Exercise-induced NT-proBNP changes during CPET imaging in cardiac failure of different origin

Background

N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels are the gold standard for the diagnosis and management of HF, regardless of HF phenotypes. Exercise testing is a physiological stressor that may impact on many determinants of NT-pro-BNP release, affecting primarily both intracardiac volume and pressure. However, the dynamic of NT-proBNP values from rest to maximal exercise performance is quite explored.

Aim

To depict the NT-proBNP levels changes during exercise adaptations and its correlates with the limited performance.

Methods

Consecutive subjects referred to a tertiary dyspnea clinic from January 2024 -September 2024 were enrolled and underwent combined cardiopulmonary exercise testing and imaging (CPET imaging) and blood sampling for NT-pro-BNP analysis at rest, at peak, and at the recovery phase of a maximal test. Lung ultrasound to detect B-lines was performed at baseline and at the peak of exercise. Non-parametric comparisons between groups were performed using the Kruskal–Wallis test.

Results

A total of 189 subjects (129 patients with HF -55 HFrEF and 74 HFpEF, 17 with hypertrophic cardiomyopathy -HCM, and 43 healthy controls). Overall, patients with HF had higher plasma levels of NT-pro-BNP at rest, peak exercise, and recovery than HCM and controls (respectively, 523 [196-1510] vs 323 [196,75-473] vs 22,3 [20-47,3] at rest; 501 [233,5-1586,5] vs 357 [196,5-500,25] vs 23,5 [20-49,25] at peak, 499 [263-1604,75] vs 360 [198,9-504,5] vs 23,9 [20-48] at recovery, p < 0.05). In both HF phenotypes, as well as in HCM and controls, no significant differences were found with regard to the NT-proBNP levels in the three exercise phases investigated (Figure 1; Table 1).

However, when NT-proBNP levels were stratified into three tertiles, significant differences were observed across tertiles in peak VO₂, peak E/e′, peak stroke volume, peak TAPSE/PAPs ratio, and peak B-lines (Table 2).

Conclusions

To ascertain how levels of NT-proBNP may change during a maximal exercise test documented no significant changes between rest, peak, and recovery phases, suggesting a non-additional stressor effect by exercise on cardiac loading. However, when stratified in tertiles, peak NT-proBNP levels correlated with disease severity and echo-CPET variables, suggesting itsadded role even during exercise to be incorporated in a better comprehensive evaluation of HF staging and management.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.