N-terminal pro-brain natriuretic peptide and high-sensitivity troponin in the evaluation of acute chest pain of uncertain etiology. A PITAGORAS substudy.
OBJECTIVE
High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients.


METHODS
A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event.


RESULTS
Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P=.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P=.004). N-terminal pro-brain natriuretic peptide elevation (>125ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P=.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P=.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide.


CONCLUSIONS
In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.
Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain. Electronic address: sanchis_juafor@gva.es.
Juan
J
Sanchis
Servicio de Cardiología, Hospital Universitari Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain.
Alfredo
A
Bardají
Servicio de Cardiología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
Xavier
X
Bosch
Servicio de Cardiología, Hospital Josep Trueta, Girona, Spain.
Pablo
P
Loma-Osorio
Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain.
Francisco
F
Marín
Servicio de Cardiología, Hospital Gregorio Marañón, Madrid, Spain.
Pedro L
PL
Sánchez
Servicio de Cardiología, Hospital do Meixoeiro, Vigo, Pontevedra, Spain.
Francisco
F
Calvo
Servicio de Cardiología, Hospital General de Asturias, Oviedo, Asturias, Spain.
Pablo
P
Avanzas
Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain.
Carolina
C
Hernández
Servicio de Cardiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.
Silvia
S
Serrano
Servicio de Bioquímica Clínica, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.
Arturo
A
Carratalá
Servicio de Cardiologia, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.
José A
JA
Barrabés
D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000209:etiology; D000368:Aged; D015415:Biomarkers / Q000032:analysis; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D011446:Prospective Studies; D014336:Troponin / Q000097:blood*
D015415:Biomarkers; D014336:Troponin; D020097:Natriuretic Peptide, Brain
ACS; Acute coronary syndrome; ECG; Hs-TnT; N-terminal pro-brain natriuretic peptide; NT-proBNP; Natriuretic peptides; PITAGORAS; Péptidos natriuréticos; Síndrome coronario agudo; Troponin; Troponina; acute coronary syndrome; electrocardiogram; high-sensitivity troponin T; troPonIna ulTrAsensible en pacientes atendidos en urGencias por dOlor toRácico en hospitales espAñoleS (in English: High-Sensitivity Troponin in Patients With Chest Pain Presenting To Spanish Emergency Departments)