Pitfalls in the evaluation of shortness of breath

Diagnostic value of MR-proANP for heart failure in patients with acute dyspnea：a meta-analysis

Objectives: This study aimed to review the diagnostic value of mid-regional pro-atrial natriuretic peptide (MR-proANP) for heart failure (HF) in patients who presented to the emergency department (ED) with acute dyspnoea.Methods: Relevant studies were searched on the databases of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, with publication date limited to 30 March 2018. Literature identification, quality assessment, data extraction, synthesis, and statistical analysis were performed by standard meta-analysis methods. Individual and pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated.Results: A total of eight studies were retrieved, involving 1562 HF patients and 2249 non-HF patients. The sensitivity for each included study ranged from 80 to 97%, with a pooled sensitivity of 90% (95% CI: 88-91%), while the specificity ranged from 37 to 86%, with a pooled specificity of 68% (95% CI: 66-70%). The pooled PLR for included studies was 2.88(95% CI: 2.12-3.93), with a pooled NLR of 0.16 (95% CI: 0.11-0.24), and a pooled DOR of 18.97 (95% CI: 11.73-30.68).Conclusions: With a decent sensitivity, MR-proANP is a useful biomarker for correctly identifying HF in patients with acute dyspnoea.

Evaluation of mid-regional pro-atrial natriuretic peptide, procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients

OBJECTIVE

The aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea.

METHODS

We prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates.

RESULTS

One hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR-) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR-: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91).

CONCLUSION

The good negative LR- of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..

Pleural disease in the emergency department

Emergency department presentations of pleural-based diseases are common, with severity ranging from mild to life threatening. The acute assessment, diagnosis, and treatment of pleural disease are critical as urgent invasive maneuvers such as thoracocentesis and thoracostomy may be indicated. The emergency physician must have a systematic approach to these conditions that allows for rapid recognition, diagnosis, and definitive management. This article focuses on nontraumatic pleural disease, including diagnostic and treatment considerations of pleural effusion, empyema, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pediatric pneumothorax, spontaneous hemothorax, and spontaneous tension pneumothorax.