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(Circulation. 2008;117:e23.)
© 2008 American Heart Association, Inc.

Correspondence

Letter by Ballo et al Regarding Article, "Serial Biomarker Measurements in Ambulatory Patients With Chronic Heart Failure: The Importance of Change Over Time"

Piercarlo Ballo, MD

Cardiology Operative Unit, S. Andrea Hospital, La Spezia, Italy

Arianna Bocelli, MD

Meyer Hospital, University of Florence, Florence, Italy

Sergio Mondillo, MD

Department of Cardiovascular Diseases, University of Siena, Siena, Italy

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

We greatly appreciated the article by Miller et al.¹ In contrast to several studies showing a major role of brain natriuretic peptide (BNP) as a predictor of adverse prognosis in heart failure,^2,3 the study by Miller et al reported that elevated BNP at baseline was not significantly associated with outcome (primary end point: death/cardiac transplantation) in a cohort of 190 patients with New York Heart Association class III-IV heart failure who were followed up for 24 months, after adjustment for troponin T levels, New York Heart Association class, biventricular pacing, and history of myocardial infarction (hazard ratio 1.53, P=0.15). Notably, an association between elevated BNP and outcome was evident in univariate analysis and in unadjusted models that were based on simple interaction of troponin T and BNP values or in those accounting for temporal changes in BNP levels.

An unexpected finding in their study¹ is that biventricular pacing was identified as a powerful predictor of the primary end point (hazard ratio 2.79, P=0.011). Although this may reflect a particularly advanced degree of heart failure in subjects who had previously undergone biventricular pacemaker implantation, a beneficial effect of cardiac resynchronization therapy could reasonably be expected to emerge in multivariate models after adjusting for markers of heart failure severity. Surprisingly, the association between biventricular pacing and the risk of death or transplantation was maintained and further strengthened in multivariate analysis (hazard ratio 3.42, P=0.003).

Considering the large amount of evidence supporting the beneficial independent prognostic impact . . . [Full Text of this Article]