure the BNP values in all infants born less than 32 weeks gestation with and without a PDA. We will also do serial BNP levels with concurrent echocardiograms in infants with a PDA to determine a cutoff value of BNP above which an infant is likely to have a hsPDA. We hope that our study, with a larger sample size and on all infants with and without a PDA, will be able to not only gather more definitive data on what the cutoff BNP level is, but also gather normative BNP data on premature infants without PDAs.

• Study Type: Observational
• Enrollment (Actual): 109

Contacts and Locations

Study Locations

• United States
  • New York
    • Albany, New York, United States, 12208
      • Albany Medical Center Neonatal Intesive Care Unit

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 hour to 1 day (Child)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Preterm infants between 24 0/7 weeks gestation and 31 6/7 weeks gestation.

Description

Inclusion Criteria:

• gestational age between 24 0/7 weeks gestation and 31 6/7 weeks gestation. - Infants must be enrolled by 24 hours of life.

Exclusion Criteria:

• congenital heart disease,
• necrotizing enterocolitis,
• culture positive sepsis or culture negative but treated for presumed sepsis.

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
BNP level and size of PDA	BNP levels measured at several time points during first 2 weeks of life and compared to findings on echocardiogram to see if size of PDA correlated with BNP level.	within first 2 weeks of life

Collaborators and Investigators

• Sponsor: Albany Medical College
• Collaborators: Alere, Inc.
• Investigators: Principal Investigator: Kate A Tauber, MD, Albany Medical College; Study Director: Upender K Munshi, MD, Albany Medical College; Study Director: Robin Doyle, MD, Capital Distric Pediatric Cardiology, affiliated with Albany Medical Center

Publications and helpful links

General Publications

• Sanjeev S, Pettersen M, Lua J, Thomas R, Shankaran S, L'Ecuyer T. Role of plasma B-type natriuretic peptide in screening for hemodynamically significant patent ductus arteriosus in preterm neonates. J Perinatol. 2005 Nov;25(11):709-13. doi: 10.1038/sj.jp.7211383.
• Holmstrom H, Hall C, Thaulow E. Plasma levels of natriuretic peptides and hemodynamic assessment of patent ductus arteriosus in preterm infants. Acta Paediatr. 2001 Feb;90(2):184-91. doi: 10.1080/080352501300049406.

Study record dates

Study Major Dates

• Study Start: December 1, 2011
• Primary Completion (Actual): April 1, 2013
• Study Completion (Actual): April 1, 2013

Study Registration Dates

• First Submitted: December 20, 2011
• First Submitted That Met QC Criteria: December 21, 2011
• First Posted (Estimate): December 22, 2011

Study Record Updates

• Last Update Posted (Estimate): July 4, 2013
• Last Update Submitted That Met QC Criteria: July 2, 2013
• Last Verified: December 1, 2011

More Information

Terms related to this study

• Keywords: Preterm infant; Patent Ductus Arteriosus; B type natriuretic peptide
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Congenital Abnormalities; Heart Defects, Congenital; Cardiovascular Abnormalities; Ductus Arteriosus, Patent
• Other Study ID Numbers: 3155