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Sartini S, Frizzi J, Borselli M, Sarcoli E, Granai C, Gialli V, Cevenini G, Guazzi G, Bruni F, Gonnelli S, Pastorelli M. Which method is best for an early accurate diagnosis of acute heart failure? Comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: a prospective study. Intern Emerg Med 2017; 12:861-869. [PMID: 27401330 DOI: 10.1007/s11739-016-1498-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 06/26/2016] [Indexed: 01/06/2023]
Abstract
Acute heart failure is a common condition among adults presenting with dyspnea in the Emergency Department (ED), still the diagnosis is challenging as objective standardized criteria are lacking. First line work-up, other then clinical findings, is nowadays made with lung ultrasound imaging study, chest X-ray study and brain natriuretic peptide (BNP) level determination; however, it is not clear which is the best diagnostic test to be used and whether there is any real benefit for clinical judgement. We set up this study to compare the performances of these three diagnostic tools; furthermore, we combined them to find the best possible approach to dyspneic patients. This is a prospective observational study based in the ED. We enrolled adults presenting with dyspnea not trauma-related, they underwent lung ultrasound, and chest X-ray studies, and NT pro-BNP level determination. Then we compared the results with the diagnosis of acute heart failure established by an independent panel of experts. 236 patients were enrolled in the study. We find sensitivity and specificity for lung ultrasound of 57.73 and 87.97 %, for chest X-ray 74.49 and 86.26 %, for NT pro-BNP 97.59 and 27.56 %, respectively. Combining together the chest X-ray and lung ultrasound, we find the best overall performance with 84.69 % sensitivity, 77.69 % specificity and 87.07 % negative predictive value. From our results, we could not identify the "best test" to diagnose acute heart failure in an emergency setting, although we could suggest that a stepwise workup combining chest X-ray and lung ultrasound at first, then for those negative, a determination of NT pro-BNP assay would be a reasonable approach to the dyspneic patient.
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Affiliation(s)
- Stefano Sartini
- IRCCS AOU San Martino, Genoa, Italy.
- , Via Marco Perennio 24/c, 52100, Arezzo, AR, Italy.
| | - Jacopo Frizzi
- Emergency Department, Hospital of Lucca, Lucca, Italy
| | - Matteo Borselli
- Emergency Department, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | | | - Carolina Granai
- Emergency Department, University Hospital of Siena, Siena, Italy
| | - Veronica Gialli
- Emergency Department, University Hospital of Siena, Siena, Italy
| | | | - Gianni Guazzi
- Department of Emergency Radiology, University Hospital of Siena, Siena, Italy
| | - Fulvio Bruni
- Emergency Department, University Hospital of Siena, Siena, Italy
| | - Stefano Gonnelli
- Internal Medicine Department, University Hospital of Siena, Siena, Italy
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Prognostic Impact of BNP Variations in Patients Admitted for Acute Decompensated Heart Failure with In-Hospital Worsening Renal Function. Heart Lung Circ 2017; 26:226-234. [DOI: 10.1016/j.hlc.2016.06.1205] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 03/15/2016] [Accepted: 06/04/2016] [Indexed: 12/20/2022]
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Li JJ, Xiang XL, Tian XY, Shi YF. Clinical Research on Brain Natriuretic Peptide Guiding the Application of β1 Receptor Blocker in Patients with Moderate to Severe Heart Failure. ACTA CARDIOLOGICA SINICA 2016; 31:52-8. [PMID: 27122846 DOI: 10.6515/acs20140728a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study aimed to explore the feasibility of guiding the application of metoprolol succinate in patients with moderate to severe heart failure (HF) through monitoring plasma brain natriuretic peptide (BNP) levels. METHODS A total of 195 patients with moderate to severe HF (NYHA Functional Class III to IV) were selected and randomized into two groups: an observation group and a BNP group. The groups were established to observe the clinical conditions and establish plasma BNP levels to guide the application of metoprolol succinate. The average start-up of metoprolol succinate and average dose of metoprolol succinate after one month, as well as the recurrence rate and mortality of HF during hospital stay were compared between the two groups. RESULTS Start-up of metoprolol succinate was shorter in the BNP group than in the observation group [(5.89 ± 1.76) d vs. (7.03 ± 2.08) d, p < 0.01], but no significant differences in recurrence rate (26.60% vs. 23.91%, p > 0.05) and mortality (6.38% vs. 5.43%, p > 0.05) of HF were observed between the two groups. The average dose of metoprolol succinate after one month was higher in the BNP group compared with that of the observation group [(47.65 ± 13.09) mg/d vs. (35.08 ± 11.08) mg/d, p < 0.01]. CONCLUSIONS Although monitoring plasma BNP might have limited the clinical impact on the change of left ventricular ejection fraction, recurrence of HF or mortality within 1 month, it could safely facilitate early use and up-titration of the metoprolol succinate in patients with moderate to severe HF. KEY WORDS BNP; Heart failure; β receptor blocker.
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Affiliation(s)
- Jiang-Jin Li
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, Jiangsu Province, P. R. China
| | - Xiao-Li Xiang
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, Jiangsu Province, P. R. China
| | - Xiao-Yi Tian
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, Jiangsu Province, P. R. China
| | - Ya-Fei Shi
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, Jiangsu Province, P. R. China
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Abstract
In the assessment of dyspnea one has to take into account both the patient's own experience of the symptom and the clinicians observations of breathing rates, sounds and effort to get a complete picture. In addition, to choose appropriate treatment, the underlying cause of dyspnea needs to be assessed. While tools for clinical evaluation of heart failure have gained great interest in research and found a place in guidelines and clinical practice, the same cannot be said for instruments to assess patient self-reported dyspnea. To date, no specific dyspnea rating tool has been recommend over another. Reports from clinical practice are lacking and large; international studies in this field are warranted.
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Affiliation(s)
- Barbro Kjellström
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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Alonso-Gonzalez R, Dimopoulos K. Biomarkers in congenital heart disease: do natriuretic peptides hold the key? Expert Rev Cardiovasc Ther 2014; 11:773-84. [PMID: 23750686 DOI: 10.1586/erc.13.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Congenital heart disease is the most common congenital abnormality. The long-term prognosis of these patients has changed significantly over the last half century, thanks to improvements in cardiovascular diagnosis, surgery and postoperative care. However, residual lesions are not uncommon and many of the interventions performed remain palliative rather than reparative, leading to the development of ventricular dysfunction and heart failure. Natriuretic peptides are well-established markers of disease severity and prognosis in patients with heart failure due to noncongenital (acquired) heart disease. However, the role of biomarkers in congenital heart disease is unclear. This review highlights the impact of neurohormonal activation in patients with congenital heart disease, as well as the usefulness of assessing natriuretic peptide levels in specific clinical situations.
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Affiliation(s)
- Rafael Alonso-Gonzalez
- Adult Congenital Heart Disease Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney Street, London, UK
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Fan D, Takawale A, Lee J, Kassiri Z. Cardiac fibroblasts, fibrosis and extracellular matrix remodeling in heart disease. FIBROGENESIS & TISSUE REPAIR 2012; 5:15. [PMID: 22943504 PMCID: PMC3464725 DOI: 10.1186/1755-1536-5-15] [Citation(s) in RCA: 577] [Impact Index Per Article: 48.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 08/16/2012] [Indexed: 12/30/2022]
Abstract
Fibroblasts comprise the largest cell population in the myocardium. In heart disease, the number of fibroblasts is increased either by replication of the resident myocardial fibroblasts, migration and transformation of circulating bone marrow cells, or by transformation of endothelial/epithelial cells into fibroblasts and myofibroblasts. The primary function of fibroblasts is to produce structural proteins that comprise the extracellular matrix (ECM). This can be a constructive process; however, hyperactivity of cardiac fibroblasts can result in excess production and deposition of ECM proteins in the myocardium, known as fibrosis, with adverse effects on cardiac structure and function. In addition to being the primary source of ECM proteins, fibroblasts produce a number of cytokines, peptides, and enzymes among which matrix metalloproteinases (MMPs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs), directly impact the ECM turnover and homeostasis. Function of fibroblasts can also in turn be regulated by MMPs and TIMPs. In this review article, we will focus on the function of cardiac fibroblasts in the context of ECM formation, homeostasis and remodeling in the heart. We will discuss the origins and multiple roles of cardiac fibroblasts in myocardial remodeling in different types of heart disease in patients and in animal models. We will further provide an overview of what we have learned from experimental animal models and genetically modified mice with altered expression of ECM regulatory proteins, MMPs and TIMPs.
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Affiliation(s)
- Dong Fan
- Department of Physiology, University of Alberta, Edmonton, AB, T6G 2S2, Canada.
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Iqbal N, Wentworth B, Choudhary R, Landa ADLP, Kipper B, Fard A, Maisel AS. Cardiac biomarkers: new tools for heart failure management. Cardiovasc Diagn Ther 2012; 2:147-64. [PMID: 24282708 PMCID: PMC3839143 DOI: 10.3978/j.issn.2223-3652.2012.06.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 06/08/2012] [Indexed: 12/14/2022]
Abstract
The last decade has seen exciting advances in the field of biomarkers used in managing patients with heart failure (HF). Biomarker research has broadened our knowledge base, shedding more light on the underlying pathophysiological mechanisms occurring in patients with both acute and chronic HF. The criterion required by an ideal cardiovascular biomarker has been progressively changing to an era of sensitive assays that can be used to guide treatment. Recent technological advances have made it possible to rapidly measure even minute amounts of these proteins by means of higher sensitivity assays. With a high prevalence of comorbidities associated with HF, an integrated approach utilizing multiple biomarkers have shown promise in predicting mortality, better risk stratification and reducing re-hospitalizations, thus lowering health-care costs. This review provides a brief insight into recent advances in the field of biomarkers currently used in the diagnosis and prognosis of patients with acute and chronic HF.
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Affiliation(s)
- Navaid Iqbal
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Bailey Wentworth
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Rajiv Choudhary
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | | | - Benjamin Kipper
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Arrash Fard
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Alan S. Maisel
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California at San Diego, La Jolla, CA, USA
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