title: Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department.
abstract: Plasma B-type natriuretic peptide (BNP) can reliably identify acute congestive heart failure (CHF) in patients presenting to the emergency department (ED) with acute dyspnea. Heart failure, asthma, and chronic obstructive pulmonary disease (COPD) are syndromes where dyspnea and wheezing are overlapping signs, and hence, these syndromes are often difficult to differentiate.
  
  
  OBJECTIVE
  To determine whether BNP can distinguish new-onset heart failure in patients with COPD or asthma presenting with dyspnea to the ED.
  
  
  METHODS
  The BNP Multinational Study was a seven-center prospective study of 1,586 adult patients presenting to the ED with acute dyspnea who had blinded BNP levels measured on arrival with a rapid, point-of-care device. This study evaluated the 417 patients with no previous history of heart failure and a history of asthma or COPD as a subgroup from the 1,586 adult patients in the BNP Multinational Study. The reference standard for CHF was adjudicated by two independent cardiologists, also blinded to BNP results, who reviewed all clinical data and standardized CHF scores.
  
  
  RESULTS
  A total of 417 subjects (mean age 62.2 years, 64.4% male) had a history of asthma or COPD without a history of CHF. Of these, 87/417 (20.9%, 95% CI = 17.1% to 25.1%) were found to have CHF as the final adjudicated diagnosis. The emergency physicians identified a minority, 32/87 (36.8%), of these patients with CHF. The mean BNP values (+/- SD) were 587.0 +/- 426.4 and 108.8 +/- 221.3 pg/mL for those with and without CHF (p < 0.0001). At a cutpoint of 100 pg/mL, BNP had the following decision statistics: sensitivity 93.1%, specificity 77.3%, positive predictive value 51.9%, negative predictive value 97.7%, accuracy 80.6%, positive likelihood ratio 4.10, and negative likelihood ratio 0.09. If BNP would have been added to clinical judgment (high > or = 80% probability of CHF), at a cutpoint of 100 pg/mL, 83/87 (95.4%) of the CHF subjects would have been correctly diagnosed. Multivariate analysis found BNP to be the most important predictor of CHF (OR = 12.1, 95% CI = 5.4 to 27.0, p < 0.0001). In the 87 subjects found to have CHF, 39.0%, 22.2%, and 54.8% were taking angiotensin-converting enzyme inhibitors (ACEIs), beta-blockers (BBs), and diuretics on a chronic basis, respectively.
  
  
  CONCLUSIONS
  The yield of adding routine BNP testing in patients with a history of asthma or COPD in picking up newly diagnosed CHF is approximately 20%. This group of patients presents a substantial therapeutic opportunity for the initiation and chronic administration of ACEI and BB therapy, as well as other CHF management strategies.
authors.affiliation: William Beaumont Hospital, Royal Oak, MI 48073, USA. pmc975@yahoo.com
authors.forename: Peter A
authors.initials: PA
authors.lastname: McCullough
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: Richard M
authors.initials: RM
authors.lastname: Nowak
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
authors.forename: Philippe
authors.initials: P
authors.lastname: Duc
authors.forename: Torbjørn
authors.initials: T
authors.lastname: Omland
authors.forename: James
authors.initials: J
authors.lastname: McCord
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
authors.forename: Philippe G
authors.initials: PG
authors.lastname: Steg
authors.forename: Arne
authors.initials: A
authors.lastname: Westheim
authors.forename: Cathrine Wold
authors.initials: CW
authors.lastname: Knudsen
authors.forename: William T
authors.initials: WT
authors.lastname: Abraham
authors.forename: Sumant
authors.initials: S
authors.lastname: Lamba
authors.forename: Alan H B
authors.initials: AH
authors.lastname: Wu
authors.forename: Alberto
authors.initials: A
authors.lastname: Perez
authors.forename: Paul
authors.initials: P
authors.lastname: Clopton
authors.forename: Padma
authors.initials: P
authors.lastname: Krishnaswamy
authors.forename: Radmila
authors.initials: R
authors.lastname: Kazanegra
authors.forename: Alan S
authors.initials: AS
authors.lastname: Maisel
mesh_terms: D000368:Aged; D001249:Asthma / Q000453:epidemiology; D009320:Atrial Natriuretic Factor / Q000097:blood*; D002316:Cardiotonic Agents / Q000097:blood*; D015897:Comorbidity; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020097:Natriuretic Peptide, Brain; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology
chemical_list: D002316:Cardiotonic Agents; D020097:Natriuretic Peptide, Brain; D009320:Atrial Natriuretic Factor