Sociedade brasileira de cardiologia a carta das mulheres / Brazilian society of cardiology the women's letter

O objetivo primordial desse documento é estimular a melhoria das condições de saúde das mulheres brasileiras, com foco na doença cardiovascular (DCV). A DCV é responsável por 17,5 milhões de mortes prematuras/ano no mundo, com previsão de aumento para 23 milhões em 2030. As DCV são responsáveis por um terço de todas as mortes no Brasil, com semelhança entre homens e mulheres após a menopausa. Esses dados revestem-se de maior importância quando consideramos que 80% das mortes prematura. (AU)

Role of Monokine Induced by Interferon Gamma in Discrimination and Prognosis of Patients With Chagas' Disease and Idiopathic Dilated Cardiomyopathy.

AIMS: Monokine induced by interferon gamma (MIG) is a chemokine that has been found to increase in the myocardium of mice infected with Trypanosoma cruzi. It is not known whether MIG is regulated in patients with Chagas' disease (CD) and idiopathic dilated cardiomyopathy (DCM). Therefore, we aimed to investigate the possible diagnostic and/or prognostic value of MIG in these patients. METHODS AND RESULTS: In this prospective cohort study, MIG was measured in patients with CD (n = 93) and DCM (n = 47) and in healthy control subjects (n = 24). MIG was found to be significantly increased in patients with CD and advanced heart failure (New York Heart Association III-IV). Although no significant increase in MIG levels was observed in patients with DCM, there was a significant correlation between MIG and left ventricular ejection fraction in patients with DCM. In contrast, despite the significant increase in patients with CD and advanced heart failure, MIG had no significant correlation with any of the echocardiographic parameters in CD. MIG also failed to predict mortality and necessity for heart transplant in patients with CD but showed a clear trend for patients with DCM. CONCLUSIONS: To the best of our knowledge, this is the first study to investigate MIG in patients with CD and DCM. The significant increase of MIG in patients with CD and advanced heart failure, the negative correlation between MIG and left ventricular ejection fraction, and the clear trend in discrimination using a cutoff value found in patients with DCM require further investigation to clarify the diagnostic and prognostic potential of MIG in these patients.

Beta blockers prevent correlation of plasma ACE2 activity with echocardiographic parameters in patients with idiopathic dilated cardiomyopathy.

Plasma angiotensin-converting enzyme (ACE) 2 activity has been demonstrated to be an independent prognostic marker in Chagas' disease, equally potent as B-type natriuretic peptide. This study aimed to investigate the prognostic potency of circulating ACE2 activity in patients with idiopathic dilated cardiomyopathy (DCM). Blood samples were withdrawn from patients with idiopathic DCM and healthy control subjects. The DCM patients were subdivided into 2 groups according to their New York Heart Association classification. The plasma ACE2 activity was measured by a fluorescence method. Plasma ACE2 activity was significantly increased in DCM patients, correlating with clinical severity. It was correlating with echocardiographic parameters in patients with DCM. Furthermore, plasma ACE2 activity had the potency to predict cardiac death and heart transplantation. However, compared with patients with Chagas' disease, the correlation and predictive value of ACE2 activity in patients with DCM was much less pronounced. Beta blocker treatment in patients with DCM was identified to prevent the association between circulating ACE2 activity and echocardiographic parameters. Although ACE2 activity in blood samples of patients with DCM without beta blockers is potent in correlating with the severity of disease and in predicting death and heart transplantation, its correlation and prediction potency are significantly diminished by beta blocker treatment.

Prognostic value of circulating levels of stem cell growth factor beta (SCGF beta) in patients with Chagas' disease and idiopathic dilated cardiomyopathy.

Chagas' disease (CD) often leads to dilated cardiomyopathy (DCM), and during its chronic stage hematopoietic stem or progenitor cells are involved in its pathological process. However, it is not clear whether stem cell growth factor (SCGF) beta can be regulated in patients with CD and idiopathic DCM. In present study, we aim to investigate the plasma SCGF beta concentration and its correlation with echocardiographic parameters and clinical outcome. In this prospective cohort study, SCGF beta levels were quantified in patients with CD (n=94), DCM (n=48), and control healthy subjects (n=25). In comparison with healthy subjects, no statistical difference can be detected in NYHA classes I-II patients. However, SCGF beta was significantly increased in advanced heart failure patients (NYHA III-IV), compared to CD patients without heart failure. There was no group difference between CD and DCM. However, despite this significant increase in advanced heart failure patients, SCGF beta had no significant correlation with echocardiographic parameters, and it cannot be used as a prognostic marker for mortality and heart transplantation. To our best knowledge, this is the first report of SCGF beta in heart failure patients. Although it is significantly increased in advanced heart failure patients caused by CD or DCM, its prognostic value for end points is minor.

Prognostic significance of circulating levels of hepatocyte growth factor in patients with chagas' disease and idiopathic dilated cardiomyopathy.

OBJECTIVES: Hepatocyte growth factor (HGF) plays an important role in the improvement in cardiac function and remodeling in a variety of cardiovascular diseases. It is also a strong predictor of mortality in some heart failure (HF) patients. However, its prognostic value in patients with Chagas' disease (CD) or idiopathic dilated cardiomyopathy (DCM) remains to be investigated. METHODS AND RESULTS: In this prospective cohort study, HGF concentrations were measured in patients with CD (n = 91), DCM (n = 47), and control subjects (n = 25). While no difference was detected for patients with New York Heart Association class I-II, HGF was significantly increased in advanced HF patients (New York Heart Association class III-IV) in both CD and DCM groups, compared with healthy subjects. There was a strong correlation between HGF and left ventricular ejection fraction in CD patients. However, there was no correlation in patients with DCM. Despite its strong correlation with left ventricular ejection fraction in CD patients, HGF failed to predict mortality and necessity for heart transplant in both CD and DCM patients. CONCLUSIONS: Although HGF can be significantly increased in advanced HF patients with CD and DCM, its prognostic value for endpoints is minor. Therefore, the formerly described predictive power for HGF in HF might be restricted to specific etiologies of HF.

Does the aminopeptidase A have prognostic and diagnostic value in Chagas disease and other dilated cardiomyopathies?

Chagas disease (CD), which is caused by the protozoan Trypanosoma cruzi, is a major cause of heart failure in Latin America. We investigated if plasma activity of one of the enzymes being part of the renin-angiotensin system, aminopeptidase A (APA), has diagnostic and prognostic potency in patients with CD and dilated cardiomyopathies (DCMs) due to other causes. Blood samples were taken from 94 patients with CD, 46 patients with DCM, and 34 healthy control subjects. Plasma APA activity was determined by fluorometry assays. The average follow-up time was 39 months; by the end of study, 33 patients had died and another 13 received heart transplant. There was no significant alteration in plasma APA activity in the patients with CD or DCM, as compared with that in controls. The Pearson correlation of echocardiographic data with plasma APA activity in patients with CD and DCM did not reveal any significant correlation with left-ventricular ejection fraction or other echocardiographic parameters. APA activity was unable to predict mortality or the need for heart transplant. Detection of APA activity in plasma may not prove suitable for prognosis in patients with heart failure and is unable to screen or diagnose asymptomatic patients with CD for early therapy.

Plasma ACE2 activity is an independent prognostic marker in Chagas' disease and equally potent as BNP.

BACKGROUND: Angiotensin-converting enzyme (ACE) 2 is a novel homologue of ACE. It metabolizes angiotensin (Ang)II to Ang-(1-7). This study aims to investigate the diagnostic and prognostic potency of circulating ACE2 activity in patients with heart failure (HF) from Chagas' disease (CD). METHODS AND RESULTS: Blood samples were obtained from 111 CD patients and 40 age- and gender-matched healthy subjects. The CD patients were further subdivided according to their New York Heart Association classification. ACE2 activity was significantly increased in CD patients with HF, but not in patients without systolic dysfunction. Moreover, plasma ACE2 activity was significantly correlated with their clinical severity and echocardiographic parameters. Importantly, the potency of circulating ACE2 activity in CD patients was equally potent as that of B-type natriuretic peptide to predict cardiac death and heart transplant. Most importantly, patients with both parameters elevated were on a 5-fold higher risk to reach an endpoint than patients with increase in only 1 of the 2 parameters. CONCLUSIONS: Determination of ACE2 activity may provide a new and important diagnostic and prognostic marker for patients with CD. ACE2 activity and BNP concentration have additive predictive value and may be used in combination to offer a new dimension of prediction in HF.

Amino-terminal fragment of C-type natriuretic peptide precursor and C-type natriuretic peptide do not correlate in patients with Chagas disease: role for neutral endopeptidase.

Atrial and B-type natriuretic peptides (ANP and BNP), but not C-type natriuretic peptide (CNP), have been identified to be diagnostic and prognostic markers in Chagas disease (CD). Although ANP and BNP excessively rise in patients with CD, increase in CNP is just minor. Our study aimed to investigate the mechanisms leading to CNP insensitivity to heart failure (HF) stimuli. Amino-terminal fragment of CNP precursor (NT-proCNP) and activity of neutral endopeptidase (NEP) were quantified to monitor CNP generation and degradation, respectively. Blood samples were collected from patients with CD and control healthy subjects. NT-proCNP concentrations were significantly lower in patients with CD without systolic dysfunction compared with healthy subjects. Despite a trend toward increase with rising heart failure clinical severity, it was significantly correlated with left ventricular ejection fraction and other echocardiographic parameters. As shown for CNP before, NT-proCNP could not predict mortality and heart transplant. Importantly, it had no statistical correlation with CNP. Additionally, NEP activity was significantly increased in New York Heart Association III and IV patients with HF but was positively correlated with CNP concentration. Our data demonstrates that generation of CNP is not enhanced under HF condition like CD. Thus, CNP rise by severe HF is caused by its less degradation that is independent of NEP activity.

Prognostic value of natriuretic peptides in Chagas' disease: a head-to-head comparison of the 3 natriuretic peptides.

To determine the diagnostic and prognostic value of natriuretic peptides in patients with Chagas' disease (CD), the authors first measured atrial (ANP), B-type (BNP), and C-type natriuretic peptide (CNP) and compared their diagnostic and prognostic capacity with that in other dilated cardiomyopathies (DCM). The CD and DCM patients were subdivided according to their New York Heart Association (NYHA) classification. Circulating ANP and more pronounced BNP, but not CNP, were increased in CD and DCM patients in relation to NYHA class. Importantly, ANP and BNP were already significantly elevated in CD patients without systolic ventricular dysfunction. All 3 natriuretic peptides were correlated with echocardiographic parameters in CD patients. While ANP and BNP have high predictive value for mortality and necessity for heart transplant in CD, CNP can not predict them. Thus, ANP and BNP rather than CNP could be used as valuable molecular markers to identify asymptomatic CD patients for early therapy and predict clinical outcomes.

Efeito favorável da terapia farmacológica otimizada da insuficiência cardíaca sobre as arritmias ventriculares / Favorable effects of the optimized drug treatment of heart failure on ventricular arrhythmias

FUNDAMENTO: Os eventos arrítmicos ventriculares têm forte impacto na mortalidade dos pacientes com insuficiência cardíaca. O benefício do tratamento farmacológico otimizado da insuficiência cardíaca na redução da arritmia ventricular não foi ainda muito bem documentado. OBJETIVO: Análise dos efeitos do tratamento farmacológico otimizado da insuficiência cardíaca sobre a arritmia ventricular. MÉTODOS: Estudo clínico com desenho não aleatorizado, envolvendo 85 pacientes consecutivos (coorte aberta), não selecionados, idade média de 63,8±12,2 anos, 42 homens, 43 mulheres, com diagnóstico de insuficiência cardíaca, classes funcionais II a IV (NYHA - New York Heart Association), FE (fração de ejeção) < 0,40, que após otimização do tratamento foram acompanhados de janeiro de 2002 a maio de 2004, quanto ao comportamento da arritmia ventricular, à admissão e ao término do estudo. RESULTADOS: No início do estudo 60 por cento dos pacientes apresentaram mais de 1000 extra-sístoles ventriculares/24h, 100 por cento pares e 100 por cento taquicardia ventricular não sustentada (TVNS). Num seguimento que variou de 8 a 27 meses (20,0 + 4,8 meses) observou-se redução significativa do número total de extra-sístoles ventriculares/24h, do número de pares e do número de episódios de taquicardia ventricular não sustentada (p<0,05). Observou-se também melhora da classe funcional e do desempenho ao teste de caminhada de seis minutos. Em relação à fase anterior à inclusão no estudo observou-se diminuição das internações hospitalares (4,8 hospitalizações/paciente/ano e ao término do estudo 2,7 hospitalizações/paciente/ano) (p<0,005). CONCLUSÃO: O tratamento otimizado da insuficiência cardíaca diminuiu a ocorrência de arritmias ventriculares. A melhora da classe funcional, do desempenho físico e do número de hospitalizações podem ser atribuídas ao tratamento otimizado.

BACKGROUND: Ventricular arrhythmic events have a strong impact on the mortality of patients with heart failure. The benefits of the optimized drug treatment of heart failure in reducing ventricular arrhythmia have not been well documented yet. OBJECTIVE: To analyze the effects of the optimized drug treatment of heart failure on ventricular arrhythmia. METHODS: This is a clinical study with a non-randomized design of 85 consecutive (open cohort) non-selected patients, with a mean age of 63.8±12.2 years; 42 were males and 43 were females. All patients had a diagnosis of heart failure (HF), NYHA Functional Class II to IV, EF < 0.40 and, after treatment optimization, they were followed from January 2002 to May 2004, regarding the ventricular arrhythmia behavior, at admission and at the end of the study. RESULTS: At the start of the study, 60 percent of patients presented more than 1,000 ventricular extrasystoles in 24 hours, 100 percent pairs and 100 percent nonsustained ventricular tachycardia (NSVT). During a follow-up period of 8 to 27 months (20.0 + 4.8 months) a significant decrease in the total number of ventricular extrasystoles/24 hrs, number of pairs and number of NSVT episodes was observed (p<0.05). The improvement in functional class and performance at the six-minute walk test was also observed. A decrease in hospital admissions was also observed in relation to the period prior to the study inclusion (4.8 hospital admissions/patient/year and at the end of the study, 2.7 hospital admissions/patient/year) (p<0.005). CONCLUSION: The optimized treatment of HF decreased the incidence of ventricular arrhythmias. The improvement in the functional class, physical performance and the decreased number of hospitalizations can be attributed to the optimized treatment of HF.

Influence of financial subsidy and venue on advanced cardiac life support courses, in the learning of cardiovascular emergency.

BACKGROUND: The success in learning of emergency depends on many factors that can be summarized as: student, instructors and course. OBJECTIVE: To evaluate the influence of financial subsidy and venue of course in learning cardiovascular emergency. METHODS: Data were analyzed regarding the courses of Advanced Cardiac Life Support (ACLS) in the period from December 2005 to December 2006. In agreement with the financial subsidy, they were divided in: group 1 - integral subsidy; group 2 - subsidy of 50%; and group 3 - without subsidy. As for the venue of the course, they were divided in: locality A - study in city with> 1 million inhabitants; and locality B - study in city with <1 million inhabitants. The practical and theoretical approval and the theoretical average were compared. RESULTS: 819 students participated in ACLS: 199 (24%) in group 1, 122 (15%) in 2 and 498 (61%) in 3. The practical and theoretical approval and the average in the theoretical exam were greater in group 3 than in other groups (p <0.05). Four hundred and eighty two (482) took the course in venue A (59%) and 337 (41%) in venue B. The practical approval was similar for both groups (p = 0.33), however the theoretical approval was greater in venue A (73% vs. 65% - p = 0.021 - OR = 1.44 and IC: 1.05 - 1.97). The theoretical average was greater in venue A (87.1 +/- 10.4 and 86 +/- 11, respectively p <0.05). CONCLUSION: The financial subsidy and venue of the course had influence in the theoretical and practical approval.

Influência do subsídio financeiro e do local da realização do curso de suporte avançado de vida em cardiologia, no aprendizado da emergência cardiovascular / Influence of financial subsidy and venue on advanced cardiac life support courses, in the learning of cardiovascular emergency

FUNDAMENTO: O sucesso no aprendizado da emergência depende de muitos fatores que podem ser resumidos como: aluno, instrutores e curso. OBJETIVO: Avaliar a influência do subsídio financeiro e do local da realização do curso no aprendizado da emergência cardiovascular. MÉTODOS: Analisaram-se dados referentes aos cursos de Suporte Avançado de Vida em Cardiologia (ACLS) no período de dezembro de 2005 a dezembro de 2006. De acordo com o subsídio financeiro, foram divididos em: grupo 1 - subsídio integral; grupo 2 - subsídio de 50 por cento; e grupo 3 - sem subsídio. Quanto ao local do curso, foram divididos em: local A - curso em cidade com > 1 milhão de habitantes; e local B - curso em cidade com < 1 milhão de habitantes. Compararam-se a aprovação prática e teórica e a média teórica. RESULTADOS: Participaram do ACLS 819 alunos: 199 (24 por cento) no grupo 1, 122 (15 por cento) no 2 e 498 (61 por cento) no 3. A aprovação prática e teórica e a média na prova teórica foram maiores no grupo 3 que nos demais grupos (p<0,05). Quatrocentos e oitenta e dois fizeram o curso no local A (59 por cento) e 337 (41 por cento) no local B. A aprovação prática foi semelhante para ambos os grupos (p = 0,33), entretanto a aprovação teórica foi maior no local A (73 por cento vs. 65 por cento - p = 0,021 - OR = 1,44 e IC: 1,05 - 1,97). A média teórica foi maior no local A (87,1 ± 10,4 e 86 ± 11, respectivamente p<0,05). CONCLUSÃO: O subsídio financeiro e o local da realização do curso influenciaram na aprovação teórica e prática.

BACKGROUND: The success in learning of emergency depends on many factors that can be summarized as: student, instructors and course. OBJECTIVE: To evaluate the influence of financial subsidy and venue of course in learning cardiovascular emergency. METHODS: Data were analyzed regarding the courses of Advanced Cardiac Life Support (ACLS) in the period from December 2005 to December 2006. In agreement with the financial subsidy, they were divided in: group 1 - integral subsidy; group 2 - subsidy of 50 percent; and group 3 - without subsidy. As for the venue of the course, they were divided in: locality A - study in city with> 1 million inhabitants; and locality B - study in city with <1 million inhabitants. The practical and theoretical approval and the theoretical average were compared. RESULTS: 819 students participated in ACLS: 199 (24 percent) in group 1, 122 (15 percent) in 2 and 498 (61 percent) in 3. The practical and theoretical approval and the average in the theoretical exam were greater in group 3 than in other groups (p <0.05). Four hundred and eighty two (482) took the course in venue A (59 percent) and 337 (41 percent) in venue B. The practical approval was similar for both groups (p = 0.33), however the theoretical approval was greater in venue A (73 percent vs. 65 percent - p = 0.021 - OR = 1.44 and IC: 1.05 - 1.97). The theoretical average was greater in venue A (87.1 ± 10.4 and 86 ± 11, respectively p <0.05). CONCLUSION: The financial subsidy and venue of the course had influence in the theoretical and practical approval.

Advanced Cardiac Life Support Courses: live actors do not improve training results compared with conventional manikins.

PRIMARY OBJECTIVE: To determine whether using live actors to increase the reality of the scenario improves knowledge retention in Advanced Cardiac Life Support (ACLS) Courses. MAIN SECONDARY OBJECTIVES: To determine the effects of age, time since graduation from nursing or medicine, sex, medical specialty, and workplace in knowledge retention. METHODS: From December 2004 to October 2005, 19 selected ACLS courses were divided at random in two groups: group A (ACLS courses with conventional manikins plus live actors) and group B (ACLS courses with conventional manikins). The live actors vocalized appropriately to create more realistic scenarios. The participants' relevant theoretical knowledge was assessed before the course (pre-test), immediately after the course (post-test), and 6 months after the course (final-test). RESULTS: Four hundred and thirty-five participants were recruited and allocated at random allocated to either group A or B. Overall, the data of 225 participants (51.7%; 111 in group A and 114 in group B) who completed the entire sequence of pre-, post-, and final-tests were analysed. On univariate analysis, the use of live actors, workplace, gender, and healthcare provider profession did not affect pre-, post-, and final-test results (p>0.1). The results in all three tests correlated negatively with time since medical or nursing graduation (95% C.I. -0.53 to -0.17, -0.43 to -0.2, and -0.42 to -0.11, respectively, p<0.05) and age (and 95% C.I. -0.56 to -0.21, -0.42 to -0.2, and -0.38 to -0.07, respectively, p<0.05). CONCLUSION: The use of live actors did not affect knowledge retention in this group. Older age and a longer period since graduation were associated with the worst scores and the lowest levels of knowledge retention.

Prognostic value of natriuretic peptides in Chagas' disease: a 3-year follow-up investigation.

BACKGROUND: Chagas' disease (CD) affects around 18 million people in Latin America. To determine the diagnostic and prognostic value of natriuretic peptides in patients with CD, we measured atrial (ANP) and brain natriuretic peptide (BNP), and compared the findings with other dilated cardiomyopathies (DCM). METHODS: Blood samples were obtained from 111 CD patients, 62 patients with DCM due to other causes, and 43 gender- and age-matched healthy subjects. The CD and DCM patients were subdivided according to their NYHA classification. Natriuretic peptide concentrations were determined by immunoradiometric assays. RESULTS: ANP and more pronounced BNP levels were increased in CD and DCM patients in relation to the NYHA class. Circulating BNP concentrations were higher in CD patients in NYHA classes I-II than in the corresponding DCM patients (p = 0.020). Importantly, ANP and BNP were already significantly elevated in CD patients without systolic ventricular dysfunction (p < or = 0.001). In CD patients, both peptides were highly correlated with echocardiographic parameters (p < 10(-14)). Both ANP and BNP had comparable ability to predict death or the necessity for heart transplant (p < 0.0001). CONCLUSION: Natriuretic peptide levels can be used as a marker of asymptomatic CD without ventricular dysfunction and thus could be an ideal tool to identify these patients for early therapy.

Favorable effects of the optimized drug treatment of heart failure on ventricular arrhythmias.

BACKGROUND: Ventricular arrhythmic events have a strong impact on the mortality of patients with heart failure. The benefits of the optimized drug treatment of heart failure in reducing ventricular arrhythmia have not been well documented yet. OBJECTIVE: To analyze the effects of the optimized drug treatment of heart failure on ventricular arrhythmia. METHODS: This is a clinical study with a non-randomized design of 85 consecutive (open cohort) non-selected patients, with a mean age of 63.8+/-12.2 years; 42 were males and 43 were females. All patients had a diagnosis of heart failure (HF), NYHA Functional Class II to IV, EF

Insuficiência cardiáca na era moderna: das melhores evidências para a prática clínica / cardiac insufficiency in the moden age: from the best evidence to the clinical practice

A insuficiência cardíaca (IC) é a via final comum de todas as cardiopatias, constituindo-se um enorme problema de saúde pública com grandes repercussões médicas e sociais. É uma doença com alta morbimortalidade. Após o diagnóstico, 30 a 40% dos pacientes estarão mortos em um ano. Nos últimos 15 anos, ocorreu progresso considerável no tratamento dessa doença com o advento dos inibidores da enzima conversora da angiotensina, antagonista da aldosterona, beta-bloqueadores, transplante cardíaco, cardiodesfibriladores implantáveis e terapia ressincronização cardíaca. Entretanto, mesmo com a terapia moderna a IC é associada com taxa de mortalidade anual de 10%. A pesquisa por melhores tratamento constitui um dos maiores desafios da cardiologia.

Does the C-type natriuretic peptide have prognostic value in chagas disease and other dilated cardiomyopathies?

Atrial natriuretic peptides (ANP) and brain natriuretic peptides (BNP) are powerful neurohormonal indicators of left-ventricular function and prognosis in heart failure (HF). Chagas disease (CD) caused by the protozoan Trypanosoma cruzi remains a major cause of HF in Latin America. We assessed whether the plasma concentration of the third natriuretic peptide, C-type natriuretic peptide (CNP), also has diagnostic and prognostic properties in patients with CD or other dilated cardiomyopathies (DCM). Blood samples were obtained from 66 patients with CD, 50 patients with DCM from other causes, and 30 gender- and age-matched healthy subjects. Patients were subdivided according to the New York Heart Association (NYHA) class. The CNP concentration was determined by radioimmunoassay (Immundiagnostik, Bensheim, Germany). The main duration of follow-up was 31.4 months (range 13 to 54 months); 19 patients had died and 11 patients received a heart transplant. CNP concentrations were only significantly altered in patients with DCM or CD of the NYHA classes III and IV (P < 0.05). The Pearson correlation of echocardiographic data with CNP revealed an association only with the left-ventricular end systolic volume (P = 0.03) in patients with DCM. Furthermore, CNP did not predict mortality or the necessity for heart transplant. Our data are the first to demonstrate the raised levels of the third natriuretic peptide CNP in CD and other DCM. Whereas ANP and BNP have a high predictive value for mortality in both diseases, CNP is without any predictive potency.