Impact of the History of Congestive Heart Failure on the Utility of B-Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure: Results from the Breathing Not Properly Multinational Study - 19/08/11
Requests for reprints should be addressed to Alan Maisel, MD, VA San Diego Healthcare System, Cardiology 9111-A, 3350 La Jolla Village Drive, San Diego, CA 92161.Abstract |
Purpose |
B-type natriuretic peptide is known to correlate with hemodynamic state, presence and severity of congestive heart failure, and prognosis. Although low-range B-type natriuretic peptide less than 100 pg/mL has a high negative predictive value (90%), and high-range B-type natriuretic peptide greater than 500 pg/mL has a high positive predictive value (87%), there remains some ambiguity in the interpretation of results in the medium range (100-500 pg/mL). We hypothesized that taking into account the history of congestive heart failure along with other clinical variables would be helpful in this range of B-type natriuretic peptide levels.
Method |
The Breathing Not Properly Multicenter Study was an international, 7-center, prospective study including 1475 patients with a mean age of 63 years (57% were male, and 54% were female); 35% of patients with a history of congestive heart failure were enrolled, and a final diagnosis of congestive heart failure was made in 46%. The index criteria was defined as positive if any 2 index findings (ie, history of coronary artery disease, lower extremity edema, pulmonary edema, cephalization of the pulmonary arteries, and cardiomegaly) were present.
Results |
The interval likelihood ratios (LR) for low, medium, and high B-type natriuretic peptide ranges are 0.13, 1.85, and 8.1, respectively. For medium B-type natriuretic peptide levels a positive history of congestive heart failure makes the diagnosis of congestive heart failure more probable with a cumulative LR of 4.3. Also in this range a positive index criterion was strongly indicative of congestive heart failure even in the absence of a history of congestive heart failure (LR 3.3). Where there are both a positive history of congestive heart failure and a positive index criteria for the medium B-type natriuretic peptide group, the cumulative LR (10.2) is similar to that of a high B-type natriuretic peptide level (8.1).
Conclusion |
Even in the medium range (100-500 pg/mL), when using the history of congestive heart failure and index criteria, B-type natriuretic peptide can be a powerful diagnostic tool in the hands of clinicians in the emergency department.
Le texte complet de cet article est disponible en PDF.Keywords : B-type natriuretic peptide, Heart failure, Diagnosis, Gray zone, Shortness of breath, Physical signs
Plan
| Adam Strunk and Vikas Bhalla contributed equally to the preparation of this article. The following authors have received honoraria from the manufacturer of the B-type natriuretic peptide assay used in the study: A Maisel, PA McCullough, P Clopton, RM Nowak, J McCord, JE Hollander, P Duc, T Omland, AB Storrow, WT Abraham, AHB Wu, R Kazanegra. Triage BNP devices and meters and some financial support were provided by Biosite, Inc., San Diego, Calif. |
Vol 119 - N° 1
P. 69.e1-69.e11 - janvier 2006 Retour au numéro
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