title: Utility of biomarkers in the differential diagnosis of heart failure in older people: findings from the heart failure in care homes (HFinCH) diagnostic accuracy study.
abstract: BACKGROUND
  The performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF).
  
  
  METHODS
  This is the first diagnostic accuracy study in this population to assess the differential diagnostic performance and acceptability of a range of biomarkers against a clinical diagnosis using portable echocardiography. A total of 405 residents, aged 65-100 years (mean 84.2), in 33 UK long-term care facilities were enrolled between April 2009 and June 2010.
  
  
  RESULTS
  For undifferentiated HF, BNP or NT-proBNP were adequate rule-out tests but would miss one in three cases (BNP: sensitivity 67%, NPV 86%, cut-off 115 pg/ml; NT-proBNP: sensitivity 62%, NPV 87%, cut-off 760 pg/ml). Using higher test cut-offs, both biomarkers were more adequate tests of LVSD, but would still miss one in four cases (BNP: sensitivity 76%, NPV 97%, cut-off 145 pg/ml; NT-proBNP: sensitivity 73%, NPV 97%, cut-off 1000 pg/ml). At these thresholds one third of subjects would test positive and require an echocardiogram. Applying a stricter 'rule out' threshold (sensitivity 90%), only one in 10 cases would be missed, but two thirds of subjects would require further investigation. Biomarkers were less useful for HFpEF (BNP: sensitivity 63%, specificity 61%, cut-off 110 pg/ml; NT-proBNP: sensitivity 68%, specificity 56%, cut-off 477 pg/ml). Novel biomarkers (Copeptin, MR-proADM, and MR-proANP) and common signs and symptoms had little diagnostic utility.
  
  
  CONCLUSIONS
  No test, individually or in combination, adequately balanced case finding and rule-out for heart failure in this population; currently, in-situ echocardiography provides the only adequate diagnostic assessment.
  
  
  BACKGROUND
  Controlled-Trials.com ISRCTN19781227.
authors: Durham Clinical Trials Unit, Durham University, Queen's Campus, Stockton-on-Tees, United Kingdom. j.m.mason@durham.ac.uk
authors: James M
authors: JM
authors: Mason
authors: Helen C
authors: HC
authors: Hancock
authors: Helen
authors: H
authors: Close
authors: Jerry J
authors: JJ
authors: Murphy
authors: Ahmet
authors: A
authors: Fuat
authors: Mark
authors: M
authors: de Belder
authors: Raj
authors: R
authors: Singh
authors: Andrew
authors: A
authors: Teggert
authors: Esther
authors: E
authors: Wood
authors: Gill
authors: G
authors: Brennan
authors: Nehal
authors: N
authors: Hussain
authors: Nitin
authors: N
authors: Kumar
authors: Novin
authors: N
authors: Manshani
authors: David
authors: D
authors: Hodges
authors: Douglas
authors: D
authors: Wilson
authors: A Pali S
authors: AP
authors: Hungin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood*; D003937:Diagnosis, Differential; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D006699:Home Care Services; D006801:Humans; D033162:Incidental Findings; D008297:Male; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D012372:ROC Curve; D013318:Stroke Volume; D014463:Ultrasonography; D006113:United Kingdom; D018487:Ventricular Dysfunction, Left / Q000097:blood / Q000000981:diagnostic imaging / Q000503:physiopathology
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain