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Khosla K, Jin Y, Espinoza J, Kent M, Gencay M, Kunz LH, Mueller A, Xiao Y, Frank Peacock W, Neath SX, Stuart JJ, Woelkers D, Harris JM, Rana S. Signs or symptoms of suspected preeclampsia - A retrospective national database study of prevalence, costs, and outcomes. Pregnancy Hypertens 2024; 36:101124. [PMID: 38608393 DOI: 10.1016/j.preghy.2024.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia. METHODS This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control). RESULTS Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control). CONCLUSION There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management.
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Affiliation(s)
- Kavia Khosla
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Yue Jin
- Roche Diagnostics, Indianapolis, IN, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center Houston, and UT Physicians, The Fetal Center, Affiliated with Children's Memorial Hermann Hospital, TX, USA
| | - Matthew Kent
- Department of Epidemiology and Biostatistics, Genesis Research, Hoboken, NJ, USA
| | | | - Liza H Kunz
- Roche Diagnostics Systems, San Jose, CA, USA
| | - Ariel Mueller
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yan Xiao
- Roche Diagnostics Systems, San Jose, CA, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sean-Xavier Neath
- Department of Emergency Medicine, Gynecology and Reproductive Science, University of California, La Jolla, CA, USA
| | - Jennifer J Stuart
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Douglas Woelkers
- Department of Obstetrics, Gynecology and Reproductive Science, University of California, La Jolla, CA, USA
| | | | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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Beri N, Daniels LB, Jaffe A, Mueller C, Anand I, Peacock WF, Hollander JE, DeFilippi C, Schreiber D, McCord J, Limkakeng AT, Wu AHB, Apple FS, Diercks DB, Nagurney JT, Nowak RM, Cannon CM, Clopton P, Neath SX, Christenson RH, Hogan C, Vilke G, Maisel A. Copeptin to rule out myocardial infarction in Blacks versus Caucasians. European Heart Journal: Acute Cardiovascular Care 2018; 8:395-403. [DOI: 10.1177/2048872618772500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Copeptin in combination with troponin has been shown to have incremental value for the early rule-out of myocardial infarction, but its performance in Black patients specifically has never been examined. In light of a potential for wider use, data on copeptin in different relevant cohorts are needed. This is the first study to determine whether copeptin is equally effective at ruling out myocardial infarction in Black and Caucasian races. Methods: This analysis of the CHOPIN trial included 792 Black and 1075 Caucasian patients who presented to the emergency department with chest pain and had troponin-I and copeptin levels drawn. Results: One hundred and forty-nine patients were diagnosed with myocardial infarction (54 Black and 95 Caucasian). The negative predictive value of copeptin at a cut-off of 14 pmol/l (as in the CHOPIN study) for myocardial infarction was higher in Blacks (98.0%, 95% confidence interval (CI) 96.2–99.1%) than Caucasians (94.1%, 95% CI 92.1–95.7%). The sensitivity at 14 pmol/l was higher in Blacks (83.3%, 95% CI 70.7–92.1%) than Caucasians (53.7%, 95% CI 43.2–64.0%). After controlling for age, hypertension, heart failure, chronic kidney disease and body mass index in a logistic regression model, the interaction term had a P value of 0.03. A cut-off of 6 pmol/l showed similar sensitivity in Caucasians as 14 pmol/l in Blacks. Conclusions: This is the first study to identify a difference in the performance of copeptin to rule out myocardial infarction between Blacks and Caucasians, with increased negative predictive value and sensitivity in the Black population at a cut-off of 14 pmol/l. This also holds true for non-ST-segment elevation myocardial infarction and, although numbers were small, similar trends exist in the normal troponin population. This may have significant implications for early rule-out strategies using copeptin.
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Affiliation(s)
- Neil Beri
- Department of Internal Medicine, University of California, USA
| | | | | | | | - Inder Anand
- Department of Cardiology, Veterans Affairs Medical Center, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, USA
| | | | | | - James McCord
- Department of Cardiology, Henry Ford Health System, USA
| | | | - Alan H B Wu
- Department of Pathology and Laboratory Medicine, University of California, USA
| | - Fred S Apple
- Department of Pathology, Hennepin County Medical Center and University of Minnesota, USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Richard M Nowak
- Department of Emergency Medicine, Henry Ford Health System, USA
| | - Chad M Cannon
- Department of Emergency Medicine, University of Kansas, USA
| | - Paul Clopton
- Department of Research, Veterans Affairs Medical Center, USA
| | | | | | | | - Gary Vilke
- Department of Emergency Medicine, University of California, USA
| | - Alan Maisel
- Department of Cardiology, University of California, USA
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Beunders R, Struck J, Wu AH, Zarbock A, Di Somma S, Mehta RL, Koyner JL, Nadim MK, Maisel AS, Murray PT, Neath SX, Jaffe A, Pickkers P. Proenkephalin (PENK) as a Novel Biomarker for Kidney Function. ACTA ACUST UNITED AC 2017; 2:400-412. [DOI: 10.1373/jalm.2017.023598] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
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Beri N, Marston NA, Daniels LB, Nowak RM, Schreiber D, Mueller C, Jaffe A, Diercks DB, Wettersten N, DeFilippi C, Peacock WF, Limkakeng AT, Anand I, McCord J, Hollander JE, Wu AHB, Apple FS, Nagurney JT, Berardi C, Cannon CM, Clopton P, Neath SX, Christenson RH, Hogan C, Vilke G, Maisel A. Necessity of hospitalization and stress testing in low risk chest pain patients. Am J Emerg Med 2016; 35:274-280. [PMID: 27847253 DOI: 10.1016/j.ajem.2016.10.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/10/2016] [Accepted: 10/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). OBJECTIVES The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI<0.040μg/l and copeptin<14pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. METHODS This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<0.040μg/l) and copeptin<14pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis. RESULTS None of the 475 "low risk" patients were diagnosed with MI during the 180day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p=.002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p<.001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p=.040). CONCLUSIONS In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.
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Affiliation(s)
- Neil Beri
- Department of Internal Medicine, University of California, San Diego, La Jolla, CA, United States.
| | - Nicholas A Marston
- Department of Internal Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Lori B Daniels
- Division of Cardiology, Department of Internal Medicine, University of California, San Diego, La Jolla, California, United States
| | - Richard M Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, United States
| | - Donald Schreiber
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, United States
| | - Christian Mueller
- Division of Cardiology, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Allan Jaffe
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX, United States
| | - Nicholas Wettersten
- Division of Cardiology, Department of Internal Medicine, University of California, San Diego, La Jolla, California, United States
| | - Christopher DeFilippi
- Division of Cardiology, Department of Internal Medicine, University of Maryland, Baltimore, MD, United States
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States
| | | | - Inder Anand
- Division of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Minneapolis, MN, United States
| | - James McCord
- Division of Cardiology, Department of Internal Medicine, Henry Ford Health System, Detroit, MI, United States
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Alan H B Wu
- Department of Pathology and Laboratory Medicine, University of California, San Francisco, CA, United States
| | - Fred S Apple
- Department of Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis, United States
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Cecilia Berardi
- School of Medicine, "La Sapienza" University of Rome, Rome, Italy
| | - Chad M Cannon
- Department of Emergency Medicine, University of Kansas, Kansas City, KS, United States
| | - Paul Clopton
- Statistics, Veterans Affairs Medical Center, San Diego, CA, United States
| | - Sean-Xavier Neath
- Department of Emergency Medicine, University of California, San Diego, La Jolla, CA, United States
| | | | - Christopher Hogan
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Gary Vilke
- Department of Emergency Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Alan Maisel
- Division of Cardiology, Department of Internal Medicine, University of California, San Diego, La Jolla, California, United States
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Beri N, Marston N, Clopton P, Daniels L, Schreiber D, Mueller C, Jaffe A, DeFilippi C, Peacock WF, Anand I, McCord J, Limkakeng A, Hollander J, Wu A, Apple F, Diercks D, Nagurney J, Cannon C, Neath SX, Christenson R, Nowak R, Hogan C, Vilke G, Maisel A. HOSPITALIZATION OF LOW RISK CHEST PAIN PATIENTS WITH NORMAL TROPONIN AND COPEPTIN. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Beri N, Clopton P, Daniels L, DeFilippi C, Mueller C, Jaffe A, Peacock WF, Anand I, Limkakeng A, McCord J, Schreiber D, Wu A, Apple F, Hollander J, Diercks D, Nagurney J, Cannon C, Neath SX, Christenson R, Nowak R, Hogan C, Vilke G, Maisel A. BIOMARKER MODEL FOR CORONARY ARTERY DISEASE. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)32142-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Marston NA, Shah KS, Mueller C, Neath SX, Christenson RH, McCord J, Nowak RM, Daniels LB, Hollander JE, Apple F, Nagurney J, Schreiber D, deFilippi C, Diercks D, Limkakeng A, Anand IS, Wu AHB, Jaffe AS, Peacock WF, Maisel AS. Serial sampling of copeptin levels improves diagnosis and risk stratification in patients presenting with chest pain: results from the CHOPIN trial. Emerg Med J 2015; 33:23-9. [DOI: 10.1136/emermed-2015-204692] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/27/2015] [Indexed: 11/04/2022]
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Shah KS, Marston NA, Mueller C, Neath SX, Christenson RH, McCord J, Nowak RM, Vilke GM, Daniels LB, Hollander JE, Apple FS, Cannon CM, Nagurney J, Schreiber D, deFilippi C, Hogan CJ, Diercks DB, Limkakeng A, Anand IS, Wu AHB, Clopton P, Jaffe AS, Peacock WF, Maisel AS. Midregional proadrenomedullin predicts mortality and major adverse cardiac events in patients presenting with chest pain: results from the CHOPIN trial. Acad Emerg Med 2015; 22:554-63. [PMID: 25908114 DOI: 10.1111/acem.12649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/20/2014] [Accepted: 12/01/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Chest pain is a common complaint to emergency departments (EDs) and clinical risk factors are used to predict which patients are at risk for worse outcomes and mortality. The goal was to assess the novel biomarker midregional proadrenomedullin (MR-proADM) in prediction of mortality and major adverse cardiac events (MACE). METHODS This was a subanalysis of the CHOPIN study, a 16-center prospective trial that enrolled 2,071 patients presenting with chest pain within 6 hours of onset. The primary endpoint was 6-month all-cause mortality and the secondary endpoint was 30-day and 6-month MACE: ED visits or hospitalization for acute myocardial infarction, unstable angina, reinfarction, revascularization, and heart failure. RESULTS MR-proADM performed similarly to troponin (cTnI; c-statistic = 0.845 and 0.794, respectively) for mortality prediction in all subjects and had similar results in those with noncardiac diagnoses. MR-proADM concentrations were stratified by decile, and the cohort in the top decile had a 9.8% 6-month mortality risk versus 0.9% risk for those in the bottom nine deciles (p < 0.0001). MR-proADM, history of coronary artery disease (CAD), and hypertension were predictors of short-term MACE, while history of CAD, hypertension, cTnI, and MR-proADM were predictors of long-term MACE. CONCLUSIONS In patients with chest pain, MR-proADM predicts mortality and MACE in all-comers with chest pain and has similar prediction in those with a noncardiac diagnosis. This exploratory analysis is primarily hypotheses-generating and future prospective studies to identify its utility in risk stratification should be considered.
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Affiliation(s)
- Kevin S. Shah
- Department of Internal Medicine; University of California; San Diego CA
| | | | - Christian Mueller
- Department of Cardiology; University Hospital Basel; Basel Switzerland
| | - Sean-Xavier Neath
- Department of Emergency Medicine; University of California; San Diego CA
| | | | - James McCord
- Department of Emergency Medicine; Henry Ford Health System; Detroit MI
| | - Richard M. Nowak
- Department of Emergency Medicine; Henry Ford Health System; Detroit MI
| | - Gary M. Vilke
- Department of Emergency Medicine; University of California; San Diego CA
| | - Lori B. Daniels
- Department of Cardiology; University of California; San Diego CA
| | - Judd E. Hollander
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Fred S. Apple
- Department of Pathology; Hennepin County Medical Center and University of Minnesota; Minneapolis MN
| | - Chad M. Cannon
- Department of Emergency Medicine; University of Kansas Hospital; Kansas City KS
| | - John Nagurney
- Department of Emergency Medicine; Massachusetts General Hospital; Boston MA
| | - Donald Schreiber
- Department of Emergency Medicine; Stanford University School of Medicine; Palo Alto CA
| | | | | | - Deborah B. Diercks
- Department of Emergency Medicine; University of California, Davis Medical Center; Sacramento CA
| | | | - Inder S. Anand
- Department of Cardiology; Veterans Administration Hospital; Minneapolis MN
| | - Alan H. B. Wu
- Department of Pathology; University of California; San Francisco CA
| | - Paul Clopton
- Department of Research; Veterans Affairs Medical Center; San Diego CA
| | - Allan S. Jaffe
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester MN
| | - W. Frank Peacock
- Department of Emergency Medicine; Baylor College of Medicine; Houston TX
| | - Alan S. Maisel
- Department of Cardiology; University of California; San Diego CA
- Department of Cardiology; Veterans Affairs Medical Center; San Diego CA
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Neath SX, Jefferies JL, Berger JS, Wu AHB, McConnell JP, Boone JL, McCullough PA, Jesse RL, Maisel AS. The current and future landscape of urinary thromboxane testing to evaluate atherothrombotic risk. Rev Cardiovasc Med 2014; 15:119-30. [PMID: 25051129 DOI: 10.3909/ricm0739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Biomarker testing for efficacy of therapy is an accepted way for clinicians to individualize dosing to genetic and/or environmental factors that may be influencing a treatment regimen. Aspirin is used by nearly 43 million Americans on a regular basis to reduce risks associated with various atherothrombotic diseases. Despite its widespread use, many clinicians are unaware of the link between suboptimal response to aspirin therapy and increased risk for inferior clinical outcomes in several disease states, and biomarker testing for efficacy of aspirin therapy is not performed as routinely as efficacy testing in other therapeutic areas. This article reviews the clinical and laboratory aspects of determining whole-body thromboxane production, particularly as it pertains to efficacy assessment of aspirin responsiveness.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alan S Maisel
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA; Advanced Heart Failure and Cardiomyopathy Services, Pediatric Cardiology and Adult Cardiovascular Diseases, and Division of Human Genetics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Medicine, and Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, New York, NY; Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA; Health Diagnostic Laboratory, Richmond, VA; Boone Heart Institute, Denver, CO; Baylor Heart and Vascular Institute, Dallas, TX; Departments of Internal Medicine and Cardiology, Virginia Commonwealth University Health System, Richmond, VA, and Veterans Health Administration, Department of Veterans Affairs, Washington, DC; Department of Medicine, Division of Cardiovascular Medicine, University of California, San Diego and Director, Coronary Care Unit and Heart Failure Program, Veterans Affairs San Diego Healthcare System, San Diego, CA
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Marston N, Shah K, Mueller C, Neath SX, Christenson R, McCord J, Nowak R, Daniels L, Hollander J, Apple F, Cannon C, Nagurney J, Schreiber D, DeFilippi C, Hogan C, Diercks D, Limkakeng A, Anand I, Wu A, Jaffe A, Peacock WF, Maisel A. COPEPTIN PROVIDES PROGNOSTIC VALUE IN PATIENTS WITH ACUTE CHEST PAIN. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60058-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Shah K, Marston N, Mueller C, Neath SX, Christenson R, McCord J, Hollander J, Apple F, Cannon C, Nagurney J, Schreiber D, Hogan C, Diercks D, Limkakeng A, Anand I, Jaffe A, Peacock WF, Nowak R, Daniels L, DeFilippi C, Wu AH, Maisel A. MID-REGIONAL PROADRENOMEDULLIN PREDICTS LONG-TERM MORTALITY IN PATIENTS WITH CHEST PAIN. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Marston N, Shah K, Mueller C, Neath SX, Christenson R, McCord J, Nowak R, Vilke G, Daniels L, Hollander J, Apple F, Cannon C, Nagurney J, Schreiber D, DeFilippi C, Hogan C, Diercks D, Limkakeng A, Anand I, Jaffe A, Peacock WF, Maisel A, Wu A. CAN A SECOND MEASUREMENT OF COPEPTIN IMPROVE ACUTE MYOCARDIAL INFARCTION RULE OUT? J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60202-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Maisel A, Mueller C, Neath SX, Christenson RH, Morgenthaler NG, McCord J, Nowak RM, Vilke G, Daniels LB, Hollander JE, Apple FS, Cannon C, Nagurney JT, Schreiber D, deFilippi C, Hogan C, Diercks DB, Stein JC, Headden G, Limkakeng AT, Anand I, Wu AH, Papassotiriou J, Hartmann O, Ebmeyer S, Clopton P, Jaffe AS, Peacock WF. Copeptin Helps in the Early Detection of Patients With Acute Myocardial Infarction. J Am Coll Cardiol 2013; 62:150-160. [DOI: 10.1016/j.jacc.2013.04.011] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 04/04/2013] [Accepted: 04/05/2013] [Indexed: 11/25/2022]
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Richards M, Di Somma S, Mueller C, Nowak R, Peacock WF, Ponikowski P, Mockel M, Hogan C, Wu AHB, Clopton P, Filippatos GS, Anand I, Ng L, Daniels LB, Neath SX, Shah K, Christenson R, Hartmann O, Anker SD, Maisel A. Atrial fibrillation impairs the diagnostic performance of cardiac natriuretic peptides in dyspneic patients: results from the BACH Study (Biomarkers in ACute Heart Failure). JACC Heart Fail 2013; 1:192-9. [PMID: 24621869 DOI: 10.1016/j.jchf.2013.02.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the impact of atrial fibrillation (AF) on the performance of mid-region amino terminal pro-atrial natriuretic peptide (MR-proANP) in comparison with the B-type peptides (BNP and NT-proBNP) for diagnosis of acute heart failure (HF) in dyspneic patients. BACKGROUND The effects of AF on the diagnostic and prognostic performance of MR-proANP in comparison with the B type natriuretic peptides have not been previously reported. METHODS A total of 1,445 patients attending the emergency department with acute dyspnea had measurements taken of MR-proANP, BNP, and NT-proBNP values on enrollment to the BACH trial and were grouped according to presence or absence of AF and HF. RESULTS AF was present in 242 patients. Plasma concentrations of all three peptides were lowest in those with neither AF nor HF and AF without HF was associated with markedly increased levels (p < 0.00001). HF with or without AF was associated with a significant further increment (p < 0.00001 for all three markers). Areas under receiver operator characteristic curves (AUCs) for discrimination of acute HF were similar and powerful for all peptides without AF (0.893 to 0.912; all p < 0.001) with substantial and similar reductions (0.701 to 0.757) in the presence of AF. All 3 peptides were independently prognostic but there was no interaction between any peptide and AF for prediction of all-cause mortality. CONCLUSIONS AF is associated with increased plasma natriuretic peptide (MR-proANP, BNP and NT-proBNP) levels in the absence of HF. The diagnostic performance of all three peptides is impaired by AF. This warrants consideration of adjusted peptide thresholds for diagnostic use in AF and mandates the continued search for markers free of confounding by AF.
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Affiliation(s)
- Mark Richards
- University of Otago, Christchurch, New Zealand; National University Heart Centre, Singapore.
| | | | | | | | | | | | | | | | - Alan H B Wu
- University of California San Francisco, California
| | - Paul Clopton
- Veterans' Administration San Diego Healthcare System, San Diego, California
| | | | - Inder Anand
- Veterans' Administration Minneapolis, Minnesota
| | - Leong Ng
- University of Leicester, Leicester, United Kingdom
| | | | | | - Kevin Shah
- Sant'Andrea Hospital, University La Sapienza, Rome, Italy; Veterans' Administration San Diego Healthcare System, San Diego, California
| | | | - Oliver Hartmann
- BRAHMS Aktiengesellschaft Biotechnology Centre Hennigsdorf, Berlin, Germany
| | - Stefan D Anker
- Charite, Campus Virchow-Klinikum, Berlin, Germany; Centre for Clinical and Basic Research IRCCS, San Raffaele, Roma, Italy
| | - Alan Maisel
- University of California San Diego, California
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Shah K, Parekh N, Clopton P, Anand I, Christenson R, Daniels L, Somma SD, Filippatos G, McCord J, Mueller C, Neath SX, Nowak R, Peacock WF, Ponikowski P, Anker S, Maisel A. IMPROVED SURVIVAL IN PATIENTS WITH DIASTOLIC HEART FAILURE DISCHARGED ON BETA-BLOCKER AND ACE INHIBITORS. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)60634-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Wu AHB, Tabas J, Stein J, Potocki M, Mueller C, McCord J, Richards M, Hartmann O, Nowak R, Peacock WF, Ponikowski P, Moeckel M, Hogan C, Filippatos GS, Di Somma S, Anand I, Ng L, Neath SX, Christenson R, Morgenthaler NG, Anker SD, Maisel AS. The effect of diabetes on the diagnostic and prognostic performance of mid-region pro-atrial natriuretic peptide and mid-region pro-adrenomedullin in patients with acute dyspnea. Biomarkers 2012; 17:490-7. [PMID: 22616939 DOI: 10.3109/1354750x.2012.687014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Serum mid-regional pro-atrial natriuretic peptide (MR-proANP) and pro-adrenomedullin (MR-proADM) are novel biomarkers for acute heart failure (AHF). Like other AFH biomarkers, the performance of these tests are affected by the presence of clinical variables such as renal failure and obesity. In a substudy of the Biomarkers from Acute Heart Failure Study, we show that diabetes did not influence the performance of these markers with regards to AHF diagnosis or 90-day all cause death. However, in patients without AHF, increased MR-proADM alone was associated with the presence of diabetes.
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Affiliation(s)
- Alan H B Wu
- University of California, San Francisco, San Francisco, CA 94110, USA.
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17
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Maisel A, Neath SX, Landsberg J, Mueller C, Nowak RM, Peacock WF, Ponikowski P, Möckel M, Hogan C, Wu AHB, Richards M, Clopton P, Filippatos GS, Di Somma S, Anand I, Ng LL, Daniels LB, Christenson RH, Potocki M, McCord J, Terracciano G, Hartmann O, Bergmann A, Morgenthaler NG, Anker SD. Use of procalcitonin for the diagnosis of pneumonia in patients presenting with a chief complaint of dyspnoea: results from the BACH (Biomarkers in Acute Heart Failure) trial. Eur J Heart Fail 2012; 14:278-86. [PMID: 22302662 PMCID: PMC3284113 DOI: 10.1093/eurjhf/hfr177] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Biomarkers have proven their ability in the evaluation of cardiopulmonary diseases. We investigated the utility of concentrations of the biomarker procalcitonin (PCT) alone and with clinical variables for the diagnosis of pneumonia in patients presenting to emergency departments (EDs) with a chief complaint of shortness of breath. METHODS AND RESULTS The BACH trial was a prospective, international, study of 1641 patients presenting to EDs with dyspnoea. Blood samples were analysed for PCT and other biomarkers. Relevant clinical data were also captured. Patient outcomes were assessed at 90 days. The diagnosis of pneumonia was made using strictly validated guidelines. A model using PCT was more accurate [area under the curve (AUC) 72.3%] than any other individual clinical variable for the diagnosis of pneumonia in all patients, in those with obstructive lung disease, and in those with acute heart failure (AHF). Combining physician estimates of the probability of pneumonia with PCT values increased the accuracy to >86% for the diagnosis of pneumonia in all patients. Patients with a diagnosis of AHF and an elevated PCT concentration (>0.21 ng/mL) had a worse outcome if not treated with antibiotics (P = 0.046), while patients with low PCT values (<0.05 ng/mL) had a better outcome if they did not receive antibiotic therapy (P = 0.049). CONCLUSION Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty. Importantly, PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection.
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Affiliation(s)
- Alan Maisel
- VA San Diego Healthcare System, San Diego, CA, USA
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Daniels LB, Clopton P, Potocki M, Mueller C, McCord J, Richards M, Hartmann O, Anand IS, Wu AHB, Nowak R, Peacock WF, Ponikowski P, Mockel M, Hogan C, Filippatos GS, Di Somma S, Ng L, Neath SX, Christenson R, Morgenthaler NG, Anker SD, Maisel AS. Influence of age, race, sex, and body mass index on interpretation of midregional pro atrial natriuretic peptide for the diagnosis of acute heart failure: results from the BACH multinational study. Eur J Heart Fail 2011; 14:22-31. [PMID: 22140234 DOI: 10.1093/eurjhf/hfr157] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Midregional pro atrial natriuretic peptide (MR-proANP) is useful for diagnosing acute heart failure (HF) in patients presenting to the Emergency Department with dyspnoea. Optimal interpretation of MR-proANP requires understanding of how various demographic variables influence its levels and performance as a diagnostic marker. We sought to determine how age, race, sex, and body mass index (BMI) affect the levels and interpretation of MR-proANP for the diagnosis of acute HF. METHODS AND RESULTS The Biomarkers in Acute Heart Failure (BACH) study was an international 15-centre study of 1641 patients presenting to the Emergency Department with acute dyspnoea. Of these, 1352 had complete information on age, race, sex, and BMI. MR-proANP levels increased with age and were higher in men and in patients with lower BMI. MR-proANP performed better as a diagnostic marker in younger individuals and in blacks compared with whites. Despite this, MR-proANP at the recommended cut-off point of 120 pmol/L was >90 % sensitive in ruling out the diagnosis of acute HF in all subgroups of patients except white subjects <50 years old. CONCLUSION Age, race, sex, and BMI affect MR-proANP levels to various degrees. However, the diagnostic performance of the recommended cut-off point of 120 pmol/L to rule out acute HF was robust across most subgroups. Although both sex and BMI affected MR-proANP levels, they did not alter its overall diagnostic performance. Lower cut-off points for MR-proANP could be considered in younger patients and in patients with a higher BMI, to optimize diagnostic sensitivity.
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Maisel A, Mueller C, Nowak RM, Peacock WF, Ponikowski P, Mockel M, Hogan C, Wu AHB, Richards M, Clopton P, Filippatos GS, Di Somma S, Anand I, Ng LL, Daniels LB, Neath SX, Christenson R, Potocki M, McCord J, Hartmann O, Morgenthaler NG, Anker SD. Midregion prohormone adrenomedullin and prognosis in patients presenting with acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial. J Am Coll Cardiol 2011; 58:1057-67. [PMID: 21867843 DOI: 10.1016/j.jacc.2011.06.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/02/2011] [Accepted: 06/03/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to determine the prognostic utility of midregion proadrenomedullin (MR-proADM) in all patients, cardiac and noncardiac, presenting with acute shortness of breath. BACKGROUND The recently published BACH (Biomarkers in Acute Heart Failure) study demonstrated that MR-proADM had superior accuracy for predicting 90-day mortality compared with B-type natriuretic peptide (area under the curve: 0.674 vs. 0.606, respectively, p < 0.001) in acute heart failure. METHODS The BACH trial was a prospective, 15-center, international study of 1,641 patients presenting to the emergency department with dyspnea. Using this dataset, the prognostic accuracy of MR-proADM was evaluated in all patients enrolled for predicting 90-day mortality with respect to other biomarkers, the added value in addition to clinical variables, as well as the added value of additional measurements during hospital admission. RESULTS Compared with B-type natriuretic peptide or troponin, MR-proADM was superior for predicting 90-day all-cause mortality in patients presenting with acute dyspnea (c index = 0.755, p < 0.0001). Furthermore, MR-proADM added significantly to all clinical variables (all adjusted hazard ratios: >3.28), and it was also superior to all other biomarkers. MR-proADM added significantly to the best clinical model (bootstrap-corrected c index increase: 0.775 to 0.807; adjusted standardized hazard ratio: 2.59; 95% confidence interval: 1.91 to 3.50; p < 0.0001). Within the model, MR-proADM was the biggest contributor to the predictive performance, with a net reclassification improvement of 8.9%. Serial evaluation of MR-proADM performed in patients admitted provided a significant added value compared with a model with admission values only (p = 0.0005). More than one-third of patients originally at high risk could be identified by the biomarker evaluation at discharge as low-risk patients. CONCLUSIONS MR-proADM identifies patients with high 90-day mortality and adds prognostic value to natriuretic peptides in patients presenting with acute shortness of breath. Serial measurement of this biomarker may also prove useful for monitoring, although further studies will be required. (Biomarkers in Acute Heart Failure [BACH]; NCT00537628).
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Affiliation(s)
- Alan Maisel
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Maisel A, Xue Y, Shah K, Mueller C, Nowak R, Peacock WF, Ponikowski P, Mockel M, Hogan C, Wu AHB, Richards M, Clopton P, Filippatos GS, Di Somma S, Anand IS, Ng L, Daniels LB, Neath SX, Christenson R, Potocki M, McCord J, Terracciano G, Kremastinos D, Hartmann O, von Haehling S, Bergmann A, Morgenthaler NG, Anker SD. Increased 90-day mortality in patients with acute heart failure with elevated copeptin: secondary results from the Biomarkers in Acute Heart Failure (BACH) study. Circ Heart Fail 2011; 4:613-20. [PMID: 21765124 DOI: 10.1161/circheartfailure.110.960096] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In patients with heart failure (HF), increased arginine vasopressin concentrations are associated with more severe disease, making arginine vasopressin an attractive target for therapy. However, AVP is difficult to measure due to its in vitro instability and rapid clearance. Copeptin, the C-terminal segment of preprovasopressin, is a stable and reliable surrogate biomarker for serum arginine vasopressin concentrations. METHODS AND RESULTS The Biomarkers in Acute Heart Failure (BACH) trial was a 15-center, diagnostic and prognostic study of 1641 patients with acute dyspnea; 557 patients with acute HF were included in this analysis. Copeptin and other biomarker measurements were performed by a core laboratory at the University of Maryland. Patients were followed for up to 90 days after initial evaluation for the primary end point of all-cause mortality, HF-related readmissions, and HF-related emergency department visits. Patients with copeptin concentrations in the highest quartile had increased 90-day mortality (P<0.001; hazard ratio, 3.85). Mortality was significantly increased in patients with elevated copeptin and hyponatremia (P<0.001; hazard ratio, 7.36). Combined end points of mortality, readmissions, and emergency department visits were significantly increased in patients with elevated copeptin. There was no correlation between copeptin and sodium (r=0.047). CONCLUSIONS This study showed significantly increased 90-day mortality, readmissions, and emergency department visits in patients with elevated copeptin, especially in those with hyponatremia. Copeptin was highly prognostic for 90-day adverse events in patients with acute HF, adding prognostic value to clinical predictors, ser um sodium, and natriuretic peptides. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00537628.
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Affiliation(s)
- Alan Maisel
- VA San Diego Healthcare System, San Diego, CA, USA
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Maisel A, Mueller C, Nowak R, Peacock WF, Landsberg JW, Ponikowski P, Mockel M, Hogan C, Wu AHB, Richards M, Clopton P, Filippatos GS, Di Somma S, Anand I, Ng L, Daniels LB, Neath SX, Christenson R, Potocki M, McCord J, Terracciano G, Kremastinos D, Hartmann O, von Haehling S, Bergmann A, Morgenthaler NG, Anker SD. Mid-region pro-hormone markers for diagnosis and prognosis in acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial. J Am Coll Cardiol 2010; 55:2062-76. [PMID: 20447528 DOI: 10.1016/j.jacc.2010.02.025] [Citation(s) in RCA: 404] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 02/04/2010] [Accepted: 02/04/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Our purpose was to assess the diagnostic utility of mid-regional pro-atrial natriuretic peptide (MR-proANP) for the diagnosis of acute heart failure (AHF) and the prognostic value of mid-regional pro-adrenomedullin (MR-proADM) in patients with AHF. BACKGROUND There are some caveats and limitations to natriuretic peptide testing in the acute dyspneic patient. METHODS The BACH (Biomarkers in Acute Heart Failure) trial was a prospective, 15-center, international study of 1,641 patients presenting to the emergency department with dyspnea. A noninferiority test of MR-proANP versus B-type natriuretic peptide (BNP) for diagnosis of AHF and a superiority test of MR-proADM versus BNP for 90-day survival were conducted. Other end points were exploratory. RESULTS MR-proANP (> or =120 pmol/l) proved noninferior to BNP (> or =100 pg/ml) for the diagnosis of AHF (accuracy difference 0.9%). In tests of secondary diagnostic objectives, MR-proANP levels added to the utility of BNP levels in patients with intermediate BNP values and with obesity but not in renal insufficiency, the elderly, or patients with edema. Using cut-off values from receiver-operating characteristic analysis, the accuracy to predict 90-day survival of heart failure patients was 73% (95% confidence interval: 70% to 77%) for MR-proADM and 62% (95% confidence interval: 58% to 66%) for BNP (difference p < 0.001). In adjusted multivariable Cox regression, MR-proADM, but not BNP, carried independent prognostic value (p < 0.001). Results were consistent using NT-proBNP instead of BNP (p < 0.001). None of the biomarkers was able to predict rehospitalization or visits to the emergency department with clinical relevance. CONCLUSIONS MR-proANP is as useful as BNP for AHF diagnosis in dyspneic patients and may provide additional clinical utility when BNP is difficult to interpret. MR-proADM identifies patients with high 90-day mortality risk and adds prognostic value to BNP. (Biomarkers in Acute Heart Failure [BACH]; NCT00537628).
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Affiliation(s)
- Alan Maisel
- VA San Diego Healthcare System, San Diego, California 92161, USA.
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Parekh NV, Singh K, Clopton P, Anand I, Christenson R, Daniels LB, Hogan C, Neath SX, Nowak R, Peacock WF, Wu A, Anker SD, Maisel AS. Improved Mortality Associated with ACE-I and Beta Blocker Therapy in Heart Failure with Preserved Ejection Fraction: An Analysis of the Biomarkers in Acute Heart Failure (BACH) Trial. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Emergency physicians must often make assessments of complex hemodynamic parameters. To assess the utility of impedance cardiography (ICG) in the emergency department, the authors examined treating physicians' abilities to assess stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR) by comparing the clinicians' estimates of these values to ICG measurements. Treating physicians were asked to estimate the SV, CO, and SVR of acutely ill patients as being low, normal, or high. ICG measurements of SV, CO, and SVR were also categorized as low, normal, or high. Physician estimates were compared with ICG measures for concordance. Changes of therapy initiated as a result of discordance between physician's estimates and ICG measurements were recorded. The treating physician assessments and ICG hemodynamic measurements were concordant in 62 of 101 (62%) cases for SV (kappa=0.068), in 53 of 101 (53%) cases for CO (p=0.125), and in 50 of 101 (50%) measurements for SVR (p=0.148). The low concordance suggests that treating physicians did not consistently estimate SV, CO, and SVR accurately. ICG provides noninvasive hemodynamic measurements of SV, CO, and SVR that offer clinical utility and potential value in the emergency department.
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Affiliation(s)
- Sean-Xavier Neath
- Department of Emergency Medicine, University of California, San Diego, 200 W. Arbor Drive, San Diego, CA 92103, USA.
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