Papers in Press. Published October 27, 2015 as doi:10.1373/clinchem.2015.

244327
The latest version is at http://hwmaint.clinchem.org/cgi/doi/10.1373/clinchem.2015.244327
Clinical Chemistry 61:12
000 000 (2015)

Other Areas of Clinical Chemistry

Reference Values and Release Kinetics of B-Type

Natriuretic Peptide Signal Peptide in Patients with
Acute Myocardial Infarction
Christoph Liebetrau,1,2* Luise Gaede,1,2 Oliver Drr,3 Johannes Blumenstein,1,2 Stefanie Rosenburg,1,2
Jedrzej Hoffmann,1,2 Christian Troidl,1,2 Christian W. Hamm,1,2,3 Holger M. Nef,3 Helge Mllmann,1,2
A. Mark Richards,4,5 and Chris J. Pemberton4

BACKGROUND: The signal peptide for human B-type natriuretic peptide preprohormone (BNPsp), which is released from cardiomyocytes, is increased in plasma of
patients with acute myocardial infarction (AMI); however, its exact release kinetics have not been defined.
METHODS: We measured BNPsp and high-sensitivity
cardiac troponin T (hs-cTnT) in a reference group of
individuals without structural heart disease (n 285)
and determined the release kinetics of these biomarkers
in patients (n 29) with hypertrophic obstructive cardiomyopathy undergoing transcoronary ablation of septal hypertrophy (TASH), a procedure allowing exact timing of onset of iatrogenic AMI. Blood samples were
collected before TASH and at numerous preselected time
points after TASH.
RESULTS: The reference median BNPsp concentration
was 53.4 pmol/L [interquartile range (IQR) 47.0 61.0;
95th percentile 85.9 pmol/L; 99th percentile 116.3
pmol/L]. Baseline concentrations in patients undergoing
TASH were higher than in the reference group [91.9
pmol/L (IQR 62.9 116.4); P 0.0001]. BNPsp increased significantly, peaking at 15 min after induction of
AMI [149.6 pmol/L (109.5204.9) vs baseline; P
0.004] and declining slowly thereafter, falling below the
preprocedural value after 8 h (P 0.014). hs-cTnT increased significantly 15 min after induction of AMI [26
ng/L (19 39) vs 18 ng/L (1129); P 0.001] and remained high at all later time points.
CONCLUSIONS: BNPsp concentrations increased immediately after AMI induction, providing early evidence of
myocardial injury. The release kinetics of BNPsp differed

Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany;
DZHK (German Centre for Cardiovascular Research), partner site RheinMain, Frankfurt
am Main, Germany; 3 Department of Internal Medicine I, Division of Cardiology, University of Giessen, Giessen, Germany; 4 Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; 5 Cardiovascular Research Institute, National University of Singapore, Singapore.
* Address correspondence to this author at: Kerckhoff Heart and Thorax Center, Department of Cardiology, Benekestr. 2-8, 61231 Bad Nauheim, Germany. Fax +49-6032-9962361; e-mail c.liebetrau@kerckhoff-klinik.de.
Received June 5, 2015; accepted September 22, 2015.
2

from those of hs-cTnT. These findings provide information that should help in establishing the diagnostic value
of BNPsp in the setting of early AMI.
2015 American Association for Clinical Chemistry

Acute chest pain is one of the most common causes of

admission to an emergency department (1 ). The biochemical risk stratification of these patients is mainly
driven by determination of cardiac troponin I (cTnI)6,
cardiac troponin T (cTnT), B-type cardiac natriuretic
peptides (BNP), and N-terminal pro-BNP (NTproBNP). In particular, the introduction of newer, more
sensitive troponin assays has proven to facilitate the early
diagnosis of an acute myocardial infarction (AMI) (2 4 ).
This improved discrimination relies mainly on the superior sensitivity of these assays; however, additional diagnostic validation is required with routine clinical chemistry testing after the initial presentation because of the
reduced specificity of these tests (approximately 60% of
presentations with increased hsTnT results do not have
AMI) and a diagnostic gap during the first few hours (5 ).
Addressing the limitation imposed by the loss of specificity, several studies showed that a multimarker strategy
improved diagnostic accuracy in terms of diagnosing or
ruling out AMI (6 9 ).
In this context, a previous study demonstrated increases in the signal peptide for human BNP preprohormone [BNPsp(1726), here abbreviated BNPsp] in the
acute phase of myocardial infarction preceding standard
biomarkers of myocardial injury (cardiac troponin) (10 ).
The signal peptide sequence of BNP is present not only

Previously published online at DOI: 10.1373/clinchem.2015.244327

2015 American Association for Clinical Chemistry
Nonstandard abbreviations: cTnI, cardiac troponin I; cTnT, cardiac troponin T; hs, highsensitivity; BNP, brain natriuretic peptide; NT-proBNP, N-terminal pro-BNP; AMI, acute
myocardial infarction; BNPsp, BNP preprohormone signal peptide; TASH, transcoronary
ablation of septal hypertrophy; LOB, limit of blank; HOCM, hypertrophic obstructive
cardiomyopathy; CK, creatine kinase; GFR, glomerular ltration rate.
This study was previously presented as a poster at the 81st annual meeting of the German
Society of Cardiology (DGK), Mannheim, Germany, April 8 11, 2015.

Copyright (C) 2015 by The American Association for Clinical Chemistry

Fig. 1. Diagram of the study.

in cytosolic extracts of tissue from explanted human

hearts but also in the circulation of healthy human individuals (10, 11 ). Furthermore, as BNPsp concentrations
increase earlier than standardized biomarkers in AMI patients, the establishment of reference values at early time
points is of great clinical interest (10, 12 ).
We recently reported the early release kinetics of
several biomarkers, including cTnT and NT-proBNP, in
patients undergoing transcoronary ablation of septal hypertrophy (TASH) as a model for patients with AMI
(1317 ). There are currently no data, however, regarding
the exact release kinetics of BNPsp in patients with AMI.
Because of the inaccurate definition of the exact time
point of the beginning of myocardial ischemia, and because of patient-related delay before presentation to the
hospital, the early release kinetics of BNPsp in human
AMI are not well described. Therefore, the objective of
the present study was to establish reference values for
BNPsp in patients without structural heart disease and,
further, to characterize the time course of changes in
plasma BNPsp in patients undergoing TASH as a model
of patients with AMI.
Methods
REFERENCE GROUP

From July 2009 to January 2014, 5329 patients were

referred to the Kerckhoff Heart and Thorax Center for
elective coronary angiography and participation in
blood-based biomarker studies. From this population,
we selected 285 individuals who in several imaging modalities showed no evidence of structural heart disease
and were therefore included in the study as a reference
group to establish reference values for BNPsp. Coronary
angiography, echocardiography, and measurement of
high-sensitivity (hs)-cTnT and NT-proBNP were per2

Clinical Chemistry 61:12 (2015)

formed for all individuals. Patients in the reference group

were subdivided into patients with hs-cTnT values above
and below the assay limit of blank (LOB) for further
analysis (Fig. 1). Basic biochemistry and hematologic
testing indicated that all individuals were free of renal or
liver dysfunction and had healthy blood values. All individuals from the reference group provided written informed consent for their participation in the study, and
approval of the institutional ethics board (FF 43/2010)
was obtained. The investigation conforms to the principles outlined in the Declaration of Helsinki.
PATIENTS WITH HYPERTROPHIC OBSTRUCTIVE
CARDIOMYOPATHY UNDERGOING TASH

Another group of 29 patients with hypertrophic obstructive cardiomyopathy (HOCM) who were scheduled for
TASH from January 2010 to January 2014 were included in the study. Pre- and postprocedural management as well as the proof of concept of the TASH method
as an equivalent for AMI have been recently published
(1317 ). In brief, a clinical history and the results of a
physical examination, 12-lead electrocardiography, laboratory tests, echocardiography, and coronary angiography were assessed for all patients. The final diagnosis of
HOCM was made according to the current guidelines on
the basis of severe symptoms during physical activity,
asymmetrical septal hypertrophy 15 mm, systolic
movement of the anterior mitral valve leaflet, and an
intraventricular pressure gradient of 30 mmHg at rest
and/or 50 mmHg after provocation by the Valsalva
maneuver (18 ). All patients received analgesic and anxiolytic pretreatment. Patients were free of renal or liver
dysfunction and had healthy blood values. TASH was
performed according to standard clinical practice with
temporary septal branch occlusion for selective therapeutic injection of 96% ethanol. All TASH procedures were

Reference Values and Release Kinetics of BNPsp

performed in a single session with a single septal branch

occlusion. During the procedure, the mean (SD) volume
of ethanol administered was 1.67 (0.52) mL. The median
occlusion time was 15.0 min [interquartile range (IQR)
12.0 26.0 min]. Postprocedural management included
monitoring in the intensive care unit for 48 h. The preand postprocedural data documented the success of the
procedure as a reduction in the mean intraventricular
pressure gradient.
BLOOD SAMPLE COLLECTION AND PROCESSING

We collected venous blood samples for determination of

BNPsp and hs-cTnT in gel-filled tubes without additives
and in EDTA-filled tubes before the procedure; at 15, 30,
45, 60, 75, 90, and 105 min; and at 2, 4, 8, and 24 h after
induction of myocardial infarction. In the control group,
we collected venous blood samples for determination of
hs-cTnT and BNPsp in gel-filled tubes without additives
and in EDTA-filled tubes before coronary angiography.
Serum or plasma samples were processed immediately
and frozen at 80 C until assay.
BNPsp MEASUREMENTS

BNPsp was measured at the Christchurch Heart Institute, New Zealand, via specific immunoassay as previously described (10 ) with a methodological change in
sample processing before assay. The samples were airshipped on dry ice within 36 h without thawing. To
maximize recovery and reduce nonspecific interactions,
plasma samples were mixed with an equal volume of 0.1
mL HCl and centrifuged to remove high molecular
weight protein debris before extraction on Sep-Pak C18
cartridges. This method modification improved recovery
of synthetic and endogenous BNPsp from 74% to 90%
and stabilized resulting assay samples through reduced
protein interference. Because of the improved recoveries,
a new reference group was required to establish appropriate healthy range and 99th percentile values, as reported
here.
hs-cTnT MEASUREMENTS

We measured cTnT in serum with a high-sensitivity electrochemiluminescence immunoassay (Elecsys Analyzer

2010, Roche Diagnostics). For the hsTnT assay, LOB
detection was 3.0 ng/L, limit of detection was 5.0 ng/L,
and limit of quantification was 13.0 ng/L. The lowest
concentration measurable with a CV 10% for this assay
is 13.5 ng/L (13 ). The recommended clinical decision
limit to rule out AMI with this assay is 14.0 ng/L.
NT-proBNP MEASUREMENTS

We measured NT-proBNP in serum with an electrochemiluminescence immunoassay that uses monoclonal

antibodies (Elecsys Analyzer 2010, Roche Diagnostics).
The lower detection limit for the NT-proBNP assay is

5.0 ng/L, and concentrations above the upper limit of the

analytical measurement range are reported as 35 000
ng/L. The lowest concentration measurable with a CV of
20% for this assay is 50.0 ng/L. At the cutoff value of 150
ng/L, the CV is 3%. The upper reference limit is 300.0
ng/L.
STATISTICAL ANALYSIS

All data for continuous variables are expressed as mean

(SD) or median (IQR), as appropriate. Categorical variables are reported as n (%). Continuous variables were
compared with the Wilcoxon signed-rank test. Withinindividual comparisons were made across repeated observations without correction for multiple comparisons.
The TASH cohort data including BNPsp and hs-cTnT
were tested for conformity with the normal distribution
by applying the KolmogorovSmirnov test. All statistical
tests were performed with SPSS software, version 22.0. A
2-tailed P value 0.05 was considered to be statistically
significant.
Results
Table 1 shows the clinical characteristics of the reference
group, consisting of 285 individuals [117 men, 168
women; age 58.9 (11.1) years] with no coronary artery
disease, hs-cTnT concentrations 99th percentile, and
NT-proBNP concentrations below the upper reference
limit. Individuals in the subgroup with hs-cTnT concentrations below the LOB (n 220; 3 ng/L) were
younger (P 0.0001), had a lower heart rate (P
0.004), and had lower systolic blood pressure at rest (P
0.0001). Furthermore, the prevalence of arterial hypertension (P 0.014) was lower, and they had better renal
function (P 0.0001).
The reference group had a median plasma BNPsp
concentration of 53.4 pmol/L (IQR 47.0 61.0) with a
95th percentile of 85.9 pmol/L and a 99th percentile of
116.3 pmol/L. Individuals with hs-cTnT concentrations
below the limit of detection had median BNPsp 52.0
pmol/L (IQR 46.6 59.5) with a 99th percentile of 92.1
pmol/L. The distribution pattern of BNPsp in these individuals is depicted in Fig. 2. Plasma concentrations of
BNPsp correlated positively with hs-cTnT concentrations (r 0.135; P 0.023) and age (r 0.119; P
0.045). There was no difference in BNPsp between sexes
(P 0.29). Healthy volunteers 65 years old (n 92)
had higher BNPsp values [55.8 pmol/L (IQR 48.7
67.9)] than those 65 years old (n 193) [52.3 pmol/L
(46.759.5); P 0.03].
Dividing the reference group into those with hscTnT below the LOB and those with hs-cTNT above the
LOB, BNPsp concentrations were slightly but significantly lower in the group with hs-cTnT below the LOB
Clinical Chemistry 61:12 (2015) 3

Table 1. Baseline characteristics of the reference group without coronary artery disease, hs-cTnT concentrations <14 ng/L (99th
percentile), and NT-proBNP concentrations <300 ng/L.a

Variable

Reference group

285

Age, years

58.9 (11.1)

Male

117 (41.1)

Body mass index, kg/m2

29.0 (5.4)

hs-cTnT <3.0 ng/L and

NT-proBNP <300 ng/L

hs-cTnT 3.0 ng/L and

NT-proBNP <300 ng/L

220

65

55.9 (9.8)

68.6 (9.7)

94 (42.7)
28.7 (5.2)

23 (35.4)
30.1 (6.0)

<0.0001
0.32
0.12

Cardiovascular risk factors

97 (66.0)

81 (36.8)

16 (24.6)

0.075

Hypertension

Current smoking

197 (69.1)

144 (65.5)

53 (81.5)

0.014

Hypercholesterolemia

162 (56.8)

126 (57.3)

36 (55.4)

0.89

Diabetes mellitus

30 (10.5)

24 (10.9)

6 (9.2)

0.82

Family history

92 (32.3)

74 (33.6)

18 (27.7)

0.45

Beta-blockers

133 (46.7)

100 (45.5)

33 (50.8)

0.48

ACE inhibitors

139 (48.8)

95 (43.2)

44 (67.7)

0.001

68 (23.9)

58 (26.4)

10 (15.4)

0.07

4 (6.2)

0.05

Medication

Statins
Aldosterone receptor antagonists
Heart rate, bpm

7 (2.5)

3 (1.4)

67.8 (11.7)

66.7 (11.5)

71.5 (11.9)

0.004

Systolic blood pressure, mmHg

135.5 (18.9)

133.1 (17.9)

143.3 (20.3)

<0.0001

Diastolic blood pressure, mmHg

78.2 (10.5)

77.9 (10.6)

78.9 (10.0)

0.29

Left ventricular ejection fraction, %

60.2 (3.6)

60.3 (3.8)

59.9 (2.9)

0.59

BNPsp, pmol/L

53.4 (47.061.0)

52.0 (46.659.5)

56.4 (49.669.8)

0.003

90th percentile

76.2

73.9

85.5

95th percentile

85.9

84.3

100.9

97.5th percentile

91.5

88.9

125.6

Laboratory measurements

99th percentile

116.3

hs-cTnT, ng/L

<3 (<3)

<0.0001

81.6 (40.4145.5)

81.6 (39.6141.4)

82.1 (45.2158.4)

0.58

Creatinine, mg/dL

0.73 (0.610.84)

0.71 (0.610.83)

0.81 (0.650.91)

0.012

100.3 (86.9116.3)

103.5 (90.1117.6)

GFR, mL min

(1.73 m )

2 1

91.8 (26.9)

<0.0001

Data are mean (SD), n (%), or median (IQR). To convert creatinine values from mg/mL to mol/L, multiply by 88.4.

[52.0 pmol/L (IQR 46.6 59.5) vs 56.4 pmol/L (49.6

69.8); P 0.014] (Fig. 1).
Table 2 shows the clinical characteristics of all 29
TASH patients [13 men, 16 women; age 60.4 (13.4)
years]. As expected, creatine kinase (CK) serum concentrations significantly increased 1 day after TASH
compared with baseline values [maximal postprocedural CK 672.5 U/L (range 453.0 846.3) vs baseline
CK 93.0 U/L (71.5135.5); P 0.0001]. Pre- and
postprocedural echocardiographic findings are given
in Supplemental Table 1, which accompanies the online version of this article at http://www.clinchem.org/
content/vol61/issue12.
4

0
6 (59)

NT-proBNP, ng/L
1

92.1
<3 (<3)

Clinical Chemistry 61:12 (2015)

hs-cTnT was increased in TASH patients at baseline

[18 ng/L (IQR 1131)]. Measurement of serum cTnT
concentrations by the high-sensitivity assay revealed a
significant increase at 15 min compared with baseline
concentrations [27 ng/L (IQR 20 42) vs 18 ng/L (IQR
1131); P 0.001] after induction of myocardial infarction, with a continuous rise at all prespecified time points
(Fig. 3). In all patients, there was a significant increase in
the hs-cTnT concentration of 50% compared with the
baseline value after 30 min [range of percent increase
(minumummaximum) 57.3%1331.7%; range of absolute increase (minumummaximum) 9 137 ng/L].
The hs-cTnT concentrations measured 30 min postpro-

Reference Values and Release Kinetics of BNPsp

Table 2. Baseline characteristics of 29 patients

undergoing TASH.a
Variable

Age, years

Value

60.4 (13.4)

Male

13 (44.8)

Body mass index, kg/m2

30.7 (6.0)

Cardiovascular risk factors

Current smoking

10 (34.5)

Hypertension

17 (58.6)

Hypercholesterolemia

11 (37.9)

Diabetes mellitus

6 (20.7)

Family history

7 (24.1)

Medication

Fig. 2. Distribution pattern of BNPsp concentrations in individuals without coronary artery disease and hs-cTnT concentrations <99th percentile (14 ng/L).

cedure were 99th percentile in all patients. Twenty

(68.9%) patients had hs-cTnT concentrations 99th
percentile at baseline; however, the interaction term for
time point of blood draw and increased baseline cTnT
14 ng/L was not significant (P for interaction 0.31).
Therefore, the change in hs-cTnT in patients with increased baseline hs-cTnT was not significantly larger
than in patients without increased baseline cTnT (14
ng/L).
Preprocedural BNPsp concentrations were significantly higher in patients with HOCM undergoing
TASH [91.9 pmol/L (IQR 62.9 116.4)] compared with
the reference group (P 0.0001). Fifteen (51.7%) patients had BNPsp concentrations 99th percentile at
baseline. Plasma BNPsp concentrations were significantly increased 15 min after induction of AMI compared with the baseline values [149.6 pmol/L (IQR
109.5204.9) vs 91.9 pmol/L (IQR 62.9 116.4); P
0.004] (Fig. 3) and then declined steadily to fall below
baseline values by 8 h after initiation of myocardial infarction (P 0.014) (Table 3). Twenty-one of 29 patients showed a significant increase in BNPsp of 50%
compared with the baseline value after 15 min [range of
percent increase (minumummaximum) 54.4%
412.8%; range of absolute increase (minumummaximum) 63.3309.6 pmol/L]. At 24 h, all TASH patients
had BNPsp concentrations comparable to those of the
reference group [48.6 (42.356.1); P 0.62].
We observed a highly significant difference in the
kinetics of the 2 biomarkers (P 0.0001, Friedman
test for multiple comparisons). In addition, we performed a correlation analysis between the maximum
hs-cTnT concentration, representing the extent of

Beta-blockers

11 (37.9)

ACE inhibitors

12 (41.4)

Statins

10 (34.5)

Aldosterone receptor
antagonists

18 (62.1)

Calcium channel blockers

29 (100)

Laboratory measurements
Creatinine, mg/dL
GFR, mL min1 (1.73 m2)1
NT-proBNP, ng/L

0.88 (0.771.03)
90.53 (79.04113.73)
1001.0 (486.81949.5)

Data are mean (SD), n (%), or median (IQR). To convert creatinine values from mg/dL
to mol/L, multiply by 88.4.

myocardial injury, and BNPsp concentrations for the

first 240 min after induction of AMI. BNPsp and
hs-cTnT concentrations were not significantly correlated (r 0.304, P 0.22).
Pre- and postprocedural echocardiographic data are
presented in Table 4. BNPsp at baseline correlated with
pressure gradient during Valsalva (r 0.440; P
0.06) and myocardial mass (r 0.431; P 0.07), but
without reaching significance. BNPsp was not correlated
with NT-proBNP at baseline (r 0.285; P 0.13) or
pressure gradient at rest (r 0.291; P 0.19). BNPsp
24 h after the TASH procedure did not correlate with
NT-proBNP at 24 h (r 0.273; P 0.31). Similar
results were found for BNPsp 24 h after TASH and left
ventricular outflow tract pressure gradient, both at rest
(r 0.213; P 0.29) and during Valsalva (r
0.195; P 0.47), and myocardial mass (r 0.067;
P 0.74).
Discussion
Our study reports reference values of BNPsp established
in a group without any structural heart disease to enable
Clinical Chemistry 61:12 (2015) 5

Fig. 3. Plasma concentrations of BNPsp and serum concentrations of hs-cTnT [median (IQR)] in patients undergoing
TASH at baseline and throughout the study.
Light gray bars, hs-cTnT; dark gray bars, BNPsp; light gray line,
hs-cTnTspecic 99th percentile (14 ng/L); dark gray line, BNPspspecic 99th percentile (92.1 pmol/L); circles, outlier data points;
asterisks, rst time point with signicant increase (P < 0.01) compared with baseline.

a comparison with patients with heart disease such as

HOCM or AMI. We describe the early release kinetics of
BNPsp after induction of myocardial infarction in a cohort of patients undergoing TASH, a clinical model of
AMI. This is the first study to document the precise early
time course for this potentially valuable biomarker of
AMI.
There is an ongoing discussion about how to define
the health or normality of the reference population that

is used to establish accurate reference values for cardiac

biomarkers (19 21 ). First, the reference population
should be free of structural heart disease. To investigate
this characteristic, we used several surrogate markers to
screen for a reference population without structural heart
disease, including biomarkers and imaging modalities.
The individuals were characterized with echocardiography and coronary angiography to exclude cardiac abnormalities. For more extensive screening, we measured
cTnT by a high-sensitivity assay and divided the population into those with hs-cTnT concentrations below and
above the LOB (3 ng/L). Because various circulating biomarkers (especially cTnT and NT-proBNP) are sensitive
to changes in glomerular filtration rate (GFR) (22, 23 ),
we also assessed renal function. The median and 99th
percentile concentration of BNPsp was greater in individuals with hs-cTnT concentrations 3 ng/L than in
those with hs-cTnT concentrations 3 ng/L. Sex and age
have been identified as important factors in the selection
of reference individuals (24, 25 ). We observed a significant correlation between BNPsp concentration and age
but not sex. In comparing the median and 99th percentile concentrations among different age groups, we found
that these values were higher in individuals 65 years old
than in younger individuals.
Patients undergoing TASH had significantly higher
preprocedural values of BNPsp compared with the reference group, which may reflect myocardial wall stress
from the high left ventricular outflow tract gradient or
increased overall myocardial mass. This is consistent with
the previously described higher NT-proBNP values in
this study group (15 ). BNPsp at baseline correlated with
pressure gradient during Valsalva and myocardial mass,

Table 3. Concentrations of the indicated biomarkers in 29 patients undergoing TASH.

BNPsp, pmol/L
Variable

Baseline
15 min

Median (IQR)

hs-cTnT, ng/L

Minimummaximum

Median (IQR)

Minimummaximum

91.9 (62.9116.4)

43.3270.5

18 (1129)

<354

149.6 (109.5204.9)

78.6384.6

26 (1939)

1198

30 min

135.4 (105.7180.7)

62.0316.9

51 (3372)

18363

45 min

130.2 (98.6158.9)

59.3298.5

83 (68112)

28450

60 min

131.1 (88.5150.5)

60.6380.6

118 (80174)

36712

75 min

123.5 (85.1154.3)

63.8224.6

149 (109217)

49832

90 min

112.2 (81.8155.2)

63.3235.5

197 (126309)

62964

105 min

112.3 (93.2149.0)

64.6263.7

234 (154324)

93933

2h

109.1 (79.9130.9)

67.4300.2

284 (172508)

1061183

4h

81.2 (65.3102.6)

50.8274.4

553 (360861)

1281936

8h

60.9 (50.086.2)

39.1176.3

974 (7511640)

2643359

24 h

48.6 (42.356.1)

38.167.6

2239 (16392571)

6334818

Clinical Chemistry 61:12 (2015)

Reference Values and Release Kinetics of BNPsp

but because of the low number of patients, this correlation was not significant.
Nevertheless, our data show that there is a rapid and
robust release of BNPsp within the first 15 min after
induction of myocardial infarction; subsequently, concentrations decrease and return to levels comparable to
those of the reference population after 24 h, possibly
from a reduction in myocardial wall stress. We observed
a correlation between concentrations of hs-cTnT and
BNPsp in the reference population; however, there was a
significant difference in the release kinetics of the 2 biomarkers after TASH. Whereas hs-cTnT concentrations
increased continuously throughout the observation window, BNPsp concentrations peaked within 15 min and
then decreased to baseline levels or lower within 8 h after
TASH. This rapidly rising and falling (i.e., dynamic)
profile is consistent with our previous observations in
ST-segment elevation myocardial infarction patients
(10 ) and in those undergoing dobutamine stress echo
testing (26 ). The early rise after induction of AMI is also
in accordance with previous data describing the release of
NT-proBNP after TASH (15 ). Nevertheless, BNPsp
seems to have a shorter half-life than NT-proBNP and
might be more comparable to the release and half-life of
BNP. There are no reports of data showing the exact
release kinetics of BNP.
Understanding the time course of the release of
cTnT and BNPsp and correlating the concentrations
with patient symptoms and the results of electrocardiogram and imaging studies is important for early diagnosis, individual risk stratification, and individualized therapy, especially in the hours soon after symptom onset.
Measurement of BNPsp could be helpful in diagnosing
or excluding AMI in early presenters, as has been shown
for other biomarkers (6, 8 ), and may offer increased
specificity for AMI when combined with high-sensitivity
troponin assay results. Measurement of both cTnT and
BNPsp concentrations might assist in estimating the time
of onset of an AMI: high BNPsp and low cTnT concentration would indicate very recent onset, whereas low
BNPsp and high cTnT concentration might reflect an
AMI several hours into its evolution. This hypothesis
needs to be tested in a patient cohort with suspected
AMI.

This is the first study of serial BNPsp measurements

in patients with HOCM undergoing TASH. However,
the small number of enrolled consecutive patients from a
single center is a major limitation of our study that must
be considered. Additionally, the kinetics of biomarker
release after alcohol ablation might be different from the
release from the stuttering thrombotic occlusion of an
epicardial coronary artery. The data nevertheless demonstrated a significant increase in BNPsp concentrations at
15 min after TASH in almost three-quarters of the patients, especially in patients with BNPsp baseline values
99th percentile.
In summary, our study shows that BNPsp concentrations in a healthy reference group correlate with concentrations of hs-cTnT. BNPsp concentrations increase
immediately after induction of myocardial infarction,
providing early evidence of myocardial injury. BNPsp
shows different release kinetics than those of hs-cTnT.
These findings provide information that may be helpful
in establishing the diagnostic value of the relatively new
biomarker BNPsp in the setting of early AMI.

Author Contributions: All authors confirmed they have contributed to

the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising
the article for intellectual content; and (c) final approval of the published
article.
Authors Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure form. Disclosures and/or potential conflicts of interest:
Employment or Leadership: None declared.
Consultant or Advisory Role: C.W. Hamm, BRAHMS.
Stock Ownership: None declared.
Honoraria: None declared.
Research Funding: This study was supported by the William G.
Kerkhoff-Stiftung Foundation, Bad Nauheim, Germany.
Expert Testimony: None declared.
Patents: C.J. Pemberton, US patent 8298772.
Role of Sponsor: The funding organizations played no role in the
design of study, choice of enrolled patients, review and interpretation of
data, or preparation or approval of manuscript.
Acknowledgments: We thank Elizabeth Martinson, PhD, of the
KHFI Editorial Office for editorial assistance and Anett Kirchhof of the
KHFI laboratory for help in biomarker determination.

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