atrial-natriuretic-factor and Emergencies

The role of the clinical laboratory in emergency cardiac medicine is rapidly evolving; with recent redefinitions of acute myocardial infarction (AMI) and unstable angina (UA) based on troponin levels, recommended acceleration of cardiac testing protocols, and increased clinical measurement of B-type natriuretic peptide (BNP). We briefly review the background pathophysiology of acute coronary syndromes (ACS) and congestive heart failure (CHF), along with an overview of the biochemistry and physiology of the natriuretic peptides.. The assay principles and performance characteristics of the rapid BNP assays are discussed. The performance characteristics of troponin assays are at the center of controversy regarding the redefinition of AMI and UA, and will be discussed.. We review the rapidly expanding evidence regarding the clinical utility of BNP for CHF patients. While BNP has gained wide acceptance as a rapid diagnostic tool, considerable controversy remains concerning its potential for prognosis, screening, and therapeutic monitoring. Although a thorough discussion of the use of cardiac markers is well beyond the scope of this review, overviews of the redefinitions of AMI and UA, and the trend toward accelerated testing protocols to obtain a quicker diagnosis or ruling-out of AMI are included. In addition to accelerating the retesting of existing markers, a recent test for ischemia modified albumin (IMA) promises another quantum leap in cardiac diagnoses.. The positive impact of these developments on the healthcare costs and overall improvement in the quality of healthcare delivery will be discussed. A brief analysis of the downstream costs of BNP testing is also offered.

Topics: Atrial Natriuretic Factor; Biomarkers; Emergencies; Heart Failure; Humans; Medical Laboratory Science; Myocardial Ischemia; Natriuretic Peptide, Brain

Congestive heart failure poses significant challenges to physicians with both diagnosis and management. B-type natriuretic peptide (BNP) is synthesized in the cardiac ventricles. It correlates with ventricular function, NYHA classification, and prognosis. It is extremely useful in the emergency department in patients presenting with acute dyspnea. It has a particularly strong negative predictive value. In addition, it should be important in screening patients for heart diease, either for those who are at high risk (chemotherapy, diabetes) or as a possible screen before echocardiography. In the future, BNP may be used to modulate treatment of patients in the decompensated setting as well as in titrating outpatient therapy.

Topics: Atrial Natriuretic Factor; Biomarkers; Cardiotonic Agents; Dyspnea; Emergencies; Heart Failure; Humans; Natriuretic Peptide, Brain; Prognosis; Ventricular Dysfunction, Left

In patients with pulmonary disease, it is often challenging to distinguish exacerbated pulmonary disease from congestive heart failure (CHF). The impact of B-type natriuretic peptide (BNP) measurements on the management of patients with pulmonary disease and acute dyspnea remains to be defined.. This study evaluated the subgroup of 226 patients with a history of pulmonary disease included in the BASEL Study. Patients were randomly assigned to a diagnostic strategy with (n = 119, BNP group) or without (n = 107, clinical group) the use of BNP levels provided by a rapid bedside assay. Time to discharge and total cost of treatment were recorded as the primary end points.. Baseline characteristics were similar in patients assigned to the BNP and control groups. Comorbidity was extensive, including coronary artery disease and hypertension in half of patients. The primary discharge diagnosis was CHF and exacerbated obstructive pulmonary disease in 39% and 33%, respectively. The use of BNP levels significantly reduced the need for hospital admission (81% vs 91%, P = .034). Median time to discharge was 9.0 days in the BNP group as compared with 12.0 days (P = .001) in the clinical group. Median total cost of treatment was $4841 in the BNP group as compared with $5671 in the clinical group (P = .008). Inhospital mortality was 8% in both groups.. CHF is a major cause of acute dyspnea in patients with a history of pulmonary disease. Used in conjunction with other clinical information, rapid measurement of BNP reduced time to discharge and total treatment cost of these patients.

Topics: Acute Disease; Aged; Asthma; Atrial Natriuretic Factor; Biomarkers; Confidence Intervals; Coronary Artery Disease; Dyspnea; Emergencies; Female; Heart Failure; Humans; Hypertension; Length of Stay; Male; Pneumonia; Pulmonary Disease, Chronic Obstructive; Pulmonary Embolism

We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF).. The Breathing Not Properly Multinational Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P<0.0001 for all pairwise comparisons).. The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.

Topics: Adolescent; Adult; Aged; Atrial Natriuretic Factor; Dyspnea; Electrocardiography; Emergencies; Female; Heart Failure; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Radiography; Reference Standards; Reproducibility of Results; ROC Curve; Sensitivity and Specificity

To determine the utility of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure (CHF) in patients presenting with dyspnea to an emergency department (ED).. Seventy patients presenting with dyspnea to an ED from April to July 2001 were included in the study. Mean age was 72+/-16 years and 33 (47%) were male. BNP was measured in all patients at the moment of admission to the ED. Emergency-care physicians, blinded to BNP values, were required to assign a probable initial diagnosis. A cardiologist retrospectively reviewed the data (blinded to BNP measurements) and assigned a definite diagnosis, which was considered the gold standard for assessing the diagnostic performance of BNP.. The mean BNP concentration was higher in patients with CHF (n=36) than in those with other diagnoses (990+/-550 vs 80+/-67 pg/mL, p<0.0001). Patients with systolic dysfunction had higher BNP levels than those with preserved systolic function (1,180+/-641 vs 753+/-437 pg/mL, p=0.03). At a blood concentration of 200 pg/mL, BNP showed a sensitivity of 100%, specificity of 97.1%, positive predictive value of 97.3%, and negative predictive value of 100%. The application of BNP could have potentially corrected all 16 cases in which the diagnosis was missed by the emergency department physician.. BNP measurement is a useful tool in the diagnosis of CHF in patients presenting to the ED with dyspnea.

Topics: Aged; Atrial Natriuretic Factor; Biomarkers; Dyspnea; Emergencies; Female; Heart Failure; Humans; Male; Predictive Value of Tests; Sensitivity and Specificity

Topics: Adult; Atrial Natriuretic Factor; Emergencies; Humans; Hypertension; Male; Middle Aged; Nifedipine