B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study.
BACKGROUND
We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF).


RESULTS
The Breathing Not Properly Multinational Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P<0.0001 for all pairwise comparisons).


CONCLUSIONS
The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.
University of California, Veteran's Affairs Medical Center, San Diego, USA. mcculloughp@umkc.edu
Peter A
PA
McCullough
Richard M
RM
Nowak
James
J
McCord
Judd E
JE
Hollander
Howard C
HC
Herrmann
Philippe G
PG
Steg
Philippe
P
Duc
Arne
A
Westheim
Torbjørn
T
Omland
Cathrine Wold
CW
Knudsen
Alan B
AB
Storrow
William T
WT
Abraham
Sumant
S
Lamba
Alan H B
AH
Wu
Alberto
A
Perez
Paul
P
Clopton
Padma
P
Krishnaswamy
Radmila
R
Kazanegra
Alan S
AS
Maisel
D000293:Adolescent; D000328:Adult; D000368:Aged; D009320:Atrial Natriuretic Factor / Q000097:blood*; D004417:Dyspnea / Q000175:diagnosis* / Q000000981:diagnostic imaging; D004562:Electrocardiography; D004630:Emergencies; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain; D012372:ROC Curve; D011859:Radiography; D012015:Reference Standards; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
D020097:Natriuretic Peptide, Brain; D009320:Atrial Natriuretic Factor