Chest
Volume 130, Issue 4, October 2006, Pages 1220-1230
Journal home page for Chest

Special Features
Diagnostic Usefulness of B-Type Natriuretic Peptide and Functional Consequences of Muscle Alterations in COPD and Chronic Heart Failure

https://doi.org/10.1378/chest.130.4.1220Get rights and content

COPD affects up to one third of patients with chronic heart failure. The coexistence of COPD and chronic heart failure presents clinicians with diagnostic and therapeutic challenges. Measurement of B-type natriuretic peptide plasma levels facilitates the diagnosis of acute dyspnea in patients known to have both COPD and chronic heart failure. Patients with COPD or chronic heart failure have skeletal muscle abnormalities that limit functional capacity independently from primary organ failure. Exercise training reverses skeletal muscle abnormalities in patients with COPD or chronic heart failure and may be particularly indicated in patients with coexistent COPD and chronic heart failure.

Section snippets

BNP and Pro-BNP Synthesis, Release, and Inactivation

The precursor of BNP, pro-BNP, is synthesized in rapid bursts predominantly by ventricular myocytes and to a lesser extent by atrial myocytes.13 Pro-BNP is stored in secretory granules.14 Pro-BNP is cleaved by an endoprotease into BNP, the 32 amino acid active hormone, and a 76 amino acid N-terminal inactive fragment (NT-pro-BNP). The most potent stimulus for pro-BNP synthesis is an increase in ventricular wall tension.15, 16, 17 Lesser stimuli for pro-BNP synthesis are myocyte hypoxia,

Muscle Mass, Metabolism, and Fiber Distribution

As patients with COPD and chronic heart failure become increasingly symptomatic, they exhibit strikingly similar alterations in skeletal muscles.39, 40, 41, 42, 43, 44 Cross-sectional area of thigh muscle is reduced in patients with COPD and in patients with chronic heart failure when compared to age-matched healthy subjects.44, 45 Skeletal muscle biopsies reveal indistinguishable abnormalities in patients with advanced CODP and chronic heart failure.39, 44 Abnormalities include loss of muscle

COPD

Presumably due to increased energy expenditure, the changes in the respiratory muscles of patients with COPD are opposite to those observed in skeletal muscles.76 Although its mass is somewhat reduced, the diaphragm contains relatively more type I fibers than that of healthy subjects. Malnutrition and glucocorticoid therapy affect mostly type IIa and IIb diaphragmatic fibers in patients with advanced COPD.77 Mitochondrial volume density and oxidative capacity relative to adenosine triphosphate

Mechanisms of Skeletal Muscle Alterations in COPD and Chronic Heart Failure

Since skeletal muscle alterations play an important role in limiting functional capacity in patients with COPD or chronic heart failure, reversal of skeletal muscle alterations is an important therapeutic goal when managing both conditions.44, 55, 56, 57, 92, 93 Reversal of skeletal muscle alterations in patients with COPD or chronic heart failure can be best accomplished with a thorough understanding of the mechanisms that mediate these alterations (Fig 2). However, the mechanisms that are

References (127)

  • NagayaN et al.

    Plasma brain natriuretic peptide levels increase in proportion to the extent of right ventricular dysfunction in pulmonary hypertension

    J Am Coll Cardiol

    (1998)
  • LeuchteHH et al.

    Clinical significance of brain natriuretic peptide in primary pulmonary hypertension

    J Am Coll Cardiol

    (2004)
  • WrightSP et al.

    Plasma amino-terminal pro-brain natriuretic peptide and accuracy of heart-failure diagnosis in primary care: a randomized, controlled trial

    J Am Coll Cardiol

    (2003)
  • JanuzziJL et al.

    The N-terminal pro-BNP investigation of dyspnea in the emergency department (PRIDE) study

    Am J Cardiol

    (2005)
  • AdamopoulosS et al.

    Physical training improves skeletal muscle metabolism in patients with chronic heart failure

    J Am Coll Cardiol

    (1993)
  • FiaccadoriE et al.

    Skeletal muscle energetics, acid-base equilibrium and lactate metabolism in patients with severe hypercapnia and hypoxemia

    Chest

    (1987)
  • CicoiraM et al.

    Skeletal muscle mass independently predicts peak oxygen consumption and ventilatory response during exercise in noncachectic patients with chronic heart failure

    J Am Coll Cardiol

    (2001)
  • ConraadsVM et al.

    Intracellular monocyte cytokine production and CD 14 expression are up-regulated in severe vs mild chronic heart failure

    J Heart Lung Transplant

    (2005)
  • GoldsteinDJ et al.

    Circulatory resuscitation with left ventricular assist device support reduces interleukins 6 and 8 levels

    Ann Thorac Surg

    (1997)
  • Dalla LiberaL et al.

    Apoptosis in the skeletal muscle of rats with heart failure is associated with increased serum levels of TNF-α and sphingosine

    J Mol Cell Cardiol

    (2001)
  • Garcia-MartinezC et al.

    Tumour necrosis factor-α increases the ubiquitinization of rat skeletal muscle proteins

    FEBS Lett

    (1993)
  • NishiyamaY et al.

    Oxidative stress is related to exercise intolerance in patients with heart failure

    Am Heart J

    (1998)
  • LiRK et al.

    Effect of oxygen tension on the anti-oxidant enzyme activities of tetralogy of Fallot ventricular myocytes

    J Mol Cell Cardiol

    (1989)
  • TikunovBA et al.

    Changes in myofibrillar protein composition of human diaphragm elicited by congestive heart failure

    J Mol Cell Cardiol

    (1996)
  • ManciniDM et al.

    Evidence of reduced respiratory muscle endurance in patients with heart failure

    J Am Coll Cardiol

    (1994)
  • SenniM et al.

    Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991

    Circulation

    (1998)
  • ManninoDM et al.

    Chronic obstructive pulmonary disease surveillance-United States, 1971–2000

    MMWR Morb Mortal Wkly Rep

    (2002)
  • PenaVS et al.

    Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study

    Chest

    (2000)
  • LeeDS et al.

    Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model

    JAMA

    (2003)
  • Mc CulloughPA et al.

    B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study

    Circulation

    (2002)
  • Mc CulloughPA et al.

    Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department

    Acad Emerg Med

    (2003)
  • HamiltonAL et al.

    Muscle strength, symptom intensity, and exercise capacity in patients with cardiorespiratory disorders

    Am J Respir Crit Care Med

    (1995)
  • SteeleIC et al.

    Non-invasive measurement of cardiac output and ventricular ejection fractions in chronic cardiac failure: relationship to impaired exercise tolerance

    Clin Sci (Lond)

    (1997)
  • NakamuraS et al.

    Atrial natriuretic peptide and brain natriuretic peptide coexist in the secretory granules of human cardiac myocytes

    Am J Hypertens

    (1991)
  • HamaN et al.

    Rapid ventricular induction of brain natriuretic peptide gene expression in experimental acute myocardial infarction

    Circulation

    (1995)
  • BruneauBG et al.

    BNP gene expression is specifically modulated by stretch and ET-1 in a new model of isolated rat atria

    Am J Physiol

    (1997)
  • WieseS et al.

    Gene expression of brain natriuretic peptide in isolated atrial and ventricular human myocardium: influence of angiotensin II and diastolic fiber length

    Circulation

    (2000)
  • GoetzeJP et al.

    Acute myocardial hypoxia increases BNP gene expression

    FASEB J

    (2004)
  • BrotmanDJ et al.

    Effects of short-term glucocorticoids on cardiovascular biomarkers

    J Clin Endocrinol Metab

    (2005)
  • WeiT et al.

    B-type natriuretic peptide in patients with clinical hyperthyroidism

    J Endocrinol Invest

    (2005)
  • MukoyamaM et al.

    Brain natriuretic peptide as a novel cardiac hormone in humans. Evidence for an exquisite dual natriuretic peptide system, atrial natriuretic peptide and brain natriuretic peptide

    J Clin Invest

    (1991)
  • SilverMA et al.

    BNP Consensus Panel 2004: A clinical approach for the diagnostic, prognostic, screening, treatment monitoring, and therapeutic roles of natriuretic peptidesin cardiovascular diseases

    Congest Heart Fail

    (2004)
  • MuellerT et al.

    Diagnostic accuracy of B type natriuretic peptide and amino terminal proBNP in the emergency diagnosis of heart failure

    Heart

    (2005)
  • ZaphiriouA et al.

    The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study

    Eur J Heart Fail

    (2005)
  • RayP et al.

    Comparison of brain natriuretic peptide and probrain natriuretic peptide in the diagnosis of cardiogenic pulmonary edema in patients aged 65 and older

    J Am Geriatr Soc

    (2005)
  • NagayaN et al.

    Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension

    Circulation

    (2000)
  • MuellerC et al.

    Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea

    N Engl J Med

    (2004)
  • MatthayRA et al.

    Pulmonary artery hypertension in chronic obstructive pulmonary disease: determination by chest radiography

    Invest Radiol

    (1981)
  • MullerNL et al.

    Pulmonary hypertension

    (2001)
  • ManciniDM et al.

    Contribution of skeletal muscle atrophy to exercise intolerance and altered muscle metabolism in heart failure

    Circulation

    (1992)
  • Cited by (9)

    • Prevalence and management of COPD and heart failure comorbidity in the general practitioner setting

      2017, Respiratory Medicine
      Citation Excerpt :

      Several studies provide evidences that COPD and HF often co-exist and this happens more frequently than expected from their separate population prevalences [7,13,14]. The prevalence of COPD is estimated to range from 23 to 33% in patients with chronic heart failure [15]. On the other hand, a meta-analysis review has described that the prevalence of HF ranges from 5% to 41% in patients with COPD [16].

    View all citing articles on Scopus

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text