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.
McCullough
Peter A
PA
University of California, Veteran's Affairs Medical Center, San Diego, USA. mcculloughp@umkc.edu
Nowak
Richard M
RM
McCord
James
J
Hollander
Judd E
JE
Herrmann
Howard C
HC
Steg
Philippe G
PG
Duc
Philippe
P
Westheim
Arne
A
Omland
Torbjørn
T
Knudsen
Cathrine Wold
CW
Storrow
Alan B
AB
Abraham
William T
WT
Lamba
Sumant
S
Wu
Alan H B
AH
Perez
Alberto
A
Clopton
Paul
P
Krishnaswamy
Padma
P
Kazanegra
Radmila
R
Maisel
Alan S
AS
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