Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for diagnosis and triage of patients with dyspnea, but its role for predicting outcomes in such patients remains undefined.
A total of 599 breathless patients treated in the emergency department were prospectively enrolled, and a sample of blood was obtained for NT-proBNP measurements. After 1 year, the vital status of each patient was ascertained, and the association between NT-proBNP values at presentation and mortality was assessed.
At 1 year, 91 patients (15.2%) had died. Median NT-proBNP concentrations at presentation among decedents were significantly higher than those of survivors (3277 vs 299 pg/mL; P<.001). The optimal NT-proBNP cut point for predicting 1-year mortality was 986 pg/mL. In a multivariable model, an NT-proBNP concentration greater than 986 pg/mL at presentation was the single strongest predictor of death at 1 year (hazard ratio [HR], 2.88; 95% confidence interval, 1.64-5.06; P<.001), independent of a diagnosis of heart failure. Other factors associated with death included age (by decade; HR, 1.20), heart rate (by decile; HR, 1.13), urea nitrogen level (by decile; HR, 1.20), systolic blood pressure less than 100 mm Hg (HR, 1.94), heart murmur (HR, 1.92), and New York Heart Association classification (HR, 1.38 for each increase in class). The NT-proBNP concentration alone had an area under the receiver operating characteristic curve (AUC) of 0.76 for predicting mortality; the other significant covariates combined had an AUC of 0.80. The final model for predicting death, combining NT-proBNP with other covariates associated with mortality, had a superior AUC of 0.82.
In addition to assisting in emergency department diagnosis and triage, NT-proBNP concentrations at presentation are strongly predictive of 1-year mortality in dyspneic patients.
[Show abstract][Hide abstract] ABSTRACT: Natriuretic peptides, BNP and NT-proBNP, are increased in patients who have high myocardial wall tension. They have been exten- sively used to diagnose heart failure in patients presenting with dyspnoea. BNP and NT-proBNP serum levels are influenced by variables such as age, gender, body mass index and renal func- tion. More recently, their elevation in acute coronary syndromes, stable coronary heart disease, chronic obstructive lung disease, pulmonary hypertension and sepsis has been investigated. We review the diagnostic and prognostic value of circulating natriuretic peptides in the assessment of several medical diseases.
[Show abstract][Hide abstract] ABSTRACT: As you all well know, emergency physicians man the front line when patients present with any acute illness. Heart failure is no exception. With an expected ten million individuals with heart failure by the end of this year, we must be able to accurately and efficiently diagnose and treat this high morbidity condition. Just as important, it is our responsibility to be cognizant of the new research, new language, and treatment progress in the subject. For instance, the catch- all words of "heart failure" can no longer be used to refer to any patient. Terms such as "diastolic heart failure" and "acute heart failure syndrome" have specific definitions and are replacing some of the older, less specific nomenclature. Perhaps the most significant contribution to AHFS diagnosis is the testing of natriuretic peptides. (NT)-proBNP and BNP both can be measured in the blood, but each has unique characteristics and differences. Knowledge of these attributes is critical to the diagnosis of AHFS. The interpretation of specific values in varied clinical settings hinges on your knowledge of the platform and its strengths and limitations. Future directions for heart failure diagnosis include the detection of sub-clinically apparent heart sounds, measurement of cardiothoracic width, new models for risk stratification, and heart failure observation units. We hope that you enjoy and learn from this publication as we seek to provide emergency care givers with the most comprehensive and up-to-date information regarding new issues in the acute care field. Through EMCREG-International we strive to continue to provide concise and practical approaches for you to give outstanding care for your patients.
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