Natriuretic peptide (NP) levels (B-type natriuretic peptide (BNP) and N-terminal proBNP) are now widely used in clinical practice and cardiovascular research throughout the world and have been incorporated into most national and international cardiovascular guidelines for heart failure. The role of NP levels in state-of-the-art clinical practice is evolving rapidly. This paper reviews and highlights ten key messages to clinicians: 1) NP levels are quantitative plasma biomarkers of heart failure (HF). 2) NP levels are accurate in the diagnosis of HF. 3) NP levels may help risk stratify emergency department (ED) patients with regard to the need for hospital admission or direct ED discharge. 4) NP levels help improve patient management and reduce total treatment costs in patients with acute dyspnoea. 5) NP levels at the time of admission are powerful predictors of outcome in predicting death and re-hospitalisation in HF patients. 6) NP levels at discharge aid in risk stratification of the HF patient. 7) NP-guided therapy may improve morbidity and/or mortality in chronic HF. 8) The combination of NP levels together with symptoms, signs and weight gain assists in the assessment of clinical decompensation in HF. 9) NP levels can accelerate accurate diagnosis of heart failure presenting in primary care. 10) NP levels may be helpful to screen for asymptomatic left ventricular dysfunction in high-risk patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1016/j.ejheart.2008.07.014

State of the art: using natriuretic peptide levels in clinical practice.

Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure.

ContextDyspnea is a common complaint in the emergency department where physicians
must accurately make a rapid diagnosis.ObjectiveTo assess the usefulness of history, symptoms, and signs along with
routine diagnostic studies (chest radiograph, electrocardiogram, and serum
B-type natriuretic peptide [BNP]) that differentiate heart failure from other
causes of dyspnea in the emergency department.Data SourcesWe searched MEDLINE (1966-July 2005) and the reference lists from retrieved
articles, previous reviews, and physical examination textbooks.Study SelectionWe retained 22 studies of various findings for diagnosing heart failure
in adult patients presenting with dyspnea to the emergency department.Data ExtractionTwo authors independently abstracted data (sensitivity, specificity,
and likelihood ratios [LRs]) and assessed methodological quality.Data SynthesisMany features increased the probability of heart failure, with the best
feature for each category being the presence of (1) past history of heart
failure (positive LR = 5.8; 95% confidence interval [CI], 4.1-8.0);
(2) the symptom of paroxysmal nocturnal dyspnea (positive LR = 2.6;
95% CI, 1.5-4.5); (3) the sign of the third heart sound (S3) gallop
(positive LR = 11; 95% CI, 4.9-25.0); (4) the chest radiograph showing
pulmonary venous congestion (positive LR = 12.0; 95% CI, 6.8-21.0);
and (5) electrocardiogram showing atrial fibrillation (positive LR = 3.8;
95% CI, 1.7-8.8). The features that best decreased the probability of heart
failure were the absence of (1) past history of heart failure (negative LR = 0.45;
95% CI, 0.38-0.53); (2) the symptom of dyspnea on exertion (negative LR = 0.48;
95% CI, 0.35-0.67); (3) rales (negative LR = 0.51; 95% CI, 0.37-0.70);
(4) the chest radiograph showing cardiomegaly (negative LR = 0.33;
95% CI, 0.23-0.48); and (5) any electrocardiogram abnormality (negative LR = 0.64;
95% CI, 0.47-0.88). A low serum BNP proved to be the most useful test (serum
B-type natriuretic peptide <100 pg/mL; negative LR = 0.11; 95%
CI, 0.07-0.16).ConclusionsFor dyspneic adult emergency department patients, a directed history,
physical examination, chest radiograph, and electrocardiography should be
performed. If the suspicion of heart failure remains, obtaining a serum BNP
level may be helpful, especially for excluding heart failure.

/pdf/does-this-dyspneic-patient-in-the-emergency-department-have-4ljwbhw9oa.pdf

Does this dyspneic patient in the emergency department have congestive heart failure

To assess the accuracy in diagnosing heart failure of clinical features and potential primary care investigations, and to perform a decision analysis to test the impact of plausible diagnostic strategies on costs and diagnostic yield in the UK health-care setting. MEDLINE and CINAHL were searched from inception to 7 July 2006. 'Grey literature' databases and conference proceedings were searched and authors of relevant studies contacted for data that could not be extracted from the published papers. A systematic review of the clinical evidence was carried out according to standard methods. Individual patient data (IPD) analysis was performed on nine studies, and a logistic regression model to predict heart failure was developed on one of the data sets and validated on the other data sets. Cost-effectiveness modelling was based on a decision tree that compared different plausible investigation strategies. Dyspnoea was the only symptom or sign with high sensitivity (89%), but it had poor specificity (51%). Clinical features with relatively high specificity included history of myocardial infarction (89%), orthopnoea (89%), oedema (72%), elevated jugular venous pressure (70%), cardiomegaly (85%), added heart sounds (99%), lung crepitations (81%) and hepatomegaly (97%). However, the sensitivity of these features was low, ranging from 11% (added heart sounds) to 53% (oedema). Electrocardiography (ECG), B-type natriuretic peptides (BNP) and N-terminal pro-B-type natriuretic peptides (NT-proBNP) all had high sensitivities (89%, 93% and 93% respectively). Chest X-ray was moderately specific (76-83%) but insensitive (67-68%). BNP was more accurate than ECG, with a relative diagnostic odds ratio of ECG/BNP of 0.32 (95% CI 0.12-0.87). There was no difference between the diagnostic accuracy of BNP and NT-proBNP. A model based upon simple clinical features and BNP derived from one data set was found to have good validity when applied to other data sets. A model substituting ECG for BNP was less predictive. From this a simple clinical rule was developed: in a patient presenting with symptoms such as breathlessness in whom heart failure is suspected, refer directly to echocardiography if the patient has a history of myocardial infarction or basal crepitations or is a male with ankle oedema; otherwise, carry out a BNP test and refer for echocardiography depending on the results of the test. On the basis of the cost-effectiveness analysis carried out, such a decision rule is likely to be considered cost-effective to the NHS in terms of cost per additional case detected. The cost-effectiveness analysis further suggested that, if likely benefit to the patient in terms of improved life expectancy is taken into account, the optimum strategy would be to refer all patients with symptoms suggestive of heart failure directly for echocardiography. The analysis suggests the need for important changes to the NICE recommendations. First, BNP (or NT-proBNP) should be recommended over ECG and, second, some patients should be referred straight for echocardiography without undergoing any preliminary investigation. Future work should include evaluation of the clinical rule described above in clinical practice.

https://espace.library.uq.edu.au/view/UQ:216901/UQ216901_OA.pdf

Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care

Background and Purpose:Natriuretic peptides have led the way as a diagnostic and prognostic tool for the diagnosis and management of heart failure (HF). More recent evidence suggests that natriuret...

Caroline Zanker

Papers

Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea

peptide assay in the etiologic diagnosis of acute dyspnea Comparative value of Doppler echocardiography and B-type natriuretic