Brain natriuretic peptide 32

Initial labs were notable for an elevated creatinine up to 2.84 with an unclear baseline.

His lactate was also elevated at 3.1. L-aptides were within normal limits, and his NT-proBNP was markedly elevated at over 30,000.

High sensitivity troponin was also elevated at 126.

So a couple of things stand out here.

First, that very elevated NT-proBNP, which supports significant hemodynamic stress and volume overload.

Then there is a troponin elevation, which could reflect demand ischemia, but in the right clinical context also raises concern for myocardial injury from other processes.

And the renal dysfunction is important too.

Lower NYHA class, meaning less symptoms.

Lower NT-proBNP.

Lower NAC stage was the stage of how severe your disease is.

Because as a community, kudos to the community of clinicians that treat these patients, earlier diagnosis is happening.

And noted are some of the parameters that we use in pulmonary hypertension risk assessment, such as lower extremity edema, functional class, six-minute walk distance, are factors that will really be affected by pregnancy in general and are not specific to PAH.

So in this scenario, we recommend emphasizing things like jugular venous pressure, BNP, RV function.

And you can see some changes in examples of how an echocardiogram might look decompensated versus compensated with improved right heart function.

And finally, just to sort of show an example of a case series of how patients with PAH in pregnancy have done well, this is our personal experience of several patients with PAH in pregnancy.

And you can see that patients are really honed in on their right heart function and performance over the course of pregnancy and published how towards the end of pregnancy, we're striving for normal jugular venous pressure, as low BNP as possible, and as normal right ventricular size structure and function as possible.

And in this case series, we were fortunate to have a 100% maternal and fetal survival outcome and have just emphasized some principles that can help in the management along the way, including things like an assisted vaginal delivery or C-section with close monitoring, for jugular venous pressure, RV failure, really emphasizing the importance of obstetrics expertise, both MFM and obstetrics anesthesia, and performing these deliveries in the obstetrics ORs or labor and delivery service where all of the expertise and resources are available, and the importance of postpartum monitoring and management on the pulmonary hypertension cardiology unit as there are fluid shifts.

So in summary, we want to avoid any panic, remain calm, go back to our principles of cardiovascular physiology, Extensive risk counseling and availability for therapeutic abortion is important.

It was a non-inferiority margin, and the margin they chose was minus 10% points, and it was an intention to treat primary analysis.

Secondary endpoints were left ventricular ejection fraction, QRS duration, NT-proBNP symptoms, six minute walk, capture thresholds, and device implant measures.

Crossover was permitted.

So let's talk about the crossover part.

This is the whole like, oh, do I need to admit this patient to the hospital? Do I need to have the PERT team show up and look at this person? These are the kinds of ideas that they're trying to get at.

But again, these are all, like you say, they're all using pretty much the same variables or a transformation of the same clinical function, like whether it's the right ventricle or whether it's their BNP, everybody's looking at the same thing.

So we're not going to get anything different.

It's time for a new approach.

A new fistula asks the heart to do more.

A very high NT-proBNP may mark the hearts that can't.

So, the week in short.

In the ICU, starting with intermittent dialysis was linked to more deaths in the sickest patients, though how many more is still uncertain.

Now moving on to diagnostics, let's keep this super simple.

The key one that you need to know is BNP, not BMP, but BN as in Nancy and P.

When this rises, this means that the ventricles stretch.

So higher BNP means the heart failure is getting worse.

Another diagnostic is an echocardiogram, which tells us ejection fraction, which is fancy words for how much blood is being ejected out of the heart with one pump.

So the number to know, anything under 40% strongly suggests systolic heart failure.

But to figure out which type, you need testing.

Blood tests check for BNP or NT-proBNP, a substance your heart releases when it's under stress.

Normal levels make heart failure very unlikely.

Your doctor will also check kidney function, thyroid function, and your blood count.

So the drug does seem to touch the underlying heart mechanics in HFPEF, it just hasn't translated into hard outcomes.

Then, fresh off the ACC 2026 conference in New Orleans, came SPIRIT-HF, the most current attempt to settle this question.

It enrolled patients 50 and older with heart failure symptoms, an ejection fraction of 40% or above, and either a recent hospitalization or elevated NT-proBNP, randomized to spironolactone or placebo.

The results were not what anyone hoped for.