ANP, BNP and D-dimer predict right ventricular dysfunction in patients with acute pulmonary embolism

Summary Background: The aim of this study was to predict right ventricular dysfunction (RVD)using plasma concentration of D-dimer, pro-atrial natriuretic peptide (pro-ANP),brain natriuretic peptide (BNP), endothelin-1 (ET-1) and cardiac troponin I (TNI) inpatients with pulmonary embolism (PE).Methods: Patients suspected of PE had a ventilation⁄perfusion-single-photon emis-sion-tomography (V⁄Q-SPECT), pulmonary multidetector computer tomography(MDCT) angiography, blood samples and ECG-gated cardiac CT performed the sameday.Results: Pro-ANP, BNP and D-dimer are associated with significantly elevated levels inPE patients with RVD. ROC curves demonstrated that D-dimer, pro-ANP and BNPwere accurate for detection of RVD.Conclusion: Because measurements of cardiac biomarkers are inexpensive and easilyobtained they may prove useful in the clinical diagnosis of RVD. However because ofthe small sample size, the results need to be confirmed in larger studies. Introduction In patients with acute pulmonary embolism (PE), reliable riskassessment is essential. Right ventricular dysfunction (RVD) hasbeen shown to be an important prognostic indicator of 30 -daymortality as assessed by echocardiography (Konstantinides,2005). However, assessment of right ventricle (RV) functionis cumbersome owing to its complex geometry. Further,echocardiographic examination is observer dependent withlow reproducibility (Kjaergaard et al., 2006) and requirescardiology expertise. Therefore, a simple and reproduciblebiochemical method to assess RVD in patients with PE would bedesirable. Brain natriuretic peptide (BNP), atrial natriureticpeptide (ANP), and endothelin-1 (ET-1) have been the moststudied biomarkers in the context of risk stratification in PE. BNPis mainly present in the ventricles of the heart and is releasedfrom the left ventricle (LV) in response to increased fillingpressure and increased in chronic left heart failure (de Lemoset al., 2003). ANP is primarily produced in the atria and isreleased by atrial distention (Kjaer & Hesse, 2001). ANP iselevated in chronic pulmonary hypertension (Hirata et al., 1992)and could be an early marker for RVD. Plasma levels of ET-1have been shown to correlate with pulmonary pressure and arereleased from endothelial cells in pulmonary vessels (Masaki,2004). Additionally, increases in circulating levels of ET-1 havebeen reported in an experimental PE model (Lee et al., 2001).Biomarkers as BNP, ANP, and ET-1 can easily be obtained fromall patients and have shown to correlate with the severity of RVDas estimated with echocardiography in patients with PE (Krugeret al., 2004; Kucher et al., 2003b; Pieralli et al., 2006; Sohneet al., 2006; Pruszczyk et al., 2003). D-dimer, which is correlatedwith the extent of PE, might also have a potential value asprognostic marker for the severity of RVD (Ghanima et al.,2007). Finally, cardiac troponin I (TNI) is released fromdamaged myocardial tissue and has prognostic value in cardiacrisk stratification in patients with PE (Becattini et al., 2007) butnever correlated to the extent of RVD.Enhanced multi detector computer tomography (MDCT)technology has allowed for improved delineation of the cardiacchambers. We obtained a gated cardiac MDCT angiography,which is a promising modality in the precise quantification ofRV function and can be used to create volumetric cardiac cineimages, and assessed cardiac function that is comparable withMRI (Mu¨ller et al., 2009; Koch et al., 2005).