335 AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2 B-TYPE NATRIURETIC PEPTIDE (PNP) CAN PREDICT SILENT MYOCARDIAL ISCHEMIA IN ASYMPTOMATIC EGYPTIAN PATIENTS WITH TYPE 2 DIABETES MELLITUS. Khaled Massoud Dessouky 1 , Kamal Hashem Salah 2 and Abdelaziz Rezk Sheridah 3 . 1 Internal medicine, 2 Clinical pathology and 3 Cardiology Departments, Faculty of Medicine, Al-Azhar University . ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـ ـABSTRACT Background: B-type natriuretic peptide (BNP) is a hormone that is released primarily by ventricular myocyte in response to physiological and pathological stimuli. Many studies suggested that raised level of BNP in non- heart failure may indicate coronary artery disease (CAD) particularly in high risk groups. Aim of this study: is to determine whether BNP can predict myocardial ischemia in asymptomatic Egyptian patients with type 2- diabetes mellitus (DM) Patients and methods: 50 male patients with type 2 DM were enrolled in this study. We excluded patients with history or evidence of heart failure or coronary artery disease. All patients were subjected to history taking, full clinical examination and laboratory tests: renal function, BNP, lipid profile, HbA1c, Resting, exercise ECG testing and resting transthoracic 2D Doppler Echocardiography. Results: Myocardial ischemia was found in 36 patients (75%) by exercise ECG testing (positive group) While 12patients (12%) showed normal Exercise testing (Normal group). 2 patients showed equivocal exercise testing were excluded from the study. BNP level was significantly higher in positive group compared to normal group (43.54 ± 9.6) vs (15.43±3.91) pg /ml (P< 0.000). It was found that BNP level cut off > 22.4 pg / ml predicted positive exercise ECG testing with sensitivity 88.89 % and specificity 75 % for diagnosis of myocardial ischemia. CONCLUSION: BNP level is of value in
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335
AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
B-TYPE NATRIURETIC PEPTIDE (PNP) CAN PREDICT
SILENT MYOCARDIAL ISCHEMIA IN ASYMPTOMATIC
EGYPTIAN PATIENTS WITH TYPE 2 DIABETES MELLITUS.
Khaled Massoud Dessouky1, Kamal Hashem Salah
2
and Abdelaziz Rezk Sheridah3.
1Internal medicine, 2Clinical pathology and3Cardiology Departments, Faculty of
Medicine, Al-Azhar University.
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ABSTRACT
Background: B-type natriuretic peptide (BNP) is a hormone that is
released primarily by ventricular myocyte in response to physiological and
pathological stimuli. Many studies suggested that raised level of BNP in non-
heart failure may indicate coronary artery disease (CAD) particularly in high
risk groups. Aim of this study: is to determine whether BNP can predict
myocardial ischemia in asymptomatic Egyptian patients with type 2- diabetes
mellitus (DM) Patients and methods: 50 male patients with type 2 DM were
enrolled in this study. We excluded patients with history or evidence of heart
failure or coronary artery disease. All patients were subjected to history taking,
full clinical examination and laboratory tests: renal function, BNP, lipid profile,
HbA1c, Resting, exercise ECG testing and resting transthoracic 2D Doppler
Echocardiography. Results: Myocardial ischemia was found in 36 patients
(75%) by exercise ECG testing (positive group) While 12patients (12%) showed
normal Exercise testing (Normal group). 2 patients showed equivocal exercise
testing were excluded from the study. BNP level was significantly higher in
positive group compared to normal group (43.54 ± 9.6) vs (15.43±3.91) pg
/ml (P< 0.000). It was found that BNP level cut off > 22.4 pg / ml predicted
positive exercise ECG testing with sensitivity 88.89 % and specificity 75 % for
diagnosis of myocardial ischemia. CONCLUSION: BNP level is of value in
336
Khaled Massoud Dessouky et al
AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
SUPLL - 2
predicting silent myocardial ischemia in asymptomatic Egyptian patients with
type 2- DM.
INTRODUCTION
The heart is now recognized as an endocrine organ. It released a number of
hormones, which belong to the natriuretic peptide family. There are currently
four types of natriuretic peptides that have been described as ANP , BNP, CNP,
and DNP . ANP and BNP are primarily released from heart (1) .
In human, BNP is primarily derived from the ventricular myocyte . It has
several systemic effects, which counteract CV volume overload including
vasodilatation, diuresis, and inhibition of the Renin- Angiotensin- Aldosterone
system (2).
BNP synthesis is constitutive and its release is triggered by variety of
physiological and pathological stimuli including CHF, both LV systolic and
diastolic dysfunction, LVH, vulvar heart disease, pulmonary, renal diseases and
advanced age (3).
The use of BNP in the diagnosis and prognosis of heart failure patient is
now well established (4). However, Evidence point towards a role of BNP in
identifying patients with myocardial ischemia and coronary artery disease
(CAD) (3)
BNP may also help to identify CAD in asymptomatic patients and this
particularly important because patients with silent myocardial ischemia have a
21 – fold increase risk of coronary event (5). In addition almost 50 % of sudden
cardiac death still occurs in people with no documented previous history of
overt Cardiac disease (6) .Therefore, screening high risk groups with this simple
blood test may be a logic approach. Diabetic patients are clear example of such
high risk patients as they are known to have high incidence of silent coronary
disease (7).
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AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
The aim of this work is to determine whether BNP can predict silent
myocardial ischemia in asymptomatic Egyptian patients with type 2-DM .
PATIENTS AND METHODS
Fifty (50) male patients with type 2-diabetes mellitus were included in this
study. They were selected from outpatient DM clinic of Sayed Galal Al – Azhar
university hospital. The study was performed during the period from October
2013 to March 2015, after departmental ethical committee approval and patients
consents were obtained , all patients were male to avoid possible fallacies with
female gender (estrogen related) and on regular anti-diabetic therapy.
Exclusion criteria:
Females, patients suggested to have myocardial ischemia and those
known to have CAD or undergone coronary intervention. Patients with evidence
of left ventricular hypertrophy (LVH) , heart failure, LVH with ejection fraction
< 50% on transthoracic echocardiography. Patients with serum creatinin >1.2
mg /dl and patients who had parenchymal or pulmonary vascular disease.
Methods: All participants were subjected to:
1-Full history taking with special emphasis on duration of diabetes
mellitus, history of documented CAD, PCI or CABAG
2-Full clinical examination with special stress on complete cardiac
examination, body mass index ( BMI) and waist circumference ( WC).
3-Laboratory Investigations:
Renal function tests including blood urea and serum creatinine . Were
measured by enzymatic colorimetric assay, using Hitachi 911 automatic
analyzer .
Lipid profile including: Total cholesterol ( TC), triglyceride (TG),
High density lipoprotein (HDL-C ) were measured by enzymatic
colorimetric assay, using Hitachi cobas C 311. After 12 hours overnight
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Khaled Massoud Dessouky et al
AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
SUPLL - 2
fast for all subjects before collection of blood. Low density lipoprotein
cholesterol (LDL –C) was calculated using Friedewald formula (8).
HbA1C : was done by enzymatic colorimetric assay, using Hitchi cobas C
311.
BNP test: BNP samples were taken immediately after exercise testing .The
samples were measured quantitatively by fluorescence immunoassay with the