Original Article
Association of Plasma Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Subtypes and Outcome

https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.09.025Get rights and content

Background

Brain natriuretic peptide (BNP) is believed to be a diagnostic marker for cardiovascular diseases, including atrial fibrillation (AF). Recent studies have incriminated BNP as a marker of cardioembolic stroke. We aimed at investigating association of plasma BNP levels in acute ischemic stroke subtypes and their outcome in Indian patients.

Methods

We recruited 270 acute ischemic stroke patients within 48 hours of symptom onset and compared with 110 age- and sex-matched control subjects. This study was carried out at Yashoda Hospital, Hyderabad, India between April 2011 and March 2013. Serum BNP levels were estimated in stroke patients and control subjects. Good functional outcome at 3 months was defined as modified Rankin score (mRS) 2 or less.

Results

Elevated BNP levels was significantly more in patients with acute ischemic stroke patients 119 (44%) compared with controls 4 (3.6%; P < .0001). Among stroke subtypes, elevated BNP levels were observed in 75% of cardioembolic strokes, 45.8% of small artery disease, 43.1 % of larger artery atherosclerosis, and 34.5% of stroke of undetermined etiology. On multiple logistic regression analysis, elevated BNP levels were significantly associated with acute ischemic stroke (odds ratio [OR], 13.0; 95% confidence interval [CI], 8.1-15.4). Among stroke subtypes, significant association was seen with cardioembolic stroke (OR, 3.5; 95% CI, 2.2-7.2). Elevated BNP levels were independently associated with poor outcome (OR, 3.4; 95% CI, 1.2-13.7; P < .0001) and higher mortality (OR, 3.4; 95% CI, 1.2-13.7; P < .0001).

Conclusions

Elevated BNP level is an independent marker for cardioembolic stroke and poor outcome at 90 days follow-up. No significant association was seen with other stroke subtypes.

Section snippets

Material and Methods

We prospectively recruited 270 patients with acute ischemic stroke (within 48 hours of symptom onset), admitted to the stroke unit at Yashoda Hospital, a tertiary care center in South India. Another 110 age- and sex-matched controls were recruited from the outpatient clinics. The study was conducted between April 2011 and March 2013. Institutional ethics committee approved this study.

Stroke was defined according to World Health organization as “rapidly developing clinical signs of focal/global

Results

A total of 270 acute stroke patients and 110 control subjects were included in the study. Men constituted 69.6% of stroke patients and 70% of control subjects. Median age was similar in both groups (59 years in stroke patients and 58 years in control subjects). Stroke patients had significantly higher proportion of elevated BNP levels (P < .0001), hypertension (P < .0001), atrial fibrillation (AF; P = .0004), mean serum white blood cell count (P < .0001), and diabetes mellitus (P = .04).

Discussion

We found that increased plasma BNP (>100 pg/mL) levels were observed more commonly in acute ischemic stroke patients (44%) compared with control subjects (3.6%). Elevated BNP level was found as an independent predictor of acute ischemic stroke.

Our findings are in accordance to the previous reports.11, 19, 20 Yukiiri et al21 reported elevated BNP values (>77 pg/mL) in three fourths of their stroke patients. Furthermore, a strong association has been described between high plasma BNP levels and

Conclusions

Our study found that BNP is a reliable marker for the diagnosis and prognostication of cardioembolic stroke in Indian patients. Further larger multicentric studies including various ethnic groups are required to establish the potential role of these findings in stroke management.

Acknowledgments

We are thankful to Dr. G.S. Rao, Managing Director and Dr. A. Lingaih, Director of Medical services, Yashoda group of Hospitals for their generous support to carry out this study in Yashoda Hospital, Hyderabad, India.

References (46)

  • D. Nagaraja et al.

    Preceding infection as a risk factor of stroke in the young

    J Assoc Physicians India

    (1999)
  • I.Y. Bova et al.

    Acute infection as a risk factor for ischemic stroke

    Stroke

    (1996)
  • T. Sudoh et al.

    A new natriuretic peptide in porcine brain

    Nature

    (1988)
  • Z. Cakir et al.

    A prospective study of brain natriuretic peptide levels in three subgroups: stroke with hypertension, stroke without hypertension, and hypertension alone

    Ann Indian Acad Neurol

    (2010)
  • T. Tsutamoto et al.

    Attenuation of compensation of endogenous cardiac natriuretic peptide system in chronic heart failure: prognostic role of plasma brain natriuretic peptide concentration in patients with chronic symptomatic left ventricular dysfunction

    Circulation

    (1997)
  • K. Hasegawa et al.

    Ventricular expression of brain natriuretic peptide in hypertrophic cardiomyopathy

    Circulation

    (1993)
  • K. Sakai et al.

    Brain natriuretic peptide as a predictor of cardioembolism in acute ischemic stroke patients: brain natriuretic peptide stroke prospective study

    Eur Neurol

    (2013)
  • X. Chen et al.

    The prognostic value of combined NT-pro-BNP levels and NIHSS scores in patients with acute ischemic stroke

    Intern Med

    (2012)
  • A.M. Makikallio et al.

    Natriuretic peptides and mortality after stroke

    Stroke

    (2005)
  • P. Thorvaldsen et al.

    Stroke incidence, case fatality, and mortality on WHO MONICA project. Monitoring Trends and Determinates in Cardiovascular Disease

    Stroke

    (1995)
  • H.P. Adams et al.

    Classification of subtypes of acute ischemic stroke. Definition for use in a multicenter clinical trail

    Stroke

    (1993)
  • M. Hülsmann et al.

    Incidence of normal values of natriuretic peptides in patients with chronic heart failure and impact on survival: a direct comparison of N-terminal atrial natriuretic peptide, N-terminal brain natriuretic peptide and brain natriuretic peptide

    Eur J Heart Fail

    (2005)
  • O.W. Nielsen et al.

    Value of BNP to estimate cardiac risk in patients on cardioactive treatment in primary care

    Eur J Heart Fail

    (2007)
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    The authors have no conflicts of interest or disclosures to make.

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