Use of B-type natriuretic peptide for the management of women with dyspnea

doi:10.1016/j.amjcard.2004.08.029

The American Journal of Cardiology

Volume 94, Issue 12, 15 December 2004, Pages 1510-1514

https://doi.org/10.1016/j.amjcard.2004.08.029 Get rights and content

In studies with predominately male patients, B-type natriuretic peptide (BNP) levels have been shown to be helpful in the evaluation and management of patients who present with acute dyspnea. The effect of BNP levels on the management of women has not been defined. This study evaluated a predefined subgroup of 190 women included in a prospective randomized controlled study of BNP testing for emergency diagnosis of acute dyspnea. Patients were randomly assigned to a diagnostic strategy with (n = 93, BNP group) or without (n = 97, control group) the use of BNP levels provided by a rapid bedside assay. Women differed significantly from men in baseline characteristics, symptoms, signs, and final discharge diagnoses. The use of BNP levels decreased the need for hospital admission (73% vs 86%, p = 0.034) and intensive care (12% vs 23%, p = 0.048). Median time to discharge was 6 days in the BNP group versus 10 days in the control group (p = 0.023). Total cost of treatment was $4,781 in the BNP group (95% confidence interval 3,854 to 5,708) versus $6,843 in the control group (95% confidence interval 5,611 to 8,074, p = 0.009). In-hospital mortality rates were 4% in the BNP group and 10% in the control group (p = 0.165). Thus, used in conjunction with other clinical information, rapid measurement of BNP decreased time to discharge and total cost of treatment in women who presented with acute dyspnea.

Section snippets

Setting and study population

This study specifically evaluated the outcome of women in the B-type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study.¹ The BASEL study was a prospective, randomized, single-blind study that had been conducted in the emergency department of the University Hospital in Basel, Switzerland, from May 2001 to April 2002. Patients were evaluated in the emergency department by ≥2 physicians, a resident in internal medicine, and an internal medicine specialist. The study

Women versus men

Women differed significantly from men in baseline characteristics, symptoms, signs, and final discharge diagnoses (Table 1). Although CHF was the predominate cause of dyspnea in women and men, the overall final discharge diagnoses were different in women and men. In patients who had a final discharge diagnosis of CHF, left ventricular ejection fraction was significantly higher in women than in men.

Baseline characteristics and outcome in women in the BNP and control groups

Baseline characteristics were well matched between study groups (Table 2). As presented in Table 3,

Discussion

This study specifically evaluated the effect of BNP testing in women. The use of BNP levels provided by a rapid bedside assay in conjunction with other clinical information significantly decreased the need for hospital admission and intensive care and decreased time to discharge and total cost of treatment by 25% to 30%. Women who presented with acute dyspnea differed in baseline characteristics and final discharge diagnoses from men who presented with the same key symptom, and women who had

Acknowlegdment

Diagnostic devices and reagents (Triage) were provided by Biosite, San Diego, California.

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A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study
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Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea
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Cited by (44)

Biological markers: What do the natriuretic peptides contribute?
2012, Hipertension y Riesgo Vascular
Natriuretic peptide testing in EDs for managing acute dyspnea: A meta-analysis
2011, American Journal of Emergency Medicine
Citation Excerpt :
Among them, the BASEL (B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation) trial gave rise to six subgroup analyses which were not included in our review. They concerned patients with diabetes [25], with kidney disease [26], with previous pulmonary disease [27], women [28], elderly patients [29], and obese patients [30]. Moreover, 2 cost-effectiveness analyses [31,32], reporting 180-day and 360-day cost data, and a subanalysis concerning multimarker strategy [33] also derived from the BASEL trial were not included in our review.
The aim of the study was to assess the usefulness of systematic natriuretic peptide testing in the management of patients presenting with acute dyspnea to emergency departments (EDs).
We performed a systematic review and meta-analysis of randomized controlled trials assessing the usefulness of B-type natriuretic peptide (BNP) or its N-terminal fragment (NT-proBNP) in the management of patients presenting with dyspnea into ED. We searched Medline, Embase, and conference proceedings without restriction on neither language nor publication year. Selection of studies, data collection, and assessment of risk of bias were performed by 2 reviewers independently and in duplicate. Outcomes included hospital admission rate, time to discharge, and length of hospital stay, mortality and rehospitalization rates, and total direct medical costs. Combined risk ratios were estimated using fixed or random effects model. Duration and cost data were not combined.
Four randomized controlled trials, representing 2041 patients, were selected. In 4 trials, there was a tendency for hospital admission to be reduced in the intervention group (combined risk ratio, 0.95; 95% confidence interval, 0.89-1.01). Time to discharge was significantly reduced in 2 trials, whereas there was no significant reduction in hospital length of stay in 3 trials. There was no significant effect on in-hospital and 30-day mortality rates or rehospitalization rates (3 trials reporting each outcome). Two trials found significant reduction in direct costs.
The current evidence remains inconclusive on whether systematic natriuretic peptide testing is useful for the management of patients presenting to ED with acute dyspnea.
B-type natriuretic peptide and COPD in the Emergency Department
2010, Italian Journal of Medicine
The aim of this study was to evaluate, in patients with chronic obstructive pulmonary disease (COPD) and arrived to the emergency department (ED) with dyspnea / hypoxia, the existence of possible correlations between blood levels of B-type natriuretic peptide (NT-proBNP) and presence of heart failure [HF]), mortality, outcome of the ED visit (discharge, ospitalization,death), and length of post-ED hospital stays.
Clinical history, medical examination and blood levels of NT-proBNP were perfomed in all patients selected to our emergency department with the above symptoms between December 2006 and December 2008. Emergency department and hospital charts for these patients were later retrospectively reviewed to identify patients diagnosed with COPD.
A total of 546 patients (mean age 77 years, 52% women) had final diagnoses of COPD (with or without HF). Eight died in the ED, 104 were discharged after the ED visit, and 424 were hospitalized. Hospitalizations were longer for patients with COPD alone (21 days vs. 13 days for COPD + HF). Mortality among hospitalized patients was 9.7%. Seventy-six percent of the patients had elevated blood levels of NT-proBNP (>450ng/L) in the ED. Most of these patients (54%) had COPD and HF; the others (22%) had COPD alone (p < 0.01). Low levels of NT-proBNP (<450ng/L) were more frequent in patients with simple COPD who were discharged after the ED visit (89/546). In this group, 25/89 returned to the ED after more than 60 days; 17% had simple COPD, and 10/25 were hospitalized. Elevated blood NT-proBNP levels were significantly associated with mortality (p < 0.001).
The findings of the present study indicate that HF is the main cause of dyspnea and hypoxia among patients with COPD who present to the ED with these symptoms. High blood levels of NT-proBNP on ED admission can alert ED physicians to the presence of HF, allowing them to prescribe appropriate treatment and make more informed decisions regarding the need for hospitalization. Low levels of NT-proBNP appear to be associated with simple COPD and low-risk that may be manageable on an outpatient basis. Measurement of NT-proBNP levels in dyspneic patients presenting to the ER is helpful for making a correct diagnosis and identifying appropriate management strategies.
Acute heart failure: How to evaluate left ventricular filling pressure in practice?
2009, Archives of Cardiovascular Diseases
Heart failure is one of the most frequent reasons for hospitalization due to a cardiac event. In most instances, the main difficulty is how to accurately evaluate left ventricular filling pressure. It can be evaluated clinically, biologically and invasively. Although historically, invasive management has been the reference, it is being used less and less frequently and expertise in the technique is being lost. This paper discusses the strength and weaknesses of the different techniques for evaluating filling pressure in these patients, and the importance of this parameter for their optimal treatment.
L’insuffisance cardiaque est la cause la plus fréquente d’hospitalisation cardiologique. La difficulté principale est généralement d’évaluer les pressions de remplissage ventriculaires gauches. Elle peut être évaluée cliniquement, par prélèvement biologique ou de façon invasive. Bien qu’historiquement la prise en charge avec surveillance invasive ait été la référence, le cathétérisme droit est de moins en moins utilisé et l’expertise qu’elle nécessite se raréfie. Cette revue discute les avantages et faiblesses des différentes techniques évaluant les pressions de remplissage, ainsi que l’importance de ce paramètre pour le traitement optimal des patients.
Diagnosis of Heart Failure
2009, Heart Failure Clinics
Citation Excerpt :
NP levels are not affected by the presence of diabetes40,41 but are lower in overweight and obese individuals, and the test loses sensitivity in this population.42–44 NPs have ethnic and age differences;45,46 however, BNP is still effective in decreasing time to discharge and total cost of treatment in women and elderly patients.46–48 NPs are at least partially renally cleared, which impacts their clinical utility.
The approach to the diagnosis of heart failure is complex, but the diagnostic armamentarium has increased significantly in the past decade. Diagnostic markers such as B-type natriuretic peptide and NT pro–B-type natriuretic peptide have proven value for the diagnosis of heart failure over and above the traditional tools that included only the history, physical examination, and chest radiography. Invasive and noninvasive impedance cardiography can be used to diagnose or even predict development of heart failure, but its role in clinical practice still needs to be better defined.
BNP or NTproBNP? A clinician's perspective
2008, International Journal of Cardiology
Citation Excerpt :
Two cut-off values are particularly valuable: A lower one with a high negative predictive value to reliably exclude HF and a higher one with a high positive predictive value to rule in HF (Table 2). For BNP, 100 pg/ml and 400 pg/ml should be applied irrespective of age and sex [73–76]. Kidney disease and obesity, however, require adjustments; for patients with a glomerular filtration rate of less than 60 ml/min, 200 pg/ml rather than 100 pg/ml is a more appropriate cut-off point to rule out HF [76,77].
Existing literature on two natriuretic peptides — B-type natriuretic peptide (BNP) and amino terminal pro-brain natriuretic peptide (NTproBNP) — is overwhelming. Both peptides are acknowledged markers for cardiac dysfunction. Most of the sources present data on either BNP or NTproBNP making the comparison difficult.
This paper focuses on reviewing studies directly comparing two peptides in the setting of chronic and acute heart failure (HF) and coronary artery disease.
Many concomitant diseases influence these two peptides to varying extent. These characteristics should be taken into consideration when interpreting results. For most practical purposes, BNP and NTproBNP are interchangeable, and can be used based on local preferences and availability. NTproBNP seems to be more advantageous for diagnosing mild HF or asymptomatic left ventricular dysfunction.

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: This study was supported by research grants from the Swiss National Science Foundation, Bern; the Swiss Heart Foundation, Bern; the Novartis Foundation, Basel; the Krokus Foundation, Basel; and the University of Basel, Basel, Switzerland (to Dr. Mueller).

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Use of B-type natriuretic peptide for the management of women with dyspnea

Section snippets

Setting and study population

Women versus men

Baseline characteristics and outcome in women in the BNP and control groups

Discussion

Acknowlegdment

J Am Coll Cardiol

Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea

N Engl J Med

B-type natriuretic peptide (BNP): can it improve our management of patients with congestive heart failure?

Swiss Med Wkly

ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Circulation

Guidelines for the diagnosis and treatment of chronic heart failure

Eur Heart J

Recommendations of the panel on cost-effectiveness in health and medicine

JAMA