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Klinik für Anästhesiologie, Universität zu Lübeck, Lübeck, Germany
Correspondence to: Matthias Heringlake, MD, Klinik für Anästhesiologie, Universität zu Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany; e-mail: Heringlake{at}t-online.de
To the Editor:
A recent article by Jefic and coworkers1 (July 2005) on the utility of N-terminal pro-brain natriuretic peptide (NTproBNP) for estimation of pulmonary artery occlusion pressure (PAOP) in critically ill patients concluded that NTproBNP may be a strong discriminator of cardiac dysfunction in these patients. The authors observed inverse correlations between NTproBNP and cardiac index and left ventricular stroke work index (LVSWI) but not between NTproBNP and PAOP. This suggests that, in contrast to patients with heart failure,2 other factors than the physiologic stimulus ventricular stretch may be involved: the accompanying disease process (sepsis,3 surgery4) and pharmacologic factors.
We have shown that 15 mL/kg of NaCl 0.9% IV induces a 250% increase in NTproBNP levels in volunteers.5 The patients of Jefic et al1 will have been treated with a much higher volume/sodium load and, additionally, many drugs that have not been studied yet regarding effects on NTproBNP. Thus, the correlations between NTproBNP, cardiac index, and LVSWI may be an epiphenomonen of underlying disease and therapy, and increased NTproBNP levels in these patients should better be interpreted as signs of multiorgan dysfunction instead of cardiac dysfunction.
Footnotes
Dr. Heringlake has received and continues to receive support by Roche Diagnostics, Germany (manufacturer of NTproBNP kits and analyzers), in the form of analytical materials and costs for external analyses.
References
St. John Hospital and Medical Center, Detroit, MI
Correspondence to: Dane Jefic, MD, St. John Hospital and Medical Center, Cardiology Fellowship, 22151 Moross Rd, Suite 126, Detroit, MI 48236; e-mail: danejefic{at}yahoo.com
To the Editor:
We appreciate the comments of Dr. Heringlake and colleagues. In our study, we initially asked whether levels of brain natriuretic peptide (BNP) and N-terminal (NT)-proBNP could help us to discern cardiac from noncardiac causes of pulmonary infiltrates in ICU patients requiring hemodynamic monitoring. We recognized that levels of natriuretic peptides were markedly elevated in many of these critically ill patients with multiorgan failure. Heringlake et al showed that NT-proBNP could become elevated by infusion of saline even in normal volunteers.
The strong correlation that we observed between NT-proBNP and left ventricular stroke work index suggests that natriuretic peptides may prove to be markers of impaired contractility in this patient population. We suspect that in critically ill patients the levels of natriuretic peptides are elevated and that cardiac contractility is diminished due to the deleterious effects of multiorgan failure on the neurohormonal pathways affecting the cardiorenal axis.
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