Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study.
OBJECTIVE
This study examines B-type natriuretic peptide (BNP) levels in patients with systolic versus non-systolic dysfunction presenting with shortness of breath.


BACKGROUND
Preserved systolic function is increasingly common in patients presenting with symptoms of congestive heart failure (CHF) but is still difficult to diagnose.


METHODS
The Breathing Not Properly Multinational Study was a seven-center, prospective study of 1,586 patients who presented with acute dyspnea and had BNP measured upon arrival. A subset of 452 patients with a final adjudicated diagnosis of CHF who underwent echocardiography within 30 days of their visit to the emergency department (ED) were evaluated. An ejection fraction of greater than 45% was defined as non-systolic CHF.


RESULTS
Of the 452 patients with a final diagnosis of CHF, 165 (36.5%) had preserved left ventricular function on echocardiography, whereas 287 (63.5%) had systolic dysfunction. Patients with non-systolic heart failure (NS-CHF) had significantly lower BNP levels than those with systolic heart failure (S-CHF) (413 pg/ml vs. 821 pg/ml, p < 0.001). As the severity of heart failure worsened by New York Heart Association class, the percentage of S-CHF increased, whereas the percentage of NS-CHF decreased. When patients with NS-CHF were compared with patients without CHF (n = 770), a BNP value of 100 pg/ml had a sensitivity of 86%, a negative predictive value of 96%, and an accuracy of 75% for detecting abnormal diastolic dysfunction. Using Logistic regression to differentiate S-CHF from NS-CHF, BNP entered first as the strongest predictor followed by oxygen saturation, history of myocardial infarction, and heart rate.


CONCLUSIONS
We conclude that NS-CHF is common in the setting of the ED and that differentiating NS-CHF from S-CHF is difficult in this setting using traditional parameters. Whereas BNP add modest discriminatory value in differentiating NS-CHF from S-CHF, its major role is still the separation of patients with CHF from those without CHF.
Maisel
Alan S
AS
Cardiology 111-A, San Diego VA Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA. amaisel@ucsd.edu
McCord
James
J
Nowak
Richard M
RM
Hollander
Judd E
JE
Wu
Alan H B
AH
Duc
Philippe
P
Omland
Torbjørn
T
Storrow
Alan B
AB
Krishnaswamy
Padma
P
Abraham
William T
WT
Clopton
Paul
P
Steg
Gabriel
G
Aumont
Marie Claude
MC
Westheim
Arne
A
Knudsen
Cathrine Wold
CW
Perez
Alberto
A
Kamin
Richard
R
Kazanegra
Radmila
R
Herrmann
Howard C
HC
McCullough
Peter A
PA
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D009320:Atrial Natriuretic Factor / Q000378:metabolism; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure / Q000502:physiology; D004632:Emergency Medical Services; D005060:Europe / Q000453:epidemiology; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000378:metabolism / Q000503:physiopathology*; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain; D010100:Oxygen / Q000097:blood; D012119:Respiration; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology*; D013599:Systole / Q000502:physiology; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000378:metabolism / Q000503:physiopathology
D015415:Biomarkers; D020097:Natriuretic Peptide, Brain; D009320:Atrial Natriuretic Factor; D010100:Oxygen