0
May 20, 1992, Vol 267, No. 19 >
ARTICLE | May 20, 1992

Atrial Natriuretic Peptide Levels in the Prediction of Congestive Heart Failure Risk in Frail Elderly FREE

Kenneth M. Davis, MD, MSc; Loretta C. Fish, MS, RN; Dariush Elahi, PhD; Barbara A. Clark, MD; Kenneth L. Minaker, MD, FRCPC
[+] Author Affiliations

Reprint requests to Division of Gerontology, Department of Medicine, SL-435, Beth Israel Hospital, 330 Brookline Ave, Beth Israel Hospital, Boston, MA 02215 (Dr Davis).


JAMA. 1992;267(19):2625-2629. doi:10.1001/jama.1992.03480190067033
Text Size: A A A
Published online
Article
References

Objective.  —To develop a noninvasive clinical predictive model for acute congestive heart failure (CHF) in a frail elderly cohort using bedside clinical assessment (medical history and physical examination) and venous atrial natriuretic peptide (ANP) levels.

Design.  —One-year prospective blinded cohort study.

Setting.  —Life care facility.

Participants.  —Three hundred thirty-one frail, elderly volunteers free of acute illness at study entry (mean±SD age, 88±7 years; 23% male, 77% female).

Main Outcome Measure.  —Clinical episodes of CHF with confirmation of acute pulmonary edema by chest roentgengram.

Results.  —Fifteen percent of the elderly cohort developed at least one episode of CHF during the 1-year follow-up period. Those developing CHF had significantly higher mean±SE ANP values at study entry: 493±55 vs 207± 15 pmol/L. The risk for development of CHF rose progressively with increasing ANP levels at study entry. In multivariate analysis, only two independent variables significantly predicted CHF: ANP value greater than 200 pmol/L (adjusted odds ratio [OR], 7.9;95% confidence interval [CI], 3.2 to 19.2) and history of CHF in the previous year (adjusted OR, 7.0; 95% CI, 2.9 to 17). Stratifying the cohort by these two variables results in three CHF risk groups: 55% of the population at 3% annual risk of CHF, 37% of the population at 20% to 24% annual risk of CHF, and 8% of the population at 66% annual risk of CHF.

Conclusions.  —This simple clinical prediction model identifies elderly subjects at risk for CHF and allows appropriate focusing of medical resources for prevention, early detection, and treatment of this highly morbid clinical syndrome.(JAMA. 1992;267:2625-2629)

REFERENCES

1 +
Ghali JK, Cooper R, Ford E.  Trends in hospitalization rates for heart failure in the United States, 1973-1976: evidence for increasing population prevalence. Arch Intern Med . 1990;;150:769-773.
2 +
Irvine PW, Van Buren N, Crossley K.  Causes for hospitalization of nursing home residents: the role of infection. J Am Geriatr Soc . 1984;;32:103-107.
3 +
Luchi RJ, Taffet GE, Teasdale TA.  Congestive heart failure in the elderly. J Am Geriatr Soc . 1991;; 39:810-825.
4 +
Wegner NK, Furberg CD, Pitt E, eds. Coronary Heart Disease in the Elderly . New York, NY: Elsevier Science Publishing Co Inc; 1986;.
5 +
The SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
6 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310.
7 +
Graves EJ. 1988 Summary: National Hospital Discharge Survey . Hyattsville, Md: National Center for Health Statistics; 1990;. Advance Data for Vital and Health Statistics, No. 185.
8 +
Goldberger JJ, Peled HB, Stroh JA, Cohen MN, Frishman WH.  Prognostic factors in acute pulmonary edema. Arch Intern Med . 1986;;146:489-493.
9 +
Plotnick GD, Kelemen MH, Garrett RB, Randall W, Fisher ML.  Acute cardiogenic pulmonary edema in the elderly: factors predicting in hospital and 1 year mortality. South Med J . 1982;;75:565-569.
10 +
Weiner RS, Moses HW, Richeson JF, Gatewood RP Jr.  Hospital and long-term survival of patients with acute pulmonary edema associated with coronary artery disease. Am J Cardiol . 1987;; 60:33-35.
11 +
Goldstein RL, Campion EW, Mulley AG, Thibault GE.  Nursing home patients admitted to a medical intensive care unit. Med Care . 1984;;22:854-862.
12 +
Klainer LM, Gibson JC, White KC.  The epidemiology of cardiac failure. J Chronic Dis . 1965;;18: 797-814.
13 +
McKee PA, Castelli WP, McNamara PM, Kannel WB.  The natural history of congestive heart failure: the Framingham Study. N Engl J Med . 1971;;285:1441-1446.
14 +
Yamaji T, Ishibashi M, Takaku F, et al.  Clinical significance of atrial natriuretic peptide in human blood. Jpn J Med . 1987;;26:207-211.
15 +
Hara H, Ogihara T, Shima J, et al.  Plasma atrial natriuretic peptide level as an index for the severity of congestive heart failure. Clin Cardiol . 1987;; 10:437-442.
16 +
Anderson JV, Woodruff PW, Bloom SR.  The effect of treatment of congestive heart failure on plasma atrial natriuretic peptide concentration: a longitudinal study. Br Heart J . 1988;;59:207-211.
17 +
Tsutamoto T, Bito K, Kinoshita M.  Plasma atrial natriuretic polypeptide as an index of left ventricular end-diastolic pressure in patients with chronic left-sided heart failure. Am Heart J . 1989;;117:599-604.
18 +
Needleman P, Greenwald JE.  Atriopeptin: a cardiac hormone intimately involved in fluid, electrolyte, and blood-pressure homeostasis. N Engl J Med . 1986;;314:828-834.
19 +
Weidmann P, Saxenhoter H, Ferrier C, Shaw SG.  Atrial natriuretic peptide in man. Am J Nephrol . 1988;;8:1-14.
20 +
Goetz KL.  Physiology and pathophysiology of atrial peptides. Am J Physiol . 1988;;254:E1-E15.
21 +
Brenner BM, Ballermann BJ, Gunning ME, Zeidel ML.  Diverse biological actions of atrial natriuretic peptide. Physiol Rev . 1990;; 70:665-699.
22 +
Bates ER, Shenker Y, Grekin RJ.  The relationship between plasma levels of immunoreactive atrial natriuretic hormone and hemodynamic function in man. Circulation . 1986;;73:1155-1161.
23 +
Raine AE, Erne P, Bürgisser E, et al.  Atrial natriuretic peptide and atrial pressure in patients with congestive heart failure. N Engl J Med . 1986;; 315:533-537.
24 +
Hirata Y, Ishii M, Matsuoka H, et al.  Plasma concentrations of alpha-human atrial natriuretic polypeptide and cyclic GMP in patients with heart disease. Am Heart J . 1987;;113:1463-1469.
25 +
Hirsch AT, Creager MA, Dzau VJ.  Relation of atrial natriuretic factor to vasoconstrictor hormones and regional blood flow in congestive heart failure. Am J Cardiol . 1989;:63:211-216.
26 +
Ngo L, Vesely DL, Bissett JK, et al.  Acute and sustained release of atrial natriuretic factor with acute myocardial infarction. Am Heart J . 1989;;118: 893-900.
27 +
Tsai RC, Yamaji T, Ishibashi M, et al.  Atrial natriuretic peptide during supraventricular tachycardia and relation to hemodynamic changes and renal function. Am J Cardiol . 1988;;61:1260-1264.
28 +
Roy D, Paillard F, Cassidy D, et al.  Atrial natriuretic factor during atrial fibrillation and supraventricular tachycardia. J Am Coil Cardiol . 1987;; 9:509-514.
29 +
Gottlieb SS, Kukin ML, Ahern D, Packer M.  Prognostic importance of atrial natriuretic peptide in patients with chronic heart failure. J Am Coll Cardiol . 1989;;13:1534-1539.
30 +
Borst JGG, Molhuysen JA.  Exact determination of the central venous pressure by a simple clinical method. Neth J Med . 1973;;16:66-72.
31 +
Shannon RP, Libby E, Elahi D, et al.  Impact of acute reduction in chronically elevated left atrial pressure on sodium and water excretion. Ann Thorac Surg . 1988;;46:430-437.
32 +
Hennekens CH, Buring JE, Mayrent SL.  Measures of disease frequency and association.  In: Hennekens CH, Buring JE, Mayrent SL, eds. Epidemiology in Medicine . 1st ed. Boston, Mass: Little Brown & Co Inc; 1987;:54-98.
33 +
SPSS Release 3.0 for VAX/VMS. Chicago, Ill: SPSS Inc; 1990.
34 +
SAS Release 6.03. Cary, NC: SAS Institute Inc; 1989.
35 +
Soldo BJ.  America's elderly in the 1980's. Popul Bull . (November) 1980;;35:1-47.
36 +
Projection of the Population ofthe United States, by Age, Sex and Race: 1983 to 2080 . Washington, DC: US Bureau of the Census; 1984;. Current Population Reports, ser P-25, No. 952.
37 +
Clark BA, Elahi D, Epstein FH.  Influence of gender, age, and the menstrual cycle on plasma on atrial natriuretic peptide. J Clin Endocrinol Metab . 1990;;70:349-352.
38 +
Aronow WS, Schwartz KS, Koenigsberg M.  Correlation of aortic cuspal and aortic root disease with aortic systolic ejection murmurs and with mitral annular calcium in persons older than 62 years in a long term health care facility. Am J Cardiol . 1986;; 58:651-652.
39 +
Stevenson LW, Perloff JK.  The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA . 1989;;261:884-888.
40 +
Mattleman SJ, Hakki A, Iskandrian AS, et al.  Reliability of bedside evaluation in determining left ventricular function: correlation with left ventricular ejection fraction determined by radionuclide ventriculography. J Am Coil Cardiol . 1983;;1:417-420.
41 +
Eagle KA, Quertermous T, Singer DE, et al.  Left ventricular ejection fraction: physician estimates compared with gated blood pool scan measurements. Arch Intern Med . 1988;;148:882-885.
42 +
Chakko S, Woska D, Martinez H, et al.  Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. Am J Med . 1991;; 90:353-359.
43 +
Dougherty AH, Naccarelli GV, Gray EL, Hicks LH, Goldstein RA.  Congestive heart failure with normal systolic function. Am J Cardiol . 1984;;54: 778-782.
44 +
Soufer R, Wohlgelertner D, Vita NA, et al.  Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol . 1985;;55: 1032-1036.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Ghali JK, Cooper R, Ford E.  Trends in hospitalization rates for heart failure in the United States, 1973-1976: evidence for increasing population prevalence. Arch Intern Med . 1990;;150:769-773.
2 +
Irvine PW, Van Buren N, Crossley K.  Causes for hospitalization of nursing home residents: the role of infection. J Am Geriatr Soc . 1984;;32:103-107.
3 +
Luchi RJ, Taffet GE, Teasdale TA.  Congestive heart failure in the elderly. J Am Geriatr Soc . 1991;; 39:810-825.
4 +
Wegner NK, Furberg CD, Pitt E, eds. Coronary Heart Disease in the Elderly . New York, NY: Elsevier Science Publishing Co Inc; 1986;.
5 +
The SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
6 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310.
7 +
Graves EJ. 1988 Summary: National Hospital Discharge Survey . Hyattsville, Md: National Center for Health Statistics; 1990;. Advance Data for Vital and Health Statistics, No. 185.
8 +
Goldberger JJ, Peled HB, Stroh JA, Cohen MN, Frishman WH.  Prognostic factors in acute pulmonary edema. Arch Intern Med . 1986;;146:489-493.
9 +
Plotnick GD, Kelemen MH, Garrett RB, Randall W, Fisher ML.  Acute cardiogenic pulmonary edema in the elderly: factors predicting in hospital and 1 year mortality. South Med J . 1982;;75:565-569.
10 +
Weiner RS, Moses HW, Richeson JF, Gatewood RP Jr.  Hospital and long-term survival of patients with acute pulmonary edema associated with coronary artery disease. Am J Cardiol . 1987;; 60:33-35.
11 +
Goldstein RL, Campion EW, Mulley AG, Thibault GE.  Nursing home patients admitted to a medical intensive care unit. Med Care . 1984;;22:854-862.
12 +
Klainer LM, Gibson JC, White KC.  The epidemiology of cardiac failure. J Chronic Dis . 1965;;18: 797-814.
13 +
McKee PA, Castelli WP, McNamara PM, Kannel WB.  The natural history of congestive heart failure: the Framingham Study. N Engl J Med . 1971;;285:1441-1446.
14 +
Yamaji T, Ishibashi M, Takaku F, et al.  Clinical significance of atrial natriuretic peptide in human blood. Jpn J Med . 1987;;26:207-211.
15 +
Hara H, Ogihara T, Shima J, et al.  Plasma atrial natriuretic peptide level as an index for the severity of congestive heart failure. Clin Cardiol . 1987;; 10:437-442.
16 +
Anderson JV, Woodruff PW, Bloom SR.  The effect of treatment of congestive heart failure on plasma atrial natriuretic peptide concentration: a longitudinal study. Br Heart J . 1988;;59:207-211.
17 +
Tsutamoto T, Bito K, Kinoshita M.  Plasma atrial natriuretic polypeptide as an index of left ventricular end-diastolic pressure in patients with chronic left-sided heart failure. Am Heart J . 1989;;117:599-604.
18 +
Needleman P, Greenwald JE.  Atriopeptin: a cardiac hormone intimately involved in fluid, electrolyte, and blood-pressure homeostasis. N Engl J Med . 1986;;314:828-834.
19 +
Weidmann P, Saxenhoter H, Ferrier C, Shaw SG.  Atrial natriuretic peptide in man. Am J Nephrol . 1988;;8:1-14.
20 +
Goetz KL.  Physiology and pathophysiology of atrial peptides. Am J Physiol . 1988;;254:E1-E15.
21 +
Brenner BM, Ballermann BJ, Gunning ME, Zeidel ML.  Diverse biological actions of atrial natriuretic peptide. Physiol Rev . 1990;; 70:665-699.
22 +
Bates ER, Shenker Y, Grekin RJ.  The relationship between plasma levels of immunoreactive atrial natriuretic hormone and hemodynamic function in man. Circulation . 1986;;73:1155-1161.
23 +
Raine AE, Erne P, Bürgisser E, et al.  Atrial natriuretic peptide and atrial pressure in patients with congestive heart failure. N Engl J Med . 1986;; 315:533-537.
24 +
Hirata Y, Ishii M, Matsuoka H, et al.  Plasma concentrations of alpha-human atrial natriuretic polypeptide and cyclic GMP in patients with heart disease. Am Heart J . 1987;;113:1463-1469.
25 +
Hirsch AT, Creager MA, Dzau VJ.  Relation of atrial natriuretic factor to vasoconstrictor hormones and regional blood flow in congestive heart failure. Am J Cardiol . 1989;:63:211-216.
26 +
Ngo L, Vesely DL, Bissett JK, et al.  Acute and sustained release of atrial natriuretic factor with acute myocardial infarction. Am Heart J . 1989;;118: 893-900.
27 +
Tsai RC, Yamaji T, Ishibashi M, et al.  Atrial natriuretic peptide during supraventricular tachycardia and relation to hemodynamic changes and renal function. Am J Cardiol . 1988;;61:1260-1264.
28 +
Roy D, Paillard F, Cassidy D, et al.  Atrial natriuretic factor during atrial fibrillation and supraventricular tachycardia. J Am Coil Cardiol . 1987;; 9:509-514.
29 +
Gottlieb SS, Kukin ML, Ahern D, Packer M.  Prognostic importance of atrial natriuretic peptide in patients with chronic heart failure. J Am Coll Cardiol . 1989;;13:1534-1539.
30 +
Borst JGG, Molhuysen JA.  Exact determination of the central venous pressure by a simple clinical method. Neth J Med . 1973;;16:66-72.
31 +
Shannon RP, Libby E, Elahi D, et al.  Impact of acute reduction in chronically elevated left atrial pressure on sodium and water excretion. Ann Thorac Surg . 1988;;46:430-437.
32 +
Hennekens CH, Buring JE, Mayrent SL.  Measures of disease frequency and association.  In: Hennekens CH, Buring JE, Mayrent SL, eds. Epidemiology in Medicine . 1st ed. Boston, Mass: Little Brown & Co Inc; 1987;:54-98.
33 +
SPSS Release 3.0 for VAX/VMS. Chicago, Ill: SPSS Inc; 1990.
34 +
SAS Release 6.03. Cary, NC: SAS Institute Inc; 1989.
35 +
Soldo BJ.  America's elderly in the 1980's. Popul Bull . (November) 1980;;35:1-47.
36 +
Projection of the Population ofthe United States, by Age, Sex and Race: 1983 to 2080 . Washington, DC: US Bureau of the Census; 1984;. Current Population Reports, ser P-25, No. 952.
37 +
Clark BA, Elahi D, Epstein FH.  Influence of gender, age, and the menstrual cycle on plasma on atrial natriuretic peptide. J Clin Endocrinol Metab . 1990;;70:349-352.
38 +
Aronow WS, Schwartz KS, Koenigsberg M.  Correlation of aortic cuspal and aortic root disease with aortic systolic ejection murmurs and with mitral annular calcium in persons older than 62 years in a long term health care facility. Am J Cardiol . 1986;; 58:651-652.
39 +
Stevenson LW, Perloff JK.  The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA . 1989;;261:884-888.
40 +
Mattleman SJ, Hakki A, Iskandrian AS, et al.  Reliability of bedside evaluation in determining left ventricular function: correlation with left ventricular ejection fraction determined by radionuclide ventriculography. J Am Coil Cardiol . 1983;;1:417-420.
41 +
Eagle KA, Quertermous T, Singer DE, et al.  Left ventricular ejection fraction: physician estimates compared with gated blood pool scan measurements. Arch Intern Med . 1988;;148:882-885.
42 +
Chakko S, Woska D, Martinez H, et al.  Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. Am J Med . 1991;; 90:353-359.
43 +
Dougherty AH, Naccarelli GV, Gray EL, Hicks LH, Goldstein RA.  Congestive heart failure with normal systolic function. Am J Cardiol . 1984;;54: 778-782.
44 +
Soufer R, Wohlgelertner D, Vita NA, et al.  Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol . 1985;;55: 1032-1036.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems