Usefulness of Cardiac Biomarkers in the Evaluation of Prognosis and Cardiac Involvement in Patients with Acute Aortic Syndrome

Jong Yoon Kim; Kye Hun Kim; Yi Rang Yim; Jae Yeong Cho; Doo Sun Sim; Hyun Ju Yoon; Nam Sik Yoon; Young Joon Hong; Hyung Wook Park; Ju Han Kim; Youngkeun Ahn; Myung Ho Jeong; Jeong Gwan Cho; Jong Chun Park

doi:10.12997/jla.2016.5.1.27

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Kim, Kim, Yim, Cho, Sim, Yoon, Yoon, Hong, Park, Kim, Ahn, Jeong, Cho, and Park: Usefulness of Cardiac Biomarkers in the Evaluation of Prognosis and Cardiac Involvement in Patients with Acute Aortic Syndrome

Original Article

Journal of Lipid and Atherosclerosis 2016; 5(1): 27-36.

Published online: 30 June 2016

DOI: https://doi.org/10.12997/jla.2016.5.1.27

Usefulness of Cardiac Biomarkers in the Evaluation of Prognosis and Cardiac Involvement in Patients with Acute Aortic Syndrome

Jong Yoon Kim, Kye Hun Kim, Yi Rang Yim, Jae Yeong Cho, Doo Sun Sim, Hyun Ju Yoon, Nam Sik Yoon, Young Joon Hong, Hyung Wook Park, Ju Han Kim, Youngkeun Ahn, Myung Ho Jeong, Jeong Gwan Cho, Jong Chun Park

The Heart Center, Chonnam National University Hospital, Gwangju, Korea.

Corresponding Author: Kye Hun Kim, Director of Echocardiography Laboratory, The Heart Center of Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 501-757, Korea. Tel: +82-62-220-6977, Fax: +82-62-223-3105, christiankyehun@hanmail.net

Received 22 December 2015 Revised 19 April 2016 Accepted 19 April 2016

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To investigate the usefulness of cardiac biomarkers in the evaluation of prognosis and cardiac involvement (CI) in patients with acute aortic syndrome (AAS).

Methods

A total of 260 AAS patients with the measurements of cardiac biomarkers were divided into 2 groups; the survived (n=215, 60.6±13.7 years, 110 males) vs the dead (n=45, 64.5±13.6 years, 19 males). N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac specific troponin-I (cTnI), C-reactive protein (CRP), creatinine kinase (CK), MB fraction of CK (CK-MB), and D-dimer were compared.

Results

NT-proBNP and D-dimer were significantly elevated in the dead group than in the survived group (3558.7±5497.2 vs 949.9±2307.3 pg/mL, p<0.001, 4.5±5.1 vs 2.0±3.2 ug/mL, p<0.001, respectively). CI was observed in 59 patients (22.7%), and NT-proBNP was significantly elevated in patients with CI than in patients without CI (2497.7±4671.3 vs 722.5±1489.1 pg/mL, p=0.034). In univariate analysis, Stanford type A, CI, NT-proBNP, and D-dimer were significantly associated with mortality, but NT-proBNP was the only significant independent predictor of mortality in multivariate analysis. By receiver operating characteristic curve analysis, the optimal cut-off value to predict mortality was 517.0 pg/mL for NT-proBNP (area under the curve 0.797, sensitivity 86.7%, specificity 71.7%).

Conclusion

The elevation of cardiac biomarkers is not infrequent in patients with AAS. NT-proBNP is significantly associated with CI and is an independent predictor of mortality in patients with AAS. The measurement of NT-proBNP would be useful in the risk stratification of AAS.

Keywords: Aortic dissection, Biomarker, Prognosis

Figures and Tables

Fig. 1

Receiver operating characteristic curve analysis to predict mortality in acute aortic syndrome. Asterisk indicates the optimal cut-off value. NT-proBNP; N-terminal pro B-type natriuretic peptide.

Table 1

Baseline clinical characteristics between the groups

	The survived (n=215)	The dead (n=45)	p value
Age (years)	60.6±13.7	64.5±13.6	0.082
Males (%)	110 (51.1)	19 (42.2)	0.177
Hypertension (%)	125 (58.1)	25 (55.6)	0.437
SBP (mmHg)	137.8±30.1	121.4±27.2	0.001
DBP (mmHg)	81.9±18.9	76.1±16.2	0.061
Heart rate (beat/min)	77.6±15.5	80.0±20.0	0.454
Smoking (%)	71 (33.0)	12 (26.7)	0.736
Diabetes mellitus (%)	12 (5.6)	0 (0.0)	0.400
Total cholesterol (mg/dL)	186.2±25.7	204.8±42.9	0.100
LDL cholesterol (mg/dL)	112.6±24.4	130.7±39.1	0.380
HDL cholesterol (mg/dL)	54.4±17.1	55.5±17.6	0.786
Triglyceride (mg/dL)	138.5±88.7	135.7±65.9	0.863
Presentation of AAS			0.733
AD (%)	177 (82.3)	38 (82.2)
Pure IMH (%)	38 (17.7)	7 (17.8)
Stanford classification			0.001
Type A (%)	104 (48.4)	34 (75.6)
Type B (%)	111 (51.6)	11 (24.4)

Values are means±SD.

SBP; systolic blood pressure, DBP; diastolic blood pressure, LDL; low-density lipoprotein, HDL; high density lipoprotein, AAS; acute aortic syndrome, AD; aortic dissection, IMH; intramural hematoma

Table 2

Echocardiographic findings between the groups

	The survived (n=215)	The dead (n=45)	p value
LVEDD (mm)	51.0±7.6	46.4±6.2	0.005
LVESD (mm)	31.6±7.0	30.2±5.6	0.327
LVEF (%)	65.6±9.0	64.4±8.6	0.524
E (m/s)	0.6±0.2	0.5±0.2	0.131
A (m/s)	0.8±0.2	0.7±0.1	0.280
DT (ms)	217.3±68.9	225.7±59.3	0.645
Em (cm/s)	6.0±2.2	5.0±1.8	0.084
E/Em	10.7±4.1	11.6±5.8	0.446
Diastolic dysfunction			0.712
Grade 1 (%)	184 (85.6)	38 (84.4)
≥grade 2 (%)	31 (14.4)	7 (15.6)
≥Moderate AR	9 (4.2)	6 (13.3)	0.017
Pericardial effusion (%)	52 (24.2)	22 (48.9)	0.001

Values are means±SD.

LVEDD; left ventricular end-diastolic dimension, LVESD; left ventricular end-systolic dimension, LVEF; left ventricular ejection fraction, E; early diastolic mitral inflow velocity, A; late diastolic mitral inflow velocity, DT; deceleration time, Em; early diastolic velocity of septal annulus, AR; aortic regurgitation

Table 3

Cardiac biomarkers and mortality between the groups

	The survived (n=215)	The dead (n=45)	p value
NT-proBNP (pg/mL)	950.0±2307.3	3558.7±5497.2	0.003
cTnI (ng/mL)	0.6±4.4	1.1±6.0	0.491
CRP (mg/dL)	3.5±5.3	3.7±6.5	0.858
CK (U/L)	255.4±547.7	256.1±356.4	0.993
CK-MB (U/L)	7.8±9.1	13.3±24.0	0.120
D-dimer (ug/mL)	2.0±3.2	4.5±5.1	<0.001

Values are means±SD.

NT-proBNP; N-terminal pro B-type natriuretic peptide, cTnI; cardiac troponin I, CRP; C-reactive protein, CK; creatinine kinase, CK-MB; MB fraction of CK

Table 4

Differences of cardiac biomarkers according to the Stanford classification of acute aortic syndrome

	Type A (n=138)	Type B (n=122)	p value
NT-proBNP (pg/mL)	1482.6±3120.6	1444.1±3604.2	0.958
cTnI (ng/mL)	1.1±6.2	0.3±1.6	0.152
CRP (mg/dL)	2.5±3.9	4.8±6.7	0.002
CK (U/L)	187.1±310.0	334.3±678.2	0.024
CK-MB (U/L)	7.7±9.2	10.0±16.6	0.173
D-dimer (ug/mL)	2.5±3.7	2.3±3.7	0.733

Values are means±SD.

NT-proBNP; N-terminal pro B-type natriuretic peptide, cTnI; cardiac troponin I, CRP; C-reactive protein, CK; creatinine kinase, CK-MB; MB fraction of CK

Table 5

Differences of cardiac biomarkers according to the cardiac involvement in patients with acute aortic syndrome

	Cardiac involvement (n=59)	No cardiac involvement (n=201)	p value
NT-proBNP (pg/mL)	2497.7±4671.3	722.5±1489.1	0.034
cTnI (ng/mL)	0.9±3.0	0.6±5.0	0.561
CRP (mg/dL)	3.2±5.3	3.7±5.6	0.566
CK (U/L)	191.7±273.8	273.5±568.8	0.135
CK-MB (U/L)	9.1±16.8	8.7±12.0	0.828
D-dimer (ug/mL)	3.1±4.7	2.2±3.4	0.168

Values are means±SD.

NT-proBNP; N-terminal pro B-type natriuretic peptide, cTnI; cardiac troponin I, CRP; C-reactive protein, CK; creatinine kinase, CK-MB; MB fraction of CK

Table 6

Cardiac involvement and Stanford classification

	Type A (n=138)	Type B (n=122)	p value
Moderate to large PE (%)	21 (15.2)	3 (2.5)	<0.001
Cardiac tamponade (%)	7 (5.1)	1 (0.1)	0.048
Advanced DD (%)	11 (8.0)	7 (5.7)	0.479
Moderate to severe AR (%)	11 (8.0)	4 (3.3)	0.105
LV dysfunction (%)	7 (5.1)	1 (0.8)	0.048
AMI (%)	3 (2.2)	0 (0.0)	0.101
Overall (%)	44 (31.9)	15 (12.3)	<0.001

PE; pericardial effusion, DD; diastolic dysfunction, AR; aortic regurgitation, LV; left ventricular, AMI; acute myocardial infarction

Table 7

Cardiac involvement between the survived and the dead

	The survived (n=215)	The dead (n=45)	p value
Moderate to large PE (%)	15 (7.0)	9 (20.0)	0.011
Cardiac tamponade (%)	5 (2.3)	3 (6.7)	0.144
Advanced DD (%)	15 (7.0)	3 (6.7)	0.941
Moderate to severe AR (%)	9 (4.2)	6 (13.3)	0.028
LV dysfunction (%)	5 (2.3)	3 (6.7)	0.144
AMI (%)	1 (0.5)	2 (4.4)	0.078
Overall (%)	44 (20.5)	15 (33.3)	0.002

PE; pericardial effusion, DD; diastolic dysfunction, AR; aortic regurgitation, LV; left ventricular, AMI; acute myocardial infarction

Table 8

Independent predictor of mortality in acute aortic syndrome

Variables	Odd ratio	95% confidence interval		p value
Variables	Odd ratio	Lower limit	Upper limit	p value
Age	1.051	0.996	1.109	0.070
Sex	0.434	0.082	2.299	0.434
Stanford type A	3.419	0.521	2.434	0.200
Cardiac involvement	3.374	0.690	16.502	0.133
LogNT-proBNP	33.772	5.659	201.569	<0.001
D-dimer	1.177	0.993	1.394	0.060
cTni	0.489	0.191	1.254	0.137
CK-MB	0.224	0.971	1.132	0.224

NT-proBNP; N-terminal pro B-type natriuretic peptide, cTnI; cardiac troponin I, CK-MB; MB fraction of crastinine kinase

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