|Year : 2018 | Volume
| Issue : 3 | Page : 240-245
The role of brain natriuretic peptide in correlation to mitral annular plane systolic excursion in predicting sepsis-induced myocardial dysfunction
Selim Hashem, Walid Farouk, Aymen Gaber, Mohamed A Shehata
Department of Critical Care Medicine, Cairo University, Giza, Egypt
|Date of Submission||22-Nov-2017|
|Date of Acceptance||08-May-2018|
|Date of Web Publication||31-Aug-2018|
Mohamed A Shehata
Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Giza
Source of Support: None, Conflict of Interest: None
Introduction Sepsis is one of the leading causes of mortality and morbidity around the world. Myocardial dysfunction is one of the important factors in the hemodynamic compromise seen in sepsis. B-type natriuretic peptide (BNP) and mitral annular plane systolic excursion (MAPSE) are proposed to be useful markers in predicting sepsis-induced myocardial dysfunction (SIMD).
Objective To signify the role of BNP, MAPSE, and their correlation in the prediction of SIMD.
Patients and methods Forty patients diagnosed with sepsis or septic shock, in addition to 10 healthy volunteers were included in the study in the period from March 2016 to March 2017 in the Critical Care Department of Cairo University and Alexandria University. All patients were subjected to BNP measurement and echocardiography measuring MAPSE on admission and after 48 h with correlation of these measurements to sepsis-induced cardiomyopathy.
Results The studied patients were divided into two groups. Group I: patients who did not develop myocardial dysfunction (n=16) and group II patients who developed myocardial dysfunction (n=24).There was statistically significant difference between both groups as regards BNP level and MAPSE both on admission and after 48 h with a P value of less than 0.001, with patients who developed sepsis-induced cardiomyopathy exhibiting higher levels of BNP and lower MAPSE. In addition, the current study demonstrated a strong negative correlation between MAPSE and BNP level on admission (P=0.004 and r=−0.572) and after 48 h (P=0.0030 and r=−0.444) in patients who developed myocardial dysfunction due to sepsis (group II).
Conclusion Both BNP level and MAPSE could significantly predict sepsis-induced cardiomyopathy with a strong negative correlation found between BNP level and MAPSE both on admission and after 48 h in the prediction of SIMD.
Keywords: brain natriuretic peptide, mitral annular plane systolic excursion, myocardial dysfunction, sepsis
|How to cite this article:|
Hashem S, Farouk W, Gaber A, Shehata MA. The role of brain natriuretic peptide in correlation to mitral annular plane systolic excursion in predicting sepsis-induced myocardial dysfunction. Res Opin Anesth Intensive Care 2018;5:240-5
|How to cite this URL:|
Hashem S, Farouk W, Gaber A, Shehata MA. The role of brain natriuretic peptide in correlation to mitral annular plane systolic excursion in predicting sepsis-induced myocardial dysfunction. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2018 Nov 19];5:240-5. Available from: http://www.roaic.eg.net/text.asp?2018/5/3/240/240277
| Introduction|| |
Sepsis is one of the leading causes of morbidity and mortality worldwide with septic shock being the most severe form of sepsis accounting for significant mortality among critically ill patients . An important component of this process is the development of progressive hemodynamic and cardiovascular instability due to sepsis-induced myocardial dysfunction (SIMD), which is characterized by decreased myocardial contractility, left ventricular (LV) dilation, and depressed ejection fraction (EF) . Patients with SIMD have significantly higher mortality (70%) compared with septic patients without cardiovascular impairment (20%) .
Early identification of patients with higher mortality risk upon admission to the ICU may help determine therapeutic interventions or further diagnostic procedures aiming at preventing shock and multiple organ failure with all their complications . Patients with sepsis-induced cardiomyopathy certainly fall into this category of high-risk patients, which warrants searching for tools to early identify such patients as this could reflect positively on their outcome.
Brain natriuretic peptide (BNP) is secreted by cardiomyocytes into the blood in response to atrial or ventricular wall stretch or myocardial ischemia . It is considered an accurate marker for LV dysfunction and its elevated plasma levels are associated with multiple echocardiographic parameters of systolic and diastolic dysfunction . Several prospective studies have been performed to investigate the potential role of BNP in predicting mortality in septic patients and to study the association of BNP levels with hemodynamic and echocardiographic parameters, severity of the disease, and prognosis of those patients .
Mitral annular plane systolic excursion (MAPSE) has been proposed as a useful echocardiographic parameter for the assessment of LV longitudinal function and correlates with global systolic function of the LV making it a good marker of myocardial injury and dysfunction, besides being easily measured ,. MAPSE value could be a promising tool for the assessment of LV systolic function in patients with SIMD.
| Aim|| |
To assess the role of BNP level and MAPSE in the prediction of SIMD both individually and in correlation to each other.
| Patients and methods|| |
This study was conducted on 40 adult patients admitted to the units of the Critical Care Medicine Department, Cairo University Hospitals and Alexandria University Hospitals and 10 healthy volunteers who were taken as control in the period from March 2016 to March 2017.
Informed consent was taken from the patients. In case of incompetent patients, informed consent will be taken from the next of kin.
Patients with suspected or proven infection with the following criteria :
- Age more than 18 years with no sex preference.
- Patients with
- Sepsis: suspected or documented infection and an acute increase of at least 2 sequential organ failure assessment (SOFA) points as a proxy for organ dysfunction.
- Septic shock: sepsis and vasopressor therapy needed to elevate MAP of at least 65 mmgHg and lactate more than 2 mmol/l (18 mg/dl) after adequate fluid resuscitation.
- Chronic heart disease (coronary artery disease, cardiac failure, severe valvulopathy, and/or cardiomyopathy).
- Chronic renal failure.
- Pulmonary hypertension.
All patients were subjected to the following:
- Full history taking (age, sex, source of sepsis, and comorbidities).
- Clinical parameters at baseline (blood pressure, heart rate, and temperature).
- The degree of organ dysfunction or organ failure was quantified by the SOFA score which will be performed on admission and after 48 h.
- Lab parameters at baseline [complete blood count (CBC), liver function, renal function, coagulation profile, and arterial blood gases (ABG)].
- Follow-up outcome parameters (length of ICU stay and 28 days mortality).
- Laboratory BNP measurement using the RayBio (Critical Care Medicine Department, Cairo, Egypt) BNP Enzyme Immunoassay Kit (performed on day 0 and after 48 h).
- Transthoracic echocardiography:
Transthoracic echocardiography was performed on day 0 and after 48 h by the same experienced operator and echocardiography device to minimize intraobserver variation with the measurement of:
- LV end diastolic dimension.
- LV end systolic dimension.
- Left ventricular ejection fraction (LVEF).
Patients were considered to develop sepsis-induced cardiomyopathy if their LVEF decreased by at least 5% from the baseline measurement ([Figure 1],[Figure 2],[Figure 3] and [Table 1],[Table 2],[Table 3]).
|Figure 1 Comparison between the two studied groups according to mitral annular plane systolic excursion (MAPSE).|
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|Figure 2 Correlation between mitral annular plane systolic excursion (MAPSE) and brain natriuretic peptide (BNP) in group II.|
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|Figure 3 Receiver operator characteristic curve for brain natriuretic peptide (BNP) and mitral annular plane systolic excursion (MAPSE) in the prediction of myocardial dysfunction.|
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|Table 1 Comparison between the two studied groups according to mitral annular plane systolic excursion|
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|Table 2 Correlation between mitral annular plane systolic excursion and brain natriuretic peptide in each study group|
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|Table 3 Receiver operator characteristic curve for brain natriuretic peptide and mitral annular plane systolic excursion in the prediction of myocardial dysfunction|
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Statistical analysis of the data
Data were fed to the computer and analyzed using the IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were statistically described in terms of mean±SD, median and range, or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using Mann–Whitney U-test for independent samples. For comparing categorical data, χ2-test was performed. Exact test was used instead when the expected frequency is less than 5 (P<0.05 were considered statistically significant). Receiver operator characteristic (ROC) analysis was used to determine the optimum cutoff value for the studied diagnostic markers. The correlation between various variables was done using the Spearman rank correlation equation for non-normal variables.
| Results|| |
The current study was carried out on 40 adult patients with sepsis and septic shock, consisting of 22 men and 18 women with a mean age of 58.35±10.62 years and 10 healthy volunteers were taken as control, six of whom were men and four were women with a mean age of 52.8±4.39 years.
It was found that there was a statistically significant difference in BNP, SOFA score, and MAPSE between the study group and the control group both on day 0 and after 48 h, with BNP and SOFA being significantly higher in the study group than in controls (P˂0.001), whereas MAPSE was significantly lower (P˂0.001).
The study population was divided into two groups according to the development of myocardial dysfunction into:
- Group I patients who did not develop myocardial dysfunction.
- Group II patients who developed myocardial dysfunction (LVEF decreased by ≥5% from the baseline measurement).
There was no statistically significant difference between both groups as regards age, sex, comorbidities, source, and severity of sepsis.
There was a statistically significant difference between both groups as regards BNP both on admission and after 48 h with a P value of less than 0.001 with elevated BNP level in patients who developed myocardial dysfunction (group II).
There was no statistically significant difference between both groups as regards EF on admission, but later after 48 h there was a statistically significant lower EF in group II.
There was statistically significant difference between both groups as regards MAPSE both on admission and after 48 h with a P value of less than 0.001 as patients in group II had a significantly lower MAPSE.
A strong positive correlation was found between BNP level and SOFA score both on admission (P=0.005 and r=0.549) and after 48 h (P=0.007 and r=0.536) in patients who developed myocardial dysfunction.
A strong negative correlation was elicited between SOFA score and MAPSE both on admission (P=0.036 and r=−0.429) and after 48 h (P=0.002 and r=−0.597) in patients of group II.
A strong negative correlation was also found between MAPSE and BNP level on admission (P=0.004 and r=−0.572) and after 48 h (P=00.030 and r=−0.444) in patients with SIMD.
The ROC curve demonstrates that a cutoff BNP level on admission of more than 198 pg/dl can signify a sensitivity of 83% and a specificity of 62% in the prediction of myocardial dysfunction, while after 48 h a BNP level of more than 324 pg/dl can signify a sensitivity of 97% and a specificity of 83% in predicting myocardial dysfunction.
The ROC curve demonstrates that a cutoff MAPSE on admission of up to 12 mm can signify a sensitivity of 78% and a specificity of 73% in the prediction of myocardial dysfunction, while MAPSE after 48 h of up to 10 mm can signify a sensitivity of 87% and a specificity of 93% in eliciting myocardial dysfunction.
| Discussion|| |
Sepsis and septic shock are common problems in modern ICUs and are associated with significant morbidity and mortality, despite advances in our understanding of the underlying mechanisms and improved treatment strategies, the mortality of severe sepsis and septic shock remains elevated due to the development of progressive hemodynamic and cardiovascular instability, with sepsis-induced cardiomyopathy being at the core of this process. BNP and MAPSE are two promising tools that can potentially aid in identifying this problem.
From the above results, the study group had a significantly higher mean BNP level as compared with healthy controls with a P value of less than 0.001; this was concordant with Nikalaou et al.  who reported that BNP levels were significantly elevated in 54 patients with sepsis from community-acquired infections and Rivers et al.  measured BNP levels at 0 and 48 h after admission in 252 patients with severe sepsis and septic shock and found that the elevated BNP level was found in 42 and 69%, respectively.
Reversible myocardial depression in patients with septic shock was described in 1984 by Parker et al.  and accordingly we divided the study population into two groups with 24 patients out of the 40 (60%) who developed SIMD (group II) and 16 septic patients who did not develop cardiomyopathy (group I), which agreed with Vieillard A-Prins et al.  who described a 60% incidence of global LV hypokinesia in his population of septic shock patients. It is to be mentioned that there was no significant difference as regards age, sex, comorbidities, admission SOFA score, or severity of sepsis between both groups.
The present study displayed a mortality of 79.2% among patients who developed SIMD, while this percentage was variable in other studies as Romero-Bermejo et al.  who showed 40% and Sato et al.  who showed 24.2% mortality in patients with septic cardiomyopathy; this variability could be attributed to the relatively small study group in these studies including our own.
In our study, there was a statistically significant elevation in BNP level in group II patients when compared with the noncardiomyopathy group with a P value of less than 0.001; this was concordant with Post et al. , Charpentier et al. , and Rivers et al.  who demonstrated BNP level increase in patients with septic cardiomyopathy. In addition, Withhaut et al.  demonstrated an inverse correlation between BNP level and cardiac index in septic patients which goes with our study results.
Our study also elicited that the BNP levels were higher in nonsurvivors as compared with survivors with statistical significance P value (=0.003). The same result was also found by Post et al.  and Tung et al.  who reported that BNP concentration may be used as a prognostic marker to identify patients with elevated risk of mortality among septic patients.
In our study, we found a significant positive correlation between MAPSE and LVEF (r=0.81, P<0.001) in patients with sepsis-induced cardiomyopathy. This result was similar to the data reported by Stoylen and Skjaerpe  who demonstrated a significant reduction of mitral annular motion and velocity in patients who had reduced LVEF, similarly Simonson and Schiller  besides Pai et al.  found a strong correlation between systolic mitral annular displacement measured by two-dimensional echo and LVEF in septic shock patients, in addition to Qin et al.  who have reported that MAPSE correlates moderately well with LVEF in septic shock patients and Gomaa et al.  who stated that MAPSE was an independent predictor of LV systolic function in patients with SIMD.
The current study found a strong significantly negative correlation between MAPSE and BNP level in patients who developed myocardial dysfunction as those patients exhibited elevated BNP level and low MAPSE both on admission and after 48 h. This finding was concordant with Vinereanu et al.  who found that LVEF correlated with BNP level (r=−0.54) with LV longitudinal systolic function determined by MAPSE having an even stronger correlation (r=−0.78, P<0.001). Similarly Mak et al.  found that early systolic mitral annular velocity correlates strongly with plasma BNP levels and Tretjak et al.  reported a similarly significant but weaker correlation.
| Conclusion|| |
This study demonstrated that both BNP and MAPSE could detect early SIMD with a strong negative correlation existing between both measurements.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]