What happens to N-terminal pro b-type natriuretic peptide (NT pro BNP) and troponin I (Trop I) levels in acute myeloid leukemia?

NT-proBNP and Troponin I in Acute Myeloid Leukemia

Both NT-proBNP and troponin I can become elevated in acute myeloid leukemia (AML) patients, particularly during chemotherapy treatment, with NT-proBNP showing more consistent elevations that may have prognostic significance for treatment outcomes and survival.

NT-proBNP in AML

• NT-proBNP levels are frequently elevated in AML patients at baseline and during treatment, with 63.8% of patients showing elevated levels at diagnosis 1
• Induction chemotherapy for AML is associated with acute neurohumoral activation, causing transient elevation of NT-proBNP in most patients, indicating subclinical cardiotoxicity 2
• Progressive elevation of NT-proBNP during chemotherapy cycles (rather than transient spikes) may predict development of congestive heart failure in AML patients 2
• NT-proBNP is an independent prognostic factor in AML, with higher levels associated with:
  • Increased risk of induction failure
  • Higher early death rates
  • Reduced overall survival 1

Troponin I in AML

• Troponin I typically remains within normal range during standard AML induction chemotherapy regimens containing anthracyclines at standard doses 2
• Detectable troponin elevation would suggest structural myocardial damage, which is uncommon with standard AML treatment protocols 2, 3
• In contrast to NT-proBNP, troponin I is less likely to show elevation unless there is actual myocardial injury rather than just cardiac stress 3
• Serial troponin measurements in hematologic malignancies treated with high-dose anthracyclines (beyond standard AML protocols) may show correlation with ejection fraction reduction 3

Mechanisms and Clinical Significance

• NT-proBNP elevation in AML reflects:

  • Cardiac stress from volume overload during intensive hydration protocols 3
  • Direct cardiotoxic effects of chemotherapy agents, particularly anthracyclines 3, 2
  • Potential pre-existing cardiac dysfunction in older AML patients 1

• The prognostic value of NT-proBNP in AML is significant:

  • Median NT-proBNP levels differ significantly among patients achieving complete remission (153.3 pg/ml), no remission (225.9 pg/ml), or experiencing early death (735.5 pg/ml) 1
  • Highly elevated NT-proBNP (>2000 pg/ml) is associated with significantly worse overall survival 1

Monitoring Recommendations

• Baseline measurement of NT-proBNP before initiation of chemotherapy in AML patients is valuable for risk stratification 1
• Serial NT-proBNP measurements during treatment can help identify patients at risk for developing cardiac complications 2, 4
• Pattern of NT-proBNP elevation is important - transient elevations are common, but progressive increases across treatment cycles warrant closer cardiac monitoring 2, 4
• Troponin I monitoring may be less informative for standard-dose regimens but could be considered with high-dose anthracycline protocols 3, 5

Clinical Implications

• AML patients with elevated NT-proBNP at diagnosis may require more careful cardiac monitoring during treatment 1
• NT-proBNP can serve as an early warning sign of cardiac dysfunction before clinical symptoms develop or ejection fraction decreases 2, 5
• In patients showing progressive NT-proBNP elevation during treatment, consideration should be given to cardiac protective strategies or modification of chemotherapy regimens 2, 4
• The combination of NT-proBNP elevation with other cardiac biomarkers (like GPBB) may provide more comprehensive assessment of cardiac toxicity during AML treatment 6