Neuroendocrine prediction of left ventricular function and heart failure after acute myocardial infarction

Objective-To determine the relations of plasma levels of brain natriuretic peptide (BNP), atrial natriuretic factor (ANF), N-terminal ANF (N-ANF), cyc lic guanosine monophosphate (cGMP; the cardiac peptide second messenger), a nd plasma catecholamines to left ventricular function and to prognosis in p atients admitted with acute myocardial infarction. Design-Plasma hormones and ventricular function (radionuclide ventriculogra phy) were measured 1-4 days after myocardial infarction in 220 patients adm itted to a single coronary care unit. Radionuclide scanning was repeated 3- 5 months after infarction. Clinical events were recorded over a mean period of 14 months. Results-Both early and late left ventricular ejection fraction (LVEF) were most closely related to plasma BNP (r = -0.60, n = 220, p < 0.001; and r = -0.53, n = 192, p < 0.001, respectively), followed by ANF, N-ANF, cGMP, and the plasma catecholamines. Early plasma BNP concentrations less than twofo ld the upper Limit of normal (20 pmol/l) had 100% negative predictive value for LVEF < 40% at 3-5 months after infarction. In multivariate analysis in corporating all the neurohormonal factors, only BNP remained independently predictive of LVEF < 40% (p < 0.005). Survival analysis by median levels of candidate predictors identified BNP as the most powerful discriminator for death (p < 0.0001). No early deaths (within 4 months) occurred in patients with plasma BNP concentrations below the group median (27 pmol/l), and ove r follow up only three of 26 deaths occurred in this subgroup. Of all episo des of left ventricular failure, 85% occurred in patients with plasma BNP a bove the median (p < 0.001). In multivariate analyses, BNP alone gave addit ional predictive information beyond sex, age, clinical history, LVEF, and p lasma noradrenaline for both subsequent onset of LVF and death. Conclusions-Plasma BNP measured within 1-4 days of acute myocardial infarct ion is a powerful independent predictor of left ventricular function, heart failure, or death over the subsequent 14 months, and superior to ANF, N-AN F, cGMP, and plasma catecholamines.