Hostname: page-component-78c5997874-dh8gc Total loading time: 0 Render date: 2024-11-10T17:12:37.888Z Has data issue: false hasContentIssue false
  • English
  • Français

Potential impact of N-terminal pro-BNP testing on the emergency department evaluation of acute dyspnea

Published online by Cambridge University Press:  21 May 2015

Heather Murray ,
Bruce Cload ,
Christine P. Collier  and
Marco L.A. Sivilotti
Heather Murray*
Affiliation:
Department of Emergency Medicine, Queen's University, Kingston, Ont.
Bruce Cload
Affiliation:
Department of Emergency Medicine, Queen's University, Kingston, Ont.
Christine P. Collier
Affiliation:
Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ont.
Marco L.A. Sivilotti
Affiliation:
Department of Emergency Medicine, Queen's University, Kingston, Ont. Department of Pharmacology and Toxicology, Queen's University, Kingston, Ont.
*
Kingston General Hospital, 76 Stuart St., Kingston ON K7L 2V7

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objectives:

Measurement of the serum B-type natriuretic peptide (BNP) level and more recently its precursor, N-terminal proBNP (NT-proBNP), has been advocated to facilitate the diagnosis of heart failure in the emergency department (ED). We sought to determine the potential impact of adding NT-proBNP testing to the routine evaluation of emergency patients with acute dyspnea.

Methods:

This prospective cohort study enrolled a convenience sample of acutely dyspneic patients at a tertiary care ED. We excluded trauma patients and those under 30 years of age. Patients underwent standard evaluation, including radiography when indicated. At the point of final diagnosis and blinded to the NT-proBNP result, physicians documented the likelihood that heart failure accounted for the patient's acute dyspnea on a 7-point Likert scale, the data from which was subsequently collapsed to 3 categories for analysis purposes. The primary outcome was the agreement between clinical impression and the NT-proBNP assay classified using manufacturer-recommended, age-specific cut-offs. Newly proposed cut-offs from a recent study were also evaluated.

Results:

One hundred and twenty-nine patients making 139 ED visits were enrolled (median age 76 years; 59% admitted). The serum NT-proBNP assay was positive in 119 (86%, 95% confidence interval [CI] 80%–91%) cases, including 75% (43/57, 95% CI 62%–86%) of the cases that the treating physician felt were not caused by heart failure, and 86% (25/29, 95% CI 68%–96%) where the treating physician was unsure. The median NT-proBNP concentration was higher in patients clinically believed to have heart failure rather than pneumonia or chronic obstructive pulmonary disease; however, the ranges of these values overlapped extensively (median 4361 pg/mL; interquartile range [IQR] 2386–10877 v. 1651 pg/mL; IQR 370–4745, respectively).

Conclusions:

There is high discordance between the clinical impression of treating physicians and NT-proBNP concentrations, notably in patients who are believed not to have heart failure. Although the reference standard of ED diagnosis is imperfect, the broad overlap in NT-proBNP concentrations suggests poor specificity in this target patient population. The introduction of routine ED NT-proBNP testing using the current cut-offs would be expected to result in substantial indirect costs from further diagnostic testing. It remains unclear whether the introduction of this diagnostic test would have a positive impact on clinically relevant patient outcomes.

Keywords

NT-proBNPnatriuretic peptidesheart failurediagnostic tests
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 8 , Issue 4 , July 2006 , pp. 251 - 258
Copyright
Copyright © Canadian Association of Emergency Physicians 2006

References

1.Clerico, A, Iervasi, G, Del Chicca, MG, et al. Circulating levels of cardiac natriuretic peptides (ANP and BNP) measured by highly sensitive and specific immunoradiometric assays in normal subjects and in patients with different degrees of heart failure. J Endocrinol Invest 1998;21:170–9.Google Scholar
2.Landray, MJ, Lehman, R, Arnold, I. Measuring brain natriuretic peptide in suspected left ventricular systolic dysfunction in general practice: cross-sectional study. BMJ 2000;320:985–6.CrossRefGoogle ScholarPubMed
3.Talwar, S, Siebenhofer, A, Williams, B, et al. Influence of hypertension, left ventricular hypertrophy, and left ventricular systolic dysfunction on plasma N terminal proBNP. Heart 2000;83:278–82.CrossRefGoogle ScholarPubMed
4.Krishnaswamy, P, Lubien, E, Clopton, P, et al. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med 2001;111:274–9.CrossRefGoogle ScholarPubMed
5.Kragelund, C, Gronning, B, Kober, L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med 2005;352:666–75.Google Scholar
6.Alehagen, U, Lindstedt, G, Levin, LA, et al. Risk of cardiovascular death in elderly patients with possible heart failure. B-type natriuretic peptide (BNP) and the aminoterminal fragment of ProBNP (N-terminal proBNP) as prognostic indicators in a 6-year follow-up of a primary care population. Int J Cardiol 2005; 100:125–33.Google Scholar
7.Morrison, LK, Harrison, A, Krishnaswamy, P, et al. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol 2002;39:202–9.Google Scholar
8.McCullough, PA, Hollander, JE, Nowak, RM, 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;10:198–204.Google Scholar
9.McCullough, PA, Nowak, RM, McCord, J, 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;106:416–22.Google Scholar
10.Knudsen, CW, Omland, T, Clopton, P, et al. Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004;116:363–8.Google Scholar
11.Schwam, E. B-type natriuretic peptide for diagnosis of heart failure in emergency department patients: a critical appraisal. Acad Emerg Med 2004;11:686–91.Google Scholar
12.Hohl, CM, Mitelman, BY, Wyer, P, Lang, E. Should emergency physicians use B-type natriuretic peptide testing in patients with unexplained dyspnea? Can J Emerg Med 2003;5(3):162–5.Google Scholar
13.Hall, C. Essential biochemistry and physiology of (NT-pro)BNP [review]. Eur J Heart Fail 2004;6:257–60.CrossRefGoogle ScholarPubMed
14.Lainchbury, JG, Campbell, E, Frampton, CM, et al. Brain natriuretic peptide and n-terminal brain natriuretic peptide in the diagnosis of heart failure in patients with acute shortness of breath. J Am Coll Cardiol 2003;42:728–35.CrossRefGoogle ScholarPubMed
15.Masson, S, Vago, T, Baldi, G, et al. Comparative measurement of N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in ambulatory patients with heart failure. Clin Chem Lab Med 2002;40:761–3.Google Scholar
16.Januzzi, JL Jr, Camargo, CA, Anwaruddin, S, et al. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005;95:948–54.CrossRefGoogle ScholarPubMed
17.Mueller, C, Scholer, A, Laule-Kilian, K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647–54.Google Scholar
18.Maisel, AS, Krishnaswamy, P, Nowak, RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161–7.CrossRefGoogle ScholarPubMed
19.Harrison, A, Morrison, LK, Krishnaswamy, P, et al. B-type natriuretic peptide predicts future cardiac events in patients presenting to the emergency department with dyspnea. Ann Emerg Med 2002;39:131–8.Google Scholar
20.Mueller, C, Laule-Kilian, K, Frana, B, et al. The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea. J Intern Med 2005;258:77–85.Google Scholar
21.Wang, CS, FitzGerald, JM, Schulzer, M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? [review]. JAMA 2005;294:1944–56.CrossRefGoogle ScholarPubMed
22.Sackett, DL, Haynes, RB. The architecture of diagnostic research. BMJ 2002;324:539–41.Google Scholar
23.Jones, AE, Kline, JA. Elevated brain natriuretic peptide in septic patients without heart failure. Ann Emerg Med 2003;42:714–5.CrossRefGoogle ScholarPubMed
24.Kucher, N, Printzen, G, Goldhaber, SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2003;107:2545–7.CrossRefGoogle ScholarPubMed