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Thiruganasambandamoorthy V, McRae AD, Rowe BH, Sivilotti MLA, Mukarram M, Nemnom MJ, Booth RA, Calder LA, Stiell IG, Wells GA, Cheng W, Taljaard M. Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope? Ann Intern Med 2020; 172:648-655. [PMID: 32340039 DOI: 10.7326/m19-3515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. OBJECTIVE To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). DESIGN Prospective cohort study. SETTING 6 EDs in 2 Canadian provinces. PARTICIPANTS 1452 adult ED patients with syncope. INTERVENTION Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. MEASUREMENTS An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. RESULTS Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. LIMITATIONS Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. CONCLUSION Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. PRIMARY FUNDING SOURCE Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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Affiliation(s)
| | - Andrew D McRae
- University of Calgary, Calgary, Alberta, Canada (A.D.M.)
| | - Brian H Rowe
- University of Alberta, Edmonton, Alberta, Canada (B.H.R.)
| | | | | | | | - Ronald A Booth
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Lisa A Calder
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - Ian G Stiell
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - George A Wells
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Wei Cheng
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Monica Taljaard
- The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (M.T.)
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Badertscher P, Nestelberger T, de Lavallaz JDF, Than M, Morawiec B, Kawecki D, Miró Ò, López B, Martin-Sanchez FJ, Bustamante J, Geigy N, Christ M, Di Somma S, Peacock WF, Cullen L, Sarasin F, Flores D, Tschuck M, Boeddinghaus J, Twerenbold R, Wildi K, Sabti Z, Puelacher C, Rubini Giménez M, Kozhuharov N, Shrestha S, Strebel I, Rentsch K, Keller DI, Poepping I, Buser A, Kloos W, Lohrmann J, Kuehne M, Osswald S, Reichlin T, Mueller C. Prohormones in the Early Diagnosis of Cardiac Syncope. J Am Heart Assoc 2017; 6:JAHA.117.006592. [PMID: 29426039 PMCID: PMC5779001 DOI: 10.1161/jaha.117.006592] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background The early detection of cardiac syncope is challenging. We aimed to evaluate the diagnostic value of 4 novel prohormones, quantifying different neurohumoral pathways, possibly involved in the pathophysiological features of cardiac syncope: midregional–pro‐A‐type natriuretic peptide (MRproANP), C‐terminal proendothelin 1, copeptin, and midregional‐proadrenomedullin. Methods and Results We prospectively enrolled unselected patients presenting with syncope to the emergency department (ED) in a diagnostic multicenter study. ED probability of cardiac syncope was quantified by the treating ED physician using a visual analogue scale. Prohormones were measured in a blinded manner. Two independent cardiologists adjudicated the final diagnosis on the basis of all clinical information, including 1‐year follow‐up. Among 689 patients, cardiac syncope was the adjudicated final diagnosis in 125 (18%). Plasma concentrations of MRproANP, C‐terminal proendothelin 1, copeptin, and midregional‐proadrenomedullin were all significantly higher in patients with cardiac syncope compared with patients with other causes (P<0.001). The diagnostic accuracies for cardiac syncope, as quantified by the area under the curve, were 0.80 (95% confidence interval [CI], 0.76–0.84), 0.69 (95% CI, 0.64–0.74), 0.58 (95% CI, 0.52–0.63), and 0.68 (95% CI, 0.63–0.73), respectively. In conjunction with the ED probability (0.86; 95% CI, 0.82–0.90), MRproANP, but not the other prohormone, improved the area under the curve to 0.90 (95% CI, 0.87–0.93), which was significantly higher than for the ED probability alone (P=0.003). An algorithm to rule out cardiac syncope combining an MRproANP level of <77 pmol/L and an ED probability of <20% had a sensitivity and a negative predictive value of 99%. Conclusions The use of MRproANP significantly improves the early detection of cardiac syncope among unselected patients presenting to the ED with syncope. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01548352.
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Affiliation(s)
- Patrick Badertscher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Martin Than
- GREAT Network, Rome, Italy.,Christchurch Hospital, Christchurch, New Zealand
| | - Beata Morawiec
- GREAT Network, Rome, Italy.,2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Damian Kawecki
- GREAT Network, Rome, Italy.,2nd Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Òscar Miró
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz López
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - José Bustamante
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Nicolas Geigy
- Department of Emergency Medicine, Hospital of Liestal, Switzerland
| | - Michael Christ
- GREAT Network, Rome, Italy.,Department of Emergency Care, Lucerne General Hospital, Lucerne, Switzerland
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital University Sapienza Rome, Rome, Italy
| | - W Frank Peacock
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Louise Cullen
- GREAT Network, Rome, Italy.,Royal Brisbane and Women's Hospital, Herston, Australia
| | - François Sarasin
- Emergency Department, Hôpitaux Universitaires de Genève, Switzerland
| | - Dayana Flores
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Michael Tschuck
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Zaid Sabti
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel University of Basel, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Imke Poepping
- Department of Internal Medicine, Hospital of Lachen, Switzerland
| | - Andreas Buser
- Department of Hematology, University Hospital Basel University of Basel, Switzerland.,Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Michael Kuehne
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel University of Basel, Switzerland .,GREAT Network, Rome, Italy
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