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Walkley R, Allen AJ, Cowie MR, Maconachie R, Anderson L. The cost-effectiveness of NT-proBNP for assessment of suspected acute heart failure in the emergency department. ESC Heart Fail 2023; 10:3276-3286. [PMID: 37697738 PMCID: PMC10682884 DOI: 10.1002/ehf2.14471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 06/20/2023] [Accepted: 07/02/2023] [Indexed: 09/13/2023] Open
Abstract
AIMS When relying on clinical assessment alone, an estimated 22% of acute heart failure (AHF) patients are missed, so clinical guidelines recommend the use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for AHF diagnosis. Since publication of these guidelines, there has been poor uptake of NT-proBNP testing in part due to concerns over excessive false positive referrals resulting from the low specificity of a single 'rule-out' threshold of <300 pg/mL. Low specificity can be mitigated by the addition of age-specific 'rule-in' NT-proBNP thresholds. METHODS AND RESULTS A theoretical hybrid decision tree/semi-Markov model was developed, combining global trial and audit data to evaluate the cost-effectiveness of NT-proBNP testing using age-specific rule-in/rule-out (RI/RO) thresholds, compared with NT-proBNP RO only and with clinical decision alone (CDA). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained and incremental net health benefit. In the base case, using UK-specific inputs, NT-proBNP RI/RO was associated with both greater QALYs and lower costs than CDA. At a willingness-to-pay threshold of £20 000/QALY, NT-proBNP RO was also cost-effective compared with CDA [incremental cost-effectiveness ratio (ICER) of £8322/QALY], but not cost-effective vs. RI/RO (ICER of £64 518/QALY). Overall, NT-proBNP RI/RO was the most cost-effective strategy. Sensitivity and scenario analyses were undertaken; the conclusions were not impacted by plausible variations in parameters, and similar conclusions were obtained for the Netherlands and Spain. CONCLUSIONS An NT-proBNP strategy that combines an RO threshold with age-specific RI thresholds provides a cost-effective alternative to the currently recommended NT-proBNP RO only strategy, achieving greater diagnostic specificity with minimal reduction in sensitivity and thus reducing unnecessary echocardiograms and hospital admissions.
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Affiliation(s)
| | | | - Martin R. Cowie
- Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust and Faculty of Lifesciences and MedicineKing's College LondonLondonUK
| | - Ross Maconachie
- Value, Access and Devolved Nations, Merck Sharp and Dohme (UK) LtdLondonUK
| | - Lisa Anderson
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research InstituteSt George's, University of London, St George's HospitalLondonUK
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Sahu S, Shah DN, Vempati R, Kandhi PR, Parmar MP, Bethanabotla S, Gadgil S, Chandra P, Malipatil SN, Patel Y, Natarajan B, Bingi TC. Rapid N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) Kit as a Differentiating Tool for Acute Dyspnea in a Resource-Limited Setting. Cureus 2023; 15:e48306. [PMID: 38058332 PMCID: PMC10697234 DOI: 10.7759/cureus.48306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Dyspnea is among the most prevalent symptoms experienced by patients presenting as an emergency. The underlying etiology is often a cardiovascular or pulmonary condition, of which heart failure is recognized as a major contributor. The differentials are primarily established based on the patient's clinical presentation and physical examinations but are not conclusive. Of the various investigations undertaken to determine the cause of dyspnea, the biomarker N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) was found to be significantly associated with heart failure. Its level has been proven to be in direct correlation with the severity of the disease. This study demonstrates the usability of an economical rapid test kit in measuring NT-ProBNP levels to help differentiate the cause of dyspnea in the presenting patient in a resource-limited setting. Methodology We studied 115 participants from a tertiary care center in India, which included 70 males and 45 females aged ≤30 to ≥75 years, presenting with shortness of breath. Rapid NT-ProBNP tests were conducted alongside recording their symptoms, vitals, examination findings, and other parameters. They were also classified according to New York Heart Association (NYHA) Classification, and further investigated. Results The study elucidated the efficacy and accuracy of the rapid kits in determining NT-ProBNP levels, and its relation with the severity and prognosis of heart failure. The kits utilized had a sensitivity of greater than 93% for ruling out heart failure as a cause of dyspnea, and a sensitivity of greater than 96% for ruling out elevated NT-ProBNP levels in general. Other parameters such as presenting symptoms and vitals were also analyzed, establishing a correlation with NT-ProBNP levels. Conclusion This study guided us in understanding the effective utilization of the rapid testing kits for emergency care, minimizing the burden on other limited resources. The lower cost and ease of use would serve as a quick means of reaching a conclusive diagnosis, especially in an emergency, which in turn would aid in receiving timely and specific treatment. These kits could act as a stepping stone in creating a sustainable and efficient healthcare system for patients as well as healthcare workers.
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Affiliation(s)
- Sweta Sahu
- Surgery, JJM (Jagadguru Jayadeva Murugarajendra) Medical College, Davanagere, IND
| | - Devarsh N Shah
- Medicine and Surgery, Medical College Baroda, Vadodara, IND
| | - Roopeessh Vempati
- Internal Medicine, Gandhi Medical College, Secunderabad, IND
- Cardiology, Heart & Vascular Institute, Detroit, USA
| | | | - Mihirkumar P Parmar
- Internal Medicine, Gujarat Medical Education and Research Society, Vadnagar, IND
| | | | - Shardool Gadgil
- Medicine and Surgery, Lokmanya Tilak Municipal General Hospital and Medical College, Mumbai, IND
| | - Prerna Chandra
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | | | - Yash Patel
- Internal Medicine, Gujarat Medical Education and Research Society, Vadnagar, IND
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3
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Norman S, Moragues J, Zaki NM, Lee A. N-Terminal Pro B-Type Natriuretic Peptide as a Screening Tool for Inpatient Echocardiogram Requirement Among Patients With Suspected Heart Failure: Using NT-proBNP to Reduce Hospital Length of Stay. Heart Lung Circ 2023; 32:1215-1221. [PMID: 37749024 DOI: 10.1016/j.hlc.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2023] [Accepted: 08/10/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a cardiac biomarker with diagnostic and prognostic utility in patients with heart failure (HF). Whether NT-proBNP can be used to triage inpatient transthoracic echocardiogram (TTE) requirements, and whether this impacts hospital length of stay (LOS), is not clear. METHODS Clinical and biochemical data were prospectively recorded on all inpatients at Wollongong Hospital, NSW, Australia, who had a TTE ordered for suspected HF over a 6-month period. NT-proBNP was used to triage TTE priority, where high-priority inpatient TTE, lower-priority inpatient TTE and outpatient (OP) TTE were performed for serum NT-proBNPs of ≥900, 300-899 and <300, respectively. Outcomes were compared with a baseline cohort of HF inpatients in whom TTE requirement was not guided by NT-proBNP. RESULTS A total of 236 patients were evaluated-31, 31, and 174 in the low, intermediate and high NT-proBNP cohorts, respectively, and 199 patients were in the baseline cohort. Average hospital LOS was significantly reduced in the study cohort compared to baseline (9.97 vs 13.87 days, p<0.001). Of the 31 patients with a very low NT-proBNP who were discharged for OP TTE, seven were readmitted within 30 days, though none were HF-related. There were no deaths at 30 days in the low or intermediate NT-proBNP groups. CONCLUSIONS Using NT-proBNP to triage requirements for inpatient TTE reduces hospital LOS. A very low NT-proBNP may help identify which patients with suspected HF can be safely discharged for OP TTE.
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Affiliation(s)
- Samuel Norman
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW, Australia.
| | - Jorge Moragues
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW, Australia
| | - Nurilia Mohd Zaki
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW, Australia
| | - Astin Lee
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW, Australia
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Lee KK, Doudesis D, Anwar M, Astengo F, Chenevier-Gobeaux C, Claessens YE, Wussler D, Kozhuharov N, Strebel I, Sabti Z, deFilippi C, Seliger S, Moe G, Fernando C, Bayes-Genis A, van Kimmenade RRJ, Pinto Y, Gaggin HK, Wiemer JC, Möckel M, Rutten JHW, van den Meiracker AH, Gargani L, Pugliese NR, Pemberton C, Ibrahim I, Gegenhuber A, Mueller T, Neumaier M, Behnes M, Akin I, Bombelli M, Grassi G, Nazerian P, Albano G, Bahrmann P, Newby DE, Japp AG, Tsanas A, Shah ASV, Richards AM, McMurray JJV, Mueller C, Januzzi JL, Mills NL. Development and validation of a decision support tool for the diagnosis of acute heart failure: systematic review, meta-analysis, and modelling study. BMJ 2022; 377:e068424. [PMID: 35697365 PMCID: PMC9189738 DOI: 10.1136/bmj-2021-068424] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2012] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics. DESIGN Individual patient level data meta-analysis and modelling study. SETTING Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies. PARTICIPANTS Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated. MAIN OUTCOME MEASURE Adjudicated diagnosis of acute heart failure. RESULTS Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure. CONCLUSIONS In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach. STUDY REGISTRATION PROSPERO CRD42019159407.
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Affiliation(s)
- Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Dimitrios Doudesis
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Mohamed Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Contributed equally
| | - Federica Astengo
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Yann-Erick Claessens
- Department of Emergency Medicine, Princess Grace Hospital Center, Monaco, Principality of Monaco
| | - Desiree Wussler
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ivo Strebel
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Zaid Sabti
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Stephen Seliger
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gordon Moe
- University of Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Carlos Fernando
- University of Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, CIBERCV, Spain
| | | | - Yigal Pinto
- University of Amsterdam, Amsterdam, Netherlands
| | - Hanna K Gaggin
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jan C Wiemer
- BRAHMS, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Martin Möckel
- Department of Emergency and Acute Medicine with Chest Pain Units, Charité - Universitätsmedizin Berlin, Campus Mitte and Virchow, Berlin, Germany
| | - Joost H W Rutten
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Anton H van den Meiracker
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, Singapore
| | - Alfons Gegenhuber
- Department of Internal Medicine, Krankenhaus Bad Ischl, Bad Ischl, Austria
| | - Thomas Mueller
- Department of Laboratory Medicine, Hospital Voecklabruck, Voecklabruck, Austria
| | - Michael Neumaier
- Institute for Clinical Chemistry, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michele Bombelli
- University of Milan Bicocca, ASST-Brianza, Pio XI Hospital of Desio, Internal Medicine, Desio, Italy
| | - Guido Grassi
- Clinica Medica, University Milan Bicocca, Milan, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Albano
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Philipp Bahrmann
- Department of Internal Medicine III, Division of Cardiology, University Hospital of Heidelberg, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alan G Japp
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
- Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Christian Mueller
- Cardiovascular Research Institute of Basel, Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - James L Januzzi
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Activity of the adrenomedullin system to personalise post-discharge diuretic treatment in acute heart failure. Clin Res Cardiol 2021; 111:627-637. [PMID: 34302189 PMCID: PMC9151518 DOI: 10.1007/s00392-021-01909-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Background Quantifying the activity of the adrenomedullin system might help to monitor and guide treatment in acute heart failure (AHF) patients. The aims were to (1) identify AHF patients with marked benefit or harm from specific treatments at hospital discharge and (2) predict mortality by quantifying the adrenomedullin system activity. Methods This was a prospective multicentre study. AHF diagnosis and phenotype were centrally adjudicated by two independent cardiologists among patients presenting to the emergency department with acute dyspnoea. Adrenomedullin system activity was quantified using the biologically active component, bioactive adrenomedullin (bio-ADM), and a prohormone fragment, midregional proadrenomedullin (MR-proADM). Bio-ADM and MR-proADM concentrations were measured in a blinded fashion at presentation and at discharge. Interaction with specific treatments at discharge and the utility of these biomarkers on predicting outcomes during 365-day follow-up were assessed. Results Among 1886 patients with adjudicated AHF, 514 patients (27.3%) died during 365-day follow-up. After adjusting for age, creatinine, and treatment at discharge, patients with bio-ADM plasma concentrations above the median (> 44.6 pg/mL) derived disproportional benefit if treated with diuretics (interaction p values < 0.001). These findings were confirmed when quantifying adrenomedullin system activity using MR-proADM (n = 764) (interaction p values < 0.001). Patients with bio-ADM plasma concentrations above the median were at increased risk of death (hazard ratio 1.87, 95% CI 1.57–2.24; p < 0.001). For predicting 365-day all-cause mortality, both biomarkers performed well, with MR-proADM presenting an even higher predictive accuracy compared to bio-ADM (p < 0.001). Conclusions Quantifying the adrenomedullin’s system activity may help to personalise post-discharge diuretic treatment and enable accurate risk-prediction in AHF. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01909-9.
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Jansen PM, Stowasser M. Aldosterone-producing adenoma associated with non-suppressed renin: a case series. J Hum Hypertens 2021; 36:373-380. [PMID: 33785905 DOI: 10.1038/s41371-021-00525-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/25/2021] [Accepted: 03/08/2021] [Indexed: 11/09/2022]
Abstract
Although the aldosterone/renin ratio (ARR) is the preferred screening test for primary aldosteronism (PA), patients with non-suppressed renin and a falsely negative ARR on non-interfering medications have occasionally been reported. This report describes the clinical characteristics and outcomes of seven patients with proven aldosterone-producing adenoma (APA) and non-suppressed renin.Chart review of seven PA patients with an APA and a non-suppressed plasma renin concentration (PRC > 8.4 mU/L) was undertaken to collect data on anthropometric and biochemical characteristics, diagnostic evaluation and postsurgical outcomes.Seven patients (two women and five men) with a proven APA had median (range) PRC, plasma aldosterone and ARR of 20 (9-43) mU/L, 750 (270-1940) pmol/L and 45 (8-62, normal <70), respectively, on non-interfering medications. Six patients had two consecutive ARR measurements and in five of them both were normal. Renal artery stenosis was carefully excluded in all patients. Further evaluation for PA was pursued because of high clinical suspicion (either hypokalaemia and/or a known adrenal mass lesion on imaging). All underwent adrenal vein sampling confirming unilateral PA which was managed by unilateral adrenalectomy. Postsurgical follow-up data either confirmed or were highly suggestive of cure of PA.Strict control of factors known to influence the ARR is crucial to avoid false-negative results. Other causes that could explain a non-suppressed renin should be excluded. In patients with a consistently non-suppressed renin further diagnostic workup for PA should be considered if clinical suspicion remains high.
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Affiliation(s)
- Pieter Martijn Jansen
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
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Long B, Koyfman A, Gottlieb M. Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. West J Emerg Med 2019; 20:875-884. [PMID: 31738714 PMCID: PMC6860389 DOI: 10.5811/westjem.2019.9.43732] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Pourafkari L, Tajlil A, Nader ND. Biomarkers in diagnosing and treatment of acute heart failure. Biomark Med 2019; 13:1235-1249. [PMID: 31580155 DOI: 10.2217/bmm-2019-0134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Acute heart failure (AHF) is a complex disorder involving different pathophysiological pathways. In recent years, there is an increased focus on biomarkers that help with diagnosis, risk stratification and disease monitoring of AHF. Finding a reliable set of biomarkers not only improves morbidity and mortality but it can also potentially reveal the new targets of therapy. In this paper, we have reviewed the biomarkers found useful for the diagnosis as well as for risk stratification and prognostication in patients with AHF. We have discussed the established biomarkers for AHF including cardiac troponins and natriuretic peptides and emerging biomarkers including adiponectin, mi-RNA, sST2, Gal-3, MR-proADM, OPG, CT-proAVP and H-FABP for the purposes of making diagnosis, their use as a guide of therapy or for determination of prognosis.
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Affiliation(s)
- Leili Pourafkari
- Department of Anesthesiology, University at Buffalo, Buffalo, NY 14203, USA
| | - Arezou Tajlil
- Cardiovascular Research Center, Tabriz University of Medical Science, Tabriz, Iran
| | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, Buffalo, NY 14203, USA
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9
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Draper J, Webb J, Jackson T, Jones H, Rinaldi CA, Schiff R, McDonagh T, Razavi R, S Carr-White G. Comparison of the Diagnostic Accuracy of Plasma N-Terminal Pro-Brain Natriuretic Peptide in Patients <80 to those >80 Years of Age with Heart Failure. Am J Cardiol 2018; 122:2075-2079. [PMID: 30309625 DOI: 10.1016/j.amjcard.2018.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 12/28/2022]
Abstract
Plasma N-Terminal Pro-Brain Natriuretic Peptide (NTproBNP) is known to increase with age, however, the performance of this biomaker is unclear in patients >80. This study sought to define the diagnostic accuracy of plasma NTproBNP in patients >80 in a large unselected population of heart failure (HF) patients admitted to a Tertiary Hospital in the United Kingdom. 1,995 consecutive patients over a 12 month period were screened for HF through our NTproBNP led HF service. 413 patients had their first presentation of HF and 36.1% of these patients were >80. There was a reduction in accuracy of NTproBNP with age according to the area under the curve, with an area under the curve for all HF patients of 0.734 and a 7.5% reduction in receiver operating characteristic curve area for patients >80 years compared with those under 60 to 79 years of age. The lowest NTproBNP recorded for patients with HF >80 years of age was 466 pg/ml. In HF patients >80, 40.6% patients were diagnosed with HFrEF, 31.1% with HFpEF and 28.2% with HFmrEF. Overall NTproBNP is less accurate at identifying HF in patients >80 years of age and the lowest NTproBNP recorded for a HF patient was 466 pg/ml suggesting that the NTproBNP threshold for ruling out HF in patients >80 years of age should be modified.
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Affiliation(s)
- Jane Draper
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jessica Webb
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom.
| | - Tom Jackson
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom
| | - Hamish Jones
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Christopher A Rinaldi
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom
| | - Rebekah Schiff
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Theresa McDonagh
- Department of Cardiology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Reza Razavi
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom
| | - Gerald S Carr-White
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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11
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Webb J, Draper J, Rua T, Yiu Y, Piper S, Teall T, Fovargue L, Bolca E, Jackson T, Claridge S, Sieniewicz B, Porter B, McDiarmid A, Rajani R, Kapetanakis S, Rinaldi CA, Razavi R, McDonagh TA, Carr-White G. A cost effectiveness study establishing the impact and accuracy of implementing the NICE guidelines lowering plasma NTproBNP threshold in patients with clinically suspected heart failure at our institution. Int J Cardiol 2018; 257:131-136. [PMID: 29506684 DOI: 10.1016/j.ijcard.2017.10.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 10/17/2022]
Abstract
AIMS The 2014 National Institute of Clinical Excellence (NICE) guidelines on the management of acute heart failure recommended using a plasma NT-proBNP threshold of 300pg/ml to assist in ruling out the diagnosis of heart failure (HF), updating previous guidelines recommending using a threshold of 400pg/ml. NICE based their recommendations on 6 studies performed in other countries. This study sought to determine the diagnostic and economic implications of using these thresholds in a large unselected UK population. METHODS Patient and clinical demographics were recorded for all consecutive suspected HF patients over 12months, as well as clinical outcomes including time to HF hospitalisation and time to death (follow up 15.8months). RESULTS Of 1995 unselected patients admitted with clinically suspected HF, 1683 (84%) had a NTproBNP over the current NICE recommended threshold, of which 35% received a final diagnosis of HF. Lowering the threshold from 400 to 300pg/ml would have involved screening an additional 61 patients and only would have identified one new patient with HF (sensitivity 0.985, NPV 0.976, area under the curve (AUC) at 300pg/ml 0.67; sensitivity 0.983, NPV 0.977, AUC 0.65 at 400pg/ml). The economic implications of lowering the threshold would have involved additional costs of £42,842.04 (£702.33 per patient screened, or £ 42,824.04 per new HF patient). CONCLUSION Applying the recent updated NICE guidelines to an unselected real world population increases the AUC but would have a significant economic impact and only identified one new patient with heart failure.
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Affiliation(s)
- Jessica Webb
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom.
| | - Jane Draper
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Tiago Rua
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Yee Yiu
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Susan Piper
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Department of Cardiology, King's College Hospital NHS Foundation Trust, London SE5 9RS
| | - Thomas Teall
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Lauren Fovargue
- Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Elena Bolca
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Tom Jackson
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Simon Claridge
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Ben Sieniewicz
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Bradley Porter
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Adam McDiarmid
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom
| | - Ronak Rajani
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Stamatis Kapetanakis
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Christopher A Rinaldi
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Reza Razavi
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
| | - Theresa A McDonagh
- Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom; Department of Cardiology, King's College Hospital NHS Foundation Trust, London SE5 9RS
| | - Gerald Carr-White
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom; Division of Imaging Sciences and Biomedical Engineering, King's College London, SE1 7EH, United Kingdom
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12
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Griffin EA, Wonderling D, Ludman AJ, Al-Mohammad A, Cowie MR, Hardman SMC, McMurray JJV, Kendall J, Mitchell P, Shote A, Dworzynski K, Mant J. Cost-Effectiveness Analysis of Natriuretic Peptide Testing and Specialist Management in Patients with Suspected Acute Heart Failure. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1025-1033. [PMID: 28964433 DOI: 10.1016/j.jval.2017.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/16/2017] [Accepted: 05/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward. METHODS We used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases. Inputs for the model were derived from systematic reviews, the UK national heart failure audit, randomized controlled trials, expert consensus from a National Institute for Health and Care Excellence guideline development group, and a national online survey. The main benefit from specialist care (cardiology ward and specialist outreach) was the increased likelihood of discharge on disease-modifying drugs for people with left ventricular systolic dysfunction, which improve mortality and reduce re-admissions due to worsened heart failure (associated with lower utility). Costs included diagnostic investigations, admissions, pharmacological therapy, and follow-up heart failure care. RESULTS NP testing and specialist outreach are both higher cost, higher QALY, cost-effective strategies (incremental cost-effectiveness ratios of £11,656 and £2,883 per QALY gained, respectively). Combining NP and specialist outreach is the most cost-effective strategy. This result was robust to both univariate deterministic and probabilistic sensitivity analyses. CONCLUSIONS NP testing for the diagnostic workup of new suspected AHF is cost-effective. The use of specialist heart failure outreach for inpatients with AHF residing off the cardiology ward is cost-effective. Both interventions will help improve outcomes for this high-risk group.
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Affiliation(s)
- Edward A Griffin
- National Clinical Guideline Centre, Royal College of Physicians, London, UK.
| | - David Wonderling
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
| | | | | | - Martin R Cowie
- Imperial College Healthcare NHS Foundation Trust (Royal Brompton Hospital), London, UK
| | | | - John J V McMurray
- Institute of Cardiovascular Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Jason Kendall
- Emergency Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Polly Mitchell
- National Institute for Cardiovascular Outcomes Research, UCL Institute of Cardiovascular Science, London, UK
| | - Aminat Shote
- National Institute for Cardiovascular Outcomes Research, UCL Institute of Cardiovascular Science, London, UK
| | | | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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13
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Claessens YE, Weiss N, Riqué T, Mallet-Coste T. [What is the place for biomarkers during acute COPD exacerbations?]. Rev Mal Respir 2017; 34:382-394. [PMID: 28499640 DOI: 10.1016/j.rmr.2017.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Y-E Claessens
- Département de médecine d'urgence, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98012 Principauté de Monaco, Monaco.
| | - N Weiss
- Département de médecine d'urgence, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98012 Principauté de Monaco, Monaco
| | - T Riqué
- Département de médecine d'urgence, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98012 Principauté de Monaco, Monaco
| | - T Mallet-Coste
- Département de médecine d'urgence, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98012 Principauté de Monaco, Monaco
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14
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Bøtker MT, Jørgensen MT, Stengaard C, Seidenfaden SC, Tarpgaard M, Granfeldt A, Mortensen TØ, Grøfte T, Friesgaard KD, Mærkedahl R, Pedersen AB, Lundorff S, Hansen TM, Kirkegaard H, Christensen EF, Terkelsen CJ. Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:302-310. [PMID: 28492084 DOI: 10.1177/2048872617709985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. METHODS Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. RESULTS A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. CONCLUSION Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.
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Affiliation(s)
- Morten T Bøtker
- 1 Research and Development, Prehospital Emergency Medical Services, Denmark
- 2 Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Maren T Jørgensen
- 1 Research and Development, Prehospital Emergency Medical Services, Denmark
| | | | | | - Mona Tarpgaard
- 1 Research and Development, Prehospital Emergency Medical Services, Denmark
| | - Asger Granfeldt
- 2 Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
- 3 Department of Cardiology B, Aarhus University Hospital, Denmark
| | - Tanja Ø Mortensen
- 4 Department of Anaesthesiology and Intensive Care Medicine, Randers Regional Hospital, Denmark
| | - Thorbjørn Grøfte
- 4 Department of Anaesthesiology and Intensive Care Medicine, Randers Regional Hospital, Denmark
| | - Kristian D Friesgaard
- 1 Research and Development, Prehospital Emergency Medical Services, Denmark
- 5 Department of Anaesthesiology and Intensive Care Medicine, Horsens Regional Hospital, Denmark
| | - Rikke Mærkedahl
- 1 Research and Development, Prehospital Emergency Medical Services, Denmark
| | - Anette B Pedersen
- 6 Department of Anaesthesiology, Silkeborg Regional Hospital, Denmark
| | - Simon Lundorff
- 7 Department of Anaesthesiology, Viborg Regional Hospital, Denmark
| | | | - Hans Kirkegaard
- 8 Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | - Erika F Christensen
- 9 Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Denmark
- 10 Department of Anaesthesiology, Aalborg University Hospital, Denmark
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15
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Harish NJ, Miller HD, Pines JM, Zane RD, Wiler JL. How alternative payment models in emergency medicine can benefit physicians, payers, and patients. Am J Emerg Med 2017; 35:906-909. [PMID: 28396098 DOI: 10.1016/j.ajem.2017.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/12/2017] [Accepted: 03/12/2017] [Indexed: 11/18/2022] Open
Abstract
While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.
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Affiliation(s)
- Nir J Harish
- Dept. of Emergency Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Yale University, New Haven, CT, United States.
| | - Harold D Miller
- Center for Healthcare Quality and Payment Reform, Pittsburgh, PA, United States
| | - Jesse M Pines
- Dept. of Emergency Medicine, George Washington University, Washington, DC, United States
| | - Richard D Zane
- Dept. of Emergency Medicine, University of Colorado, Aurora, CO, United States
| | - Jennifer L Wiler
- Dept. of Emergency Medicine, University of Colorado, Aurora, CO, United States
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16
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Mueller C, Christ M, Cowie M, Cullen L, Maisel AS, Masip J, Miro O, McMurray J, Peacock FW, Price S, DiSomma S, Bueno H, Zeymer U, Mebazaa A. European Society of Cardiology-Acute Cardiovascular Care Association Position paper on acute heart failure: A call for interdisciplinary care. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:81-86. [PMID: 26124458 DOI: 10.1177/2048872615593279] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute heart failure (AHF) continues to have unacceptably high rates of mortality and morbidity. This position paper highlights the need for more intense interdisciplinary cooperation as one key element to overcome the challenges associated with fragmentation in the care of AHF patients. Additional aspects discussed include the importance of early diagnosis and treatment, options for initial treatment, referral bias as a potential cause for treatment preferences among experts, considerable uncertainty regarding patient disposition, the diagnosis of accompanying acute myocardial infarction, the need for antibiotic therapy, as well as assessment of intravascular volume status.
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Affiliation(s)
| | - Michael Christ
- 2 Department of Emergency and Critical Care Medicine, Klinikum Nürnberg, Germany
| | - Martin Cowie
- 3 Department of Cardiology, Imperial College London, UK
| | - Louise Cullen
- 4 Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Australia.,6 School of Medicine, The University of Queensland, Australia
| | - Alan S Maisel
- 7 Coronary Care Unit and Heart Failure Program, Veteran Affairs (VA) San Diego, USA
| | | | - Oscar Miro
- 9 Emergency Department, Hospital Clínic, Barcelona, Spain.,10 Research Group: 'Emergencies: Processes and Pathologies', Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - John McMurray
- 11 British Heart Foundation (BHF) Cardiovascular Research Centre, University of Glasgow, UK
| | | | - Susanna Price
- 13 Royal Brompton and Harefield National Health Service Foundation Trust, UK
| | - Salvatore DiSomma
- 14 Emergency Department, Sant'Andrea Hospital, Italy.,15 Faculty of Medicine and Psychology, 'LaSapienza ' Rome University, Italy
| | - Hector Bueno
- 16 Hospital General Universitario Gregorio Marañón, Spain
| | - Uwe Zeymer
- 17 Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Germany
| | - Alexandre Mebazaa
- 18 Université Paris Diderot, France.,19 Hospital Lariboisière, France
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17
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Natriuretic peptide levels taken following unplanned admission to a cardiology department predict the duration of hospitalization. Eur J Heart Fail 2016; 18:1499-1505. [DOI: 10.1002/ejhf.604] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 11/07/2022] Open
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18
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Sepehrvand N, Bakal JA, Lin M, McAlister F, Wesenberg JC, Ezekowitz JA. Factors Associated With Natriuretic Peptide Testing in Patients Presenting to Emergency Departments With Suspected Heart Failure. Can J Cardiol 2016; 32:986.e1-8. [DOI: 10.1016/j.cjca.2015.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/25/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022] Open
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Athanasakis K, Arista I, Balasopoulos T, Boubouchairopoulou N, Kyriopoulos J. How peptide technology has improved costs and outcomes in patients with heart failure. Expert Rev Pharmacoecon Outcomes Res 2016; 16:371-82. [PMID: 27160541 DOI: 10.1080/14737167.2016.1187066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart failure (HF) is characterized by substantial health and economic burden, mainly attributed to increased hospitalizations and readmissions. Its diagnosis remains challenging due to the non-specific nature of the initial symptoms of the disease. Recently, scientific evidence has highlighted the potential of natriuretic peptides (NP) in improving the diagnosis and prognosis of HF and, by extension, in restraining healthcare costs. The present review aimed at providing evidence of their optimal use in terms of economic and health outcomes. AREAS COVERED Systematic literature research limited to studies published from February 2006 to February 2016 was performed with the aim of identifying and analyzing all cost-effectiveness and other economic evaluation studies that investigated the economic and health outcomes of NPs use as screening and management tools for HF. Expert commentary: NP testing either added in the standard of care, or substituting frequently used diagnostic procedures for the diagnosis and management of HF, regardless of the healthcare setting of interest, was proved to be a valid tool for clinical decision-making. Moreover it was associated with improved patient outcomes and important cost-savings mainly attributed to lower admission and readmission rates, shorter hospitalization length and improved health-related quality of life.
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Affiliation(s)
- Kostas Athanasakis
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | - Ioli Arista
- b Health Economist, Independent Researcher , Athens , Greece
| | - Thanos Balasopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
| | | | - John Kyriopoulos
- a Department of Health Economics , National School of Public Health , Athens , Greece
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Martindale JL, Wakai A, Collins SP, Levy PD, Diercks D, Hiestand BC, Fermann GJ, deSouza I, Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:223-42. [PMID: 26910112 DOI: 10.1111/acem.12878] [Citation(s) in RCA: 205] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/31/2015] [Accepted: 09/16/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. OBJECTIVES The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. METHODS PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. RESULTS Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). CONCLUSIONS Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.
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Affiliation(s)
| | - Abel Wakai
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University School of Medicine; Detroit MI
| | - Deborah Diercks
- The Department of Emergency Medicine; University of Texas Southwestern; Dallas TX
| | - Brian C. Hiestand
- The Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
| | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Ian deSouza
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
| | - Richard Sinert
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
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21
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Rubini Gimenez M, Twerenbold R, Mueller C. Beyond cardiac troponin: recent advances in the development of alternative biomarkers for cardiovascular disease. Expert Rev Mol Diagn 2015; 15:547-56. [PMID: 25676700 DOI: 10.1586/14737159.2015.1010519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Biomarkers complement clinical assessment, electrocardiogram and cardiac imaging in the diagnosis, risk stratification, triage and management of patients with suspected acute cardiovascular diseases. While there is broad consensus that cardiac troponin is the preferred biomarker in clinical practice for the detection of cardiomyocyte damage, the role of alternative biomarkers is less clear. In fact, despite high quality basic and clinical research by hundreds of groups worldwide, only a single new alternative cardiovascular biomarker (natriuretic peptides) has managed to achieve widespread clinical acceptance and inclusion in contemporary clinical practice guidelines in the last decade. This review aims to discuss the remaining unmet needs (and hence opportunities for new biomarkers) in two major clinical areas: early diagnosis of acute myocardial infarction; and early diagnosis and management of acute heart failure, and to evaluate in detail selected alternative biomarkers and recent insights gained from measuring novel biomarkers in large randomized treatment studies in patients with stable coronary artery disease, a setting in which alternative biomarkers may play a more prominent role in the future.
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Affiliation(s)
- Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland
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Noveanu M, Pargger H, Breidthardt T, Reichlin T, Schindler C, Heise A, Schoenenberger R, Manndorff P, Siegemund M, Mebazaa A, Marsch S, Mueller C. Use of B-type natriuretic peptide in the management of hypoxaemic respiratory failure. Eur J Heart Fail 2014; 13:154-62. [DOI: 10.1093/eurjhf/hfq188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Markus Noveanu
- Department of Internal Medicine; University Hospital Basel; Petersgraben 4, CH-4031 Basel Switzerland
| | - Hans Pargger
- Department of Operative Intensive Care Unit; University Hospital Basel; Basel Switzerland
| | - Tobias Breidthardt
- Department of Internal Medicine; University Hospital Basel; Petersgraben 4, CH-4031 Basel Switzerland
| | - Tobias Reichlin
- Department of Cardiology; University Hospital Basel; Basel Switzerland
| | - Christian Schindler
- Institute for Social and Preventive Medicine; University Hospital Basel; Basel Switzerland
| | - Antje Heise
- Intensive Care Unit Spital Thun-Simmental AG; Krankenhausstrasse 12, 3600 Thun Switzerland
| | - Ronald Schoenenberger
- Intensive Care Unit Bürgerspital Solothurn; Schöngrünstrasse 42, 4500 Solothurn Switzerland
| | - Patricia Manndorff
- Intensive Care Unit Spital Interlaken; Weissenaustrasse 27, 3800 Unterseen Switzerland
| | - Martin Siegemund
- Department of Operative Intensive Care Unit; University Hospital Basel; Basel Switzerland
| | | | - Stephan Marsch
- Department of Medical Intensive Care Unit; University Hospital Basel; Basel Switzerland
| | - Christian Mueller
- Department of Internal Medicine; University Hospital Basel; Petersgraben 4, CH-4031 Basel Switzerland
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Measurement of natriuretic peptides at the point of care in the emergency and ambulatory setting: current status and future perspectives. Am Heart J 2013; 166:614-621.e1. [PMID: 24093839 DOI: 10.1016/j.ahj.2013.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 06/02/2013] [Indexed: 11/21/2022]
Abstract
The measurement of natriuretic peptides (NPs), B-type NP or N-terminal pro-B-type NP, can be an important tool in the diagnosis of acute heart failure in patients presenting to an Emergency Department (ED) with acute dyspnea, according to international guidelines. Studies and subsequent meta-analyses are mixed on the absolute value of routine NP assessment of ED patients. However, levels of NPs are likely to be used also to guide treatment and to assess risk of adverse outcomes in other patients at risk of developing heart failure, including those with pulmonary embolism or diabetes, or receiving chemotherapy. Natriuretic peptide levels, like other biomarkers, can now be measured at the point of care (POC). We have reviewed the current status of NP measurement together with the potential contribution of POC measurement of NPs to clinical care delivery in the emergency and other settings. Several POC systems for measuring NP levels are now available: these produce test results within 15 minutes and appear sufficiently sensitive and robust to be used routinely in diagnostic evaluations. Point-of-care systems could be used to assess NP levels in the ED and community outpatient settings to monitor the risk of acute heart failure. Furthermore, the use of protocol-driven POC testing of NP within the time frame of a patient consultation in the ED may facilitate and accelerate the throughput and disposition of at-risk patients. Appropriately designed clinical trials will be needed to confirm these potential benefits. It is also important that processes of care delivery are redesigned to take full advantage of the faster turnaround times provided by POC technology.
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Velibey Y, Golcuk Y, Golcuk B, Oray D, Atilla OD, Colak A, Kurtulmus Y, Erbay AR, Yilmaz A, Eren M. Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure. Am J Emerg Med 2013; 31:1634-7. [PMID: 24055249 DOI: 10.1016/j.ajem.2013.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. METHODS NT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. RESULTS The mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs 72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). CONCLUSION Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.
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Affiliation(s)
- Yalcin Velibey
- Bitlis State Hospital, Department of Cardiology, Bitlis, Turkey.
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Möckel M, Searle J, Hartmann O, Anker SD, Peacock WF, Wu AHB, Maisel A. Mid-regional pro-adrenomedullin improves disposition strategies for patients with acute dyspnoea: results from the BACH trial. Emerg Med J 2012; 30:633-7. [DOI: 10.1136/emermed-2012-201530] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Palazzuoli A, Beltrami M, Pellegrini M, Nuti R. Natriuretic peptides and NGAL in heart failure: does a link exist? Clin Chim Acta 2012; 413:1832-8. [PMID: 22820397 DOI: 10.1016/j.cca.2012.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 11/30/2022]
Abstract
In recent years there has been growing interest in the development of new diagnostic tools and particularly in laboratory tests for the identification of heart failure (HF) patients. Because of the rise in HF occurrence, it is necessary to use simple and reliable method to recognize those patients at risk before the onset of the clinical symptoms. To date HF diagnosis remains difficult: its symptoms and signs are often non specific as well as being poor sensitive indicators for HF severity. Throughout the last 10 years published literature has highlighted a boom in the use of biomarkers for HF. Both B-type and N-terminal pro-B-type natriuretic peptides have demonstrated specific role in heart failure diagnosis, as well as risk assessment. A single determination of BNP at any time during the development of chronic heart failure (CHF) provides a clinically useful tool to establish the outcome. Renal dysfunction is often associated with heart failure and predicts adverse clinical outcomes. Many studies have recently suggested the clinical use of serum neutrophil gelatinase-associated lipocalin (NGAL) levels in patients admitted to the hospital for acute HF can be used to estimate the risk of early worsening renal function. This could be potentially applied in clinical practice for early identification of renal dysfunction development in patients with HF. NGAL levels appear also to predict renal dysfunction in patients with chronic HF and preserved renal function. For all these reasons, BNP and NGAL are two emerging tools useful for diagnosis and prognosis in HF. The combination of two laboratory biomarkers could potentially identify patients with more elevated risks of both cardiac hemodynamic impairment and kidney dysfunction.
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Affiliation(s)
- Alberto Palazzuoli
- Department of Internal Medicine, UOS Cardiology, S. Maria alle Scotte Hospital Siena, University of Siena, Italy.
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Hogan CJ, Ward KR, Franzen DS, Rajendran B, Thacker LR. Sublingual tissue perfusion improves during emergency treatment of acute decompensated heart failure. Am J Emerg Med 2012; 30:872-80. [PMID: 21871763 PMCID: PMC3236806 DOI: 10.1016/j.ajem.2011.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 06/03/2011] [Accepted: 06/05/2011] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The aim of this study was to measure sublingual perfused capillary density (PCD) to assess sublingual microvascular perfusion during emergency department (ED) treatment of acute decompensated heart failure (ADHF). METHODS This prospective, observational study enrolled ED patients with ADHF, measuring pre- and post-ED treatment PCD. Sidestream dark-field imaging was analyzed by 3 investigators blinded to patient identifiers and time points. Patient demographics, ADHF etiology, serum brain natriuretic peptide, and hemoglobin were measured along with a visual analogue scale (VAS), which assessed patient baseline characteristics and response to ED treatment. A paired t test analyzed changes in PCD, mean arterial pressure (MAP), and patient assessment. Interrater variability was assessed with an intraclass correlation coefficient (ICC), with a P value <.05 considered significant for all testing. RESULTS Thirty-six patients were enrolled with a mean time between pretreatment and posttreatment PCD (±SD) of 138 ± 59 minutes and a hospital length of stay of 4.0 ± 4.1 days. During this time, PCD increased (difference, 1.3 mm/mm(2); 95% confidence interval, 0.4-2.1; P = .004), as did the MAP (P = .002), patient VAS score (P < .001), and observer VAS score (P < .001). There was no correlation between the change in PCD and time (R(2) = .016, P = .47), MAP (R(2) = .013, P = .54), or VAS scores. The ICC was 0.954. CONCLUSIONS Sublingual tissue perfusion is diminished in ADHF but increases with treatment. It may represent a quantitative way to evaluate ADHF in the ED setting.
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Affiliation(s)
- Christopher J Hogan
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Medical College of Virginia Campus, Richmond, VA 23298-0401, USA.
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Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mueller C. Happy birthday BNP. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2012; 1:109-110. [PMID: 24062896 PMCID: PMC3760530 DOI: 10.1177/2048872612447143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Carpenter CR, Keim SM, Worster A, Rosen P. Brain natriuretic peptide in the evaluation of emergency department dyspnea: is there a role? J Emerg Med 2011; 42:197-205. [PMID: 22123173 DOI: 10.1016/j.jemermed.2011.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 07/13/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute decompensated congestive heart failure (ADCHF) is a common etiology of dyspnea in emergency department (ED) patients. Delayed diagnosis of ADCHF increases morbidity and mortality. Two cardiac biomarkers, N-terminal-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) have demonstrated excellent sensitivity in diagnostic accuracy studies, but the clinical impact on patient-oriented outcomes of these tests remains in question. CLINICAL QUESTION Does emergency physician awareness of BNP or NT-proBNP level improve ADCHF patient-important outcomes including ED length of stay, hospital length of stay, cardiovascular mortality, or overall health care costs? EVIDENCE REVIEW Five trials have randomized clinicians to either knowledge of or no knowledge of ADCHF biomarker levels in ED patients with dyspnea and some suspicion for heart failure. In assessing patient-oriented outcomes such as length-of-stay, return visits, and overall health care costs, the randomized controlled trials fail to provide evidence of unequivocal benefit to patients, clinicians, or society. CONCLUSION Clinician awareness of BNP or NT-proBNP levels in ED dyspnea patients does not necessarily improve outcomes. Future ADCHF biomarker trials must assess patient-oriented outcomes in conjunction with validated risk-stratification instruments.
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Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis. Am J Emerg Med 2011; 29:757-67. [DOI: 10.1016/j.ajem.2010.02.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 02/25/2010] [Accepted: 02/25/2010] [Indexed: 02/03/2023] Open
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Sokhanvar S, Shekhi M, Mazlomzadeh S, Golmohammadi Z. The Relationship between Serum NT- Pro-BNP Levels and Prognosis in Patients with Systolic Heart Failure. J Cardiovasc Thorac Res 2011; 3:57-61. [PMID: 24250954 DOI: 10.5681/jcvtr.2011.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 03/16/2011] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Most studies reported using N-terminal pro-brain natriuretic peptide (NT-proBNP) in diagnosis of heart failure but there is controversy about use of these tests in determining prognosis and classification of severity of heart failure. The objective of this study was to determine the value of plasma NT-proBNP levels assessment in evaluation of mortality and morbidity of patients with systolic left ventricular dysfunction. METHODS A cohort study was performed in 150 patients with heart failure since September 2009 until February 2010. The patients were followed for 6 months to assess their prognosis. Patients were divided into two good and bad prognosis groups according to severity of heart failure in New York Heart Association (NYHA) class and frequency of hospital admission and mortality due to cardiac causes. Patients with good prognosis had ≥1 admission or no mortality or NYHA class ≥2 and patients that had one of this criteria considered as bad prognosis groups. Pro-BNP levels were measured at baseline and left ventricular ejection fraction (LVEF) was estimated with echocardiography. Data was analyzed with using Chi-square, t-test, ANOVA, Kruskal-Wallis tests. RESULTS In patients with heart failure that enrolled in this clinical study, ten patients were lost during follow-up. The mean of NT-proBNP is significantly correlated with ejection fraction (p=0.003) and NYHA class (p<0.001). In our study among 140 patients who were follow-up for 6 months, 11(9.7%) of individuals died with mean NT-proBNP of 8994.8±8375 pg/ml, in survived patients mean NT-proBNP was 3756.8±5645.6 pg/ml that was statistically significant (P=0.02). Mean NT-proBNP in the group with good prognosis was 2723.8±4845.2 pg/ml and in the group with bad prognosis was 5420.3±6681 pg/ml, difference was statistically significant (P=0.0001). CONCLUSION Our study in consistent with other studies confirms that NT-proBNP is significantly correlated with mortality and morbidity. This could be predicting adverse out come and stratification in patients with heart failure. It is recommended that more research be performed in Iran.
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Affiliation(s)
- Sepideh Sokhanvar
- Department of Cardiology, Zanjan University of Medical Sciences, Zanjan, Iran
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Thygesen K, Mair J, Mueller C, Huber K, Weber M, Plebani M, Hasin Y, Biasucci LM, Giannitsis E, Lindahl B, Koenig W, Tubaro M, Collinson P, Katus H, Galvani M, Venge P, Alpert JS, Hamm C, Jaffe AS. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2011; 33:2001-6. [PMID: 21292681 DOI: 10.1093/eurheartj/ehq509] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kristian Thygesen
- Department of Medicine and Cardiology, Aarhus University Hospital, Tage-Hansens Gade 2, Aarhus C DK-8000, Denmark.
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Teixeira A, Legrain S, Ray P. Diagnostic étiologique de la dyspnée aiguë du sujet âgé : place des biomarqueurs en urgence. Presse Med 2009; 38:1506-15. [DOI: 10.1016/j.lpm.2008.12.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 10/29/2008] [Accepted: 12/18/2008] [Indexed: 11/28/2022] Open
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Socrates T, Arenja N, Mueller C. B-Type Natriuretic Peptide in Children. J Am Coll Cardiol 2009; 54:1476-7. [DOI: 10.1016/j.jacc.2009.04.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
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Doust JA, Craig JC. Evaluating diagnostic tests-should the same methods apply? Am Heart J 2008; 156:4-6. [PMID: 18585490 DOI: 10.1016/j.ahj.2008.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 03/11/2008] [Indexed: 11/19/2022]
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Abstract
Telomeres carry out conserved and possibly ancient functions in meiosis. During the specialized prophase of meiosis I, meiotic prophase, telomeres cluster on the nuclear envelope and move the diploid genetic material around within the nucleus so that homologous chromosomes can align two by two and efficiently recombine with precision. This recombination is in turn required for proper segregation of the homologs into viable haploid daughter cells. The meiosis-specific telomere clustering on the nuclear envelope defines the bouquet stage, so named for its resemblance to the stems from a bouquet of cut flowers. Here, a comparative analysis of the literature on meiotic telomeres from a variety of different species illustrates that the bouquet is nearly universal among life cycles with sexual reproduction. The bouquet has been well documented for over 100 years, but our understanding of how it forms and how it functions has only recently begun to increase. Early and recent observations document the timing and provide clues about the functional significance of these striking telomere movements.
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Affiliation(s)
- H W Bass
- Department of Biological Science, Florida State University, Tallahassee, Florida 32306-4370, USA.
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