Mid-region pro-hormone markers for diagnosis and prognosis in acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial.
OBJECTIVE
Our purpose was to assess the diagnostic utility of mid-regional pro-atrial natriuretic peptide (MR-proANP) for the diagnosis of acute heart failure (AHF) and the prognostic value of mid-regional pro-adrenomedullin (MR-proADM) in patients with AHF.


BACKGROUND
There are some caveats and limitations to natriuretic peptide testing in the acute dyspneic patient.


METHODS
The BACH (Biomarkers in Acute Heart Failure) trial was a prospective, 15-center, international study of 1,641 patients presenting to the emergency department with dyspnea. A noninferiority test of MR-proANP versus B-type natriuretic peptide (BNP) for diagnosis of AHF and a superiority test of MR-proADM versus BNP for 90-day survival were conducted. Other end points were exploratory.


RESULTS
MR-proANP (> or =120 pmol/l) proved noninferior to BNP (> or =100 pg/ml) for the diagnosis of AHF (accuracy difference 0.9%). In tests of secondary diagnostic objectives, MR-proANP levels added to the utility of BNP levels in patients with intermediate BNP values and with obesity but not in renal insufficiency, the elderly, or patients with edema. Using cut-off values from receiver-operating characteristic analysis, the accuracy to predict 90-day survival of heart failure patients was 73% (95% confidence interval: 70% to 77%) for MR-proADM and 62% (95% confidence interval: 58% to 66%) for BNP (difference p < 0.001). In adjusted multivariable Cox regression, MR-proADM, but not BNP, carried independent prognostic value (p < 0.001). Results were consistent using NT-proBNP instead of BNP (p < 0.001). None of the biomarkers was able to predict rehospitalization or visits to the emergency department with clinical relevance.


CONCLUSIONS
MR-proANP is as useful as BNP for AHF diagnosis in dyspneic patients and may provide additional clinical utility when BNP is difficult to interpret. MR-proADM identifies patients with high 90-day mortality risk and adds prognostic value to BNP. (Biomarkers in Acute Heart Failure [BACH]; NCT00537628).
Maisel
Alan
A
VA San Diego Healthcare System, San Diego, California 92161, USA. amaisel@ucsd.edu
Mueller
Christian
C
Nowak
Richard
R
Peacock
W Frank
WF
Landsberg
Judd W
JW
Ponikowski
Piotr
P
Mockel
Martin
M
Hogan
Christopher
C
Wu
Alan H B
AH
Richards
Mark
M
Clopton
Paul
P
Filippatos
Gerasimos S
GS
Di Somma
Salvatore
S
Anand
Inder
I
Ng
Leong
L
Daniels
Lori B
LB
Neath
Sean-Xavier
SX
Christenson
Robert
R
Potocki
Mihael
M
McCord
James
J
Terracciano
Garret
G
Kremastinos
Dimitrios
D
Hartmann
Oliver
O
von Haehling
Stephan
S
Bergmann
Andreas
A
Morgenthaler
Nils G
NG
Anker
Stefan D
SD
D053607:Adrenomedullin / Q000097:blood*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D009320:Atrial Natriuretic Factor / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D004417:Dyspnea / Q000097:blood* / Q000209:etiology; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D015203:Reproducibility of Results
C507862:ADM protein, human; D015415:Biomarkers; D053607:Adrenomedullin; D009320:Atrial Natriuretic Factor