Mikic, L

Abstract Introduction In the latest ESC Guidelines for the diagnosis and treatment of heart failure, NTproBNP has been recognized as substantial laboratory diagnostic marker. N-terminal pro-B-type natriuretic peptide is a stable degradation product of the active B-type natriuretic peptide, that is produced mainly by cardiomyocytes in response to stretching impulse. Despite being a great diagnostic marker of heart failure, the levels of NTproBNP vary depending on cardiac and non-cardiac conditions. Aim We wanted to evaluate what are the variables that correlate the most with NTproBNP levels in our population of hospitalized patients with heart failure and reduced ejection fraction (HFrEF). Methods We evaluated medical histories of 245 HFrEF patients hospitalized from March 2023 until November 2024. We focused our analysis on parameters related to the most common comorbidities – coronary disease, anemia, sideropenia, chronic kidney disease (CKD), atrial fibrillation (AF), chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2DM). We collected both numerical (NTproBNP, hemoglobin concentration, estimated glomerular filtration rate - eGFR, serum Fe) and categorical data (the presence of the comorbidity). For statistical analysis we used Spearman’s Rank correlation test and Mann Whitney U test. Results In our patient population (n=245, males 65.53%, mean age 68.48+-10.4 years), out of all analyzed variables, the strongest negative correlation was found between NTproBNP levels and eGFR (rho -0.3989, p<0.01), followed by serum Fe (rho – 0.3791, p<0.01) and hemoglobin concentration (rho -0.3417, p<0.01). There was statistically significant difference of NTproBNP levels in groups with the presence of selected comorbidities - CKD, anemia, coronary disease, COPD and right heart failure (defined as TAPSE / tricuspid annular plane systolic excursion <16mm), in relation to a group without a certain comorbidity. There was no difference found in relation to sex, T2DM and interestingly with the presence of AF. Conclusion Glomerular filtration rate, serum iron and hemoglobin concentration showed to be inversely correlated to NTproBNP levels. Comorbidities can be attributing factors for cardiac decompensation, however in CKD the mechanism of increased NTproBNP is probably related mostly by the elimination reduction, thus the high levels can be interpreted incorrectly.

Multimodal imaging plays a central role in optimizing the evaluation and management of myocardial ischemia by leveraging the complementary strengths of echocardiography, cardiac magnetic resonance imaging (CMR), single photon emission computed tomography (SPECT), positron emission tomography (PET), and invasive coronary angiography (ICA). Noninvasive functional imaging is typically recommended for patients with intermediate to high pre-test probability of coronary artery disease, while coronary computed tomography angiography (CCTA) is preferred for low to intermediate risk. Stress echocardiography is valuable for detecting wall motion abnormalities and is particularly effective in multivessel or left main disease, where perfusion techniques may miss balanced ischemia. CMR offers high spatial resolution and quantitative assessment of myocardial blood flow (MBF), while SPECT and PET quantify ischemic burden, with PET providing superior accuracy for MBF and microvascular disease. ICA remains the gold standard for defining the presence, location, and severity of epicardial coronary stenosis. It is indicated when noninvasive imaging reveals high-risk features, when symptoms are refractory to medical therapy, or when noninvasive results are inconclusive. While ICA offers high spatial resolution, it alone cannot assess the hemodynamic significance of intermediate lesions, nor the coronary microvasculature. Adjunctive invasive hemodynamic and provocative coronary testing (e.g., Fractional Flow Reserve—FFR, invasive Coronary Flow Reserve—CFR, Index of Microcirculatory Resistance—IMR, acetylcholine test) provide essential insights, especially in ischemia with nonobstructive coronary arteries. Given its procedural risks, ICA should be reserved for cases where it will impact management. Intravascular imaging may be used to further characterize lesions. In summary, modality selection should be individualized based on patient characteristics, comorbidities, contraindications, and the need for anatomical versus physiological data. Integrating noninvasive and invasive modalities provides a comprehensive, patient-centered approach to ischemia evaluation.

This review emphasizes the importance of cardiopulmonary exercise testing (CPET) in patients diagnosed with hypertrophic cardiomyopathy (HCM). In contrast to standard exercise testing and stress echoes, which are limited due to the ECG changes and wall motion abnormalities that characterize this condition, CPET allows for the assessment of the complex pathophysiology and severity of the disease, its mechanisms of functional limitation, and its risk stratification. It is useful tool to evaluate the risk for sudden cardiac death and select patients for cardiac resynchronization therapy (CRT), cardiac transplantation, or mechanical circulatory support, especially when symptomatology and functional status are uncertain. It may help in differentiating HCM from other forms of cardiac hypertrophy, such as athletes’ heart. Finally, it is used to guide and monitor therapy as well as for exercise prescription. It may be considered every 2 years in clinically stable patients or every year in patients with worsening symptoms. Although performed only in specialized centers, CPET combined with echocardiography (i.e., CPET imaging) and invasive CPET are more informative and provide a better assessment of cardiac functional status, left ventricular outflow tract obstruction, and diastolic dysfunction during exercise in patients with HCM.