TY - JOUR
T1 - Pre-admission NT-proBNP improves diagnostic yield and risk stratification – the NT-proBNP for EValuation of dyspnoeic patients in the Emergency Room and hospital (BNP4EVER) study
N1 - Funding Information:
NT-proBNP was measured in a central laboratory with a turnaround time of approximately 2 hours. Although beneficial for diagnosis and prognosis, NT-proBNP testing might have been even more valuable in the present study if results were available more rapidly, as feasible with a point-of-care assay. Clinicians might have been less likely to admit subjects with results more rapidly available, thus influencing admission rate. The observation that median NT-proBNP level can be used to further stratify ADHF-likely patients was a post-hoc finding, requiring prospective powering and validation. Although therapy at discharge is known to affect treatment during follow up, failure to up-titrate therapy during follow up could also be a cause for lack of benefit in unblinded ADHF-likely patients. In summary, the present study has shown that NT-proBNP testing performed in a central laboratory in patients presenting to the ED with dyspnoea did not affect admission rate or long-term survival. Yet, NT-proBNP testing did improve the accuracy of ADHF diagnosis in admitted patients. The findings raise the possibility that patients with ADHF presenting with dyspnoea are underdiagnosed, which may adversely affect their outcome. NT-proBNP testing will make the recognition of these patients easier, especially those with milder disease, and at the same time identify patients with very high NT-proBNP values who are at considerable risk for adverse outcome. Study results suggest that in the absence of outpatient clinic visits, a correct diagnosis at hospital discharge in ADHF-likely patients may not ensure the expected long-term benefit. Funding This work was supported by Roche Diagnostics, Siemens Diagnostics, and the Balson Clinical Scholar Fund.
PY - 2012/6
Y1 - 2012/6
N2 - Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) level is useful to diagnose or exclude acutely decompensated heart failure (ADHF) in dyspnoeic patients presenting to the emergency department (ED). To evaluate the impact of ED NT-proBNP testing on admission, length of stay (LOS), discharge diagnosis and long-term outcome. Dyspnoeic patients were randomized in the ED to NT-proBNP testing. Admission and discharge diagnoses, and outcomes were examined. During 17 months, 470 patients were enrolled and followed for 2.0±1.3 years. ADHF likelihood, determined at study conclusion by validated criteria, established ADHF diagnosis as unlikely in 86 (17%), possible in 120 (24%), and likely in 293 (59%) patients. The respective admission rates in these subgroups were 80, 91, and 96%, regardless of blinding, and 61.9% of blinded vs. 74.5% of unblinded ADHF-likely patients were correctly diagnosed at discharge (p=0.029), with similar LOS. 2-year mortality within subgroups was unaffected by test, but was lower in ADHF-likely patients with NT-proBNP levels below median (5000 pg/ml) compared with those above median (p=0.002). Incidence of recurrent cardiac events tracked NT-proBNP levels. ED NT-proBNP testing did not affect admission, LOS, 2-year survival, or recurrent cardiac events among study patients but improved diagnosis at discharge, and allowed risk stratification even within the ADHF-likely group.
AB - Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) level is useful to diagnose or exclude acutely decompensated heart failure (ADHF) in dyspnoeic patients presenting to the emergency department (ED). To evaluate the impact of ED NT-proBNP testing on admission, length of stay (LOS), discharge diagnosis and long-term outcome. Dyspnoeic patients were randomized in the ED to NT-proBNP testing. Admission and discharge diagnoses, and outcomes were examined. During 17 months, 470 patients were enrolled and followed for 2.0±1.3 years. ADHF likelihood, determined at study conclusion by validated criteria, established ADHF diagnosis as unlikely in 86 (17%), possible in 120 (24%), and likely in 293 (59%) patients. The respective admission rates in these subgroups were 80, 91, and 96%, regardless of blinding, and 61.9% of blinded vs. 74.5% of unblinded ADHF-likely patients were correctly diagnosed at discharge (p=0.029), with similar LOS. 2-year mortality within subgroups was unaffected by test, but was lower in ADHF-likely patients with NT-proBNP levels below median (5000 pg/ml) compared with those above median (p=0.002). Incidence of recurrent cardiac events tracked NT-proBNP levels. ED NT-proBNP testing did not affect admission, LOS, 2-year survival, or recurrent cardiac events among study patients but improved diagnosis at discharge, and allowed risk stratification even within the ADHF-likely group.
KW - Acute heart failure
KW - NT-proBNP
KW - diagnosis
KW - dyspnoea
UR - http://www.scopus.com/inward/record.url?scp=84924046222&partnerID=8YFLogxK
U2 - 10.1177/2048872612447049
DO - 10.1177/2048872612447049
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AN - SCOPUS:84924046222
SN - 2048-8726
VL - 1
SP - 99
EP - 108
JO - European Heart Journal: Acute Cardiovascular Care
JF - European Heart Journal: Acute Cardiovascular Care
IS - 2
ER -