title: Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients.
abstract: BACKGROUND
  Bacterial infections in patients hospitalized with acute heart failure are related to worse prognosis, but they can be difficult to diagnose. In this study we evaluated the prevalence, clinical correlates and association with outcomes of significantly elevated procalcitonin levels in patients hospitalized for acute heart failure without clear signs of bacterial infection.
  
  
  METHODS
  1781 patients from the PROTECT trial were included. Patients with a body temperature >38°C, sepsis or active infection requiring IV antibiotics were excluded. Significant elevation of procalcitonin was considered present when levels exceeded 0.20 ng/mL. In-hospital and post-discharge outcomes were compared between groups of patients with and without elevated procalcitonin levels.
  
  
  RESULTS
  Procalcitonin ≥ 0.20 ng/mL was seen in 6.0% of patients (N=104). This group of patients had lower serum albumin, lower hemoglobin, higher leukocyte count, higher C-reactive protein, higher blood urea nitrogen, higher heart rate and more pulmonary rales. Interestingly, no significant differences were observed between the two groups in terms of severity of heart failure evidenced by left ventricular ejection fraction (LVEF) or B-type natriuretic peptide (BNP) levels. Patients with significantly elevated procalcitonin levels were more often classified as treatment failure or unchanged status, and had an increased risk of 30-day all-cause mortality even after adjustment for established prognosticators; HR=2.3 (95% CI, 1.3-4.2), (P=0.005).
  
  
  CONCLUSIONS
  Patients with acute heart failure and significantly elevated procalcitonin levels, indicating probable undiagnosed/untreated bacterial infection, had poorer in-hospital and post-discharge outcomes, despite similar severity of heart failure.
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Biniyam G
authors.initials: BG
authors.lastname: Demissei
authors.affiliation: Imperial College, London, UK.
authors.forename: John G
authors.initials: JG
authors.lastname: Cleland
authors.affiliation: Duke University Medical Center, Durham, NC, USA.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.affiliation: University of Brescia, Brescia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.affiliation: Medical University, Clinical Military Hospital, Wroclaw, Poland.
authors.forename: Piotr
authors.initials: P
authors.lastname: Ponikowski
authors.affiliation: University of California at San Francisco, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
authors.forename: John R
authors.initials: JR
authors.lastname: Teerlink
authors.affiliation: Momentum Research, Durham, NC, USA.
authors.forename: Beth
authors.initials: B
authors.lastname: Davison
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Givertz
authors.affiliation: Merck Research Laboratories, Rahway, NJ, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Bloomfield
authors.affiliation: Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, IA, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Dittrich
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: van Veldhuisen
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Hans L
authors.initials: HL
authors.lastname: Hillege
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. Electronic address: a.a.voors@umcg.nl.
authors.forename: Adriaan A
authors.initials: AA
authors.lastname: Voors
authors.affiliation: Momentum Research, Durham, NC, USA.
authors.forename: Gad
authors.initials: G
authors.lastname: Cotter
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001424:Bacterial Infections / Q000097:blood* / Q000175:diagnosis / Q000401:mortality*; D015415:Biomarkers / Q000097:blood; D002116:Calcitonin / Q000097:blood*; D015740:Calcitonin Gene-Related Peptide; D004311:Double-Blind Method; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000175:diagnosis / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D010351:Patient Discharge / Q000639:trends; D011498:Protein Precursors / Q000097:blood*; D012307:Risk Factors
chemical_list: D015415:Biomarkers; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide
keywords: Acute heart failure; Bacterial infection; Procalcitonin; Prognosis