Abstract
BackgroundThe performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF).MethodsThis is the first diagnostic accuracy study in this population to assess the differential diagnostic performance and acceptability of a range of biomarkers against a clinical diagnosis using portable echocardiography. A total of 405 residents, aged 65–100 years (mean 84.2), in 33 UK long-term care facilities were enrolled between April 2009 and June 2010.ResultsFor undifferentiated HF, BNP or NT-proBNP were adequate rule-out tests but would miss one in three cases (BNP: sensitivity 67%, NPV 86%, cut-off 115 pg/ml; NT-proBNP: sensitivity 62%, NPV 87%, cut-off 760 pg/ml). Using higher test cut-offs, both biomarkers were more adequate tests of LVSD, but would still miss one in four cases (BNP: sensitivity 76%, NPV 97%, cut-off 145 pg/ml; NT-proBNP: sensitivity 73%, NPV 97%, cut-off 1000 pg/ml). At these thresholds one third of subjects would test positive and require an echocardiogram. Applying a stricter ‘rule out’ threshold (sensitivity 90%), only one in 10 cases would be missed, but two thirds of subjects would require further investigation. Biomarkers were less useful for HFpEF (BNP: sensitivity 63%, specificity 61%, cut-off 110 pg/ml; NT-proBNP: sensitivity 68%, specificity 56%, cut-off 477 pg/ml). Novel biomarkers (Copeptin, MR-proADM, and MR-proANP) and common signs and symptoms had little diagnostic utility.ConclusionsNo test, individually or in combination, adequately balanced case finding and rule-out for heart failure in this population; currently, in-situ echocardiography provides the only adequate diagnostic assessment.Trial RegistrationControlled-Trials.com ISRCTN19781227
Highlights
Whilst early, accurate diagnosis and management of heart failure (HF) may substantially improve prognosis, there is evidence to suggest that HF is missed in up to half of cases [1,2]
Our aim was to determine whether B-type natriuretic peptide (BNP), NT-pro-BNP, MR-proANP, MR-proADM, Copeptin and HsCRP could serve as biomarkers for the detection of left ventricular systolic dysfunction (LVSD) and/or HF with preserved ejection fraction (HFpEF) in older people in long-term care and whether appropriate cut off values would differ from those for the general population
Of 399 participants, 34 (8.5%) were diagnosed with LVSD: 19 (56%) mild, 9 (27%) moderate, and 6 (18%) severe; 3 with asymptomatic LVSD; 57 (14.3%) participants were diagnosed with HFpEF, of these 46 (81%) had E/E’
Summary
Accurate diagnosis and management of heart failure (HF) may substantially improve prognosis, there is evidence to suggest that HF is missed in up to half of cases [1,2]. A recent European study of nursing-home residents [1] (n = 150) suggested a cut-off for NT-proBNP of 450 pg/ml (sensitivity 71%, specificity 67%) and BNP 100 pg/ml (sensitivity 71%, specificity 70%). Other studies suggest cut-offs ranging from 93–450 pg/ml for NT-proBNP and 40–100 pg/ml for BNP [1,7,8]. Previous studies have not fully evaluated their clinical utility in older residents in long-term care and have not differentiated between types of HF despite the increased prevalence of HF with preserved ejection fraction (HFpEF) in this population [3,11,12]. The performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF)
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