B-type natriuretic peptide release and left ventricular filling pressure assessed by echocardiographic study after subarachnoid hemorrhage: a prospective study in non-cardiac patients

Eric Meaudre, Christophe Jego, Nadia Kenane, Ambroise Montcriol, Henry Boret, Philippe Goutorbe, Gilbert Habib, Bruno Palmier, Eric Meaudre, Christophe Jego, Nadia Kenane, Ambroise Montcriol, Henry Boret, Philippe Goutorbe, Gilbert Habib, Bruno Palmier

Abstract

Introduction: Serum B-type natriuretic peptide (BNP) is frequently elevated after subarachnoid hemorrhage (SAH), but whether this high BNP level is related to transient elevation of left ventricular filling pressure (LVFP) is unknown. However, in patients with preexistent cardiac pathologies, it is impossible to differentiate between BNP elevation caused by chronic cardiac abnormalities and BNP related to acute neurocardiac injury.

Methods: All adult patients with SAH admitted to our intensive care unit were eligible. Patients were excluded for the following reasons: admission >48 hours after aneurysm rupture, pre-existing hypertension, or cardiac disease. Levels of BNP and cardiac troponin Ic were measured daily for 7 days. Echocardiography was performed by a blinded cardiologist on days 1, 2, and 7. Doppler signals from the mitral inflow, tissue Doppler, and the color M-mode-derived flow propagation velocity (FPV) were obtained to assess echo-estimated LVFP.

Results: During a 3-year period, sixty-six consecutive patients with SAH were admitted. Thirty one patients were studied. The BNP level was >100 ng/L in 25 patients (80%) during the first 3 days, with a peak on day 2 (median, 126 ng/L) followed by a gradual decrease (median variation days 1 to 7, 70%). All patients had an ejection fraction >50%. Early transmitral velocity/tissue Doppler mitral annular early diastolic velocity was low: 5.4 (+/- 1.5) on day 1, 5.8 (+/- 1.2) on day 2, and 5.1 (+/- 0.9) on day 7. Early transmitral velocity/FPV was also low: 1.27 (+/- 0.4), 1.25 (+/- 0.3), and 1.1 (+/- 0.2) on days 1, 2, and 7, respectively. Cardiac troponin Ic levels ranged from 0 to 3.67 microg/L and were correlated with BNP (r = 0.63, P < 0.01).

Conclusions: BNP rises gradually over two days and return to normal within a week after SAH. Its release is associated with myocardial necrosis, but is unrelated to elevated LVFP assessed by echocardiography.

Figures

Figure 1
Figure 1
Echocardiographic parameters to estimate LV filling pressures (a) Mitral inflow, (b) color M-mode-derived flow propagation velocity (FPV), and (c) Tissue Doppler velocities at the lateral corners of the mitral annulus
Figure 2
Figure 2
Flow diagram of subarachnoid hemorrhage patients from admission to day 7
Figure 3
Figure 3
Daily median B-type natriuretic peptide (BNP) levels in 31 subarachnoid hemorrhage (SAH) patients without pre-existing chronic hypertension or cardiac disease. Error bars indicate confidence intervals.
Figure 4
Figure 4
Correlations on day 2 between BNP, cTi, E/Ea, and E/FPV (a) B-type natriuretic peptide (BNP) vs troponin Ic (cTi); (b) BNP vs early transmitral velocity (E)/tissue Doppler imaging early diastolic velocity (Ea); (c) E/color M-mode-derived flow propagation velocity (FPV).

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