Differential Diagnosis Of Acute Dyspnea Research Articles

Overview on Congestive Heart Failure Imaging

Background: Heart failure is a complex clinical syndrome that results from a functional or structural heart disorder. Acute heart failure is one of the main diagnostic and therapeutic challenges in clinical practice due to a non-specific clinical manifestation and the urgent need for timely and tailored management at the same time. During the first hours of admission the point-of-care focused on cardiac and lung ultrasound examination that are invaluable tool for rapid differential diagnosis of acute dyspnoea, which are highly feasible and relatively easy to learn. Objective: The study aimed to investigate the role of several portable and stationary imaging modalities, which are being increasingly used for the evaluation of cardiac structure and function, haemodynamic and volume status, precipitating myocardial ischaemia or valvular abnormalities, and systemic and pulmonary congestion. Methods: For article selection, the PubMed database and EBSCO Information Services were used. All articles relevant with our topic and other articles were used in our review. Other articles that were not related to this field were excluded. The data was extracted in a specific format that was reviewed by the group members. Conclusion: Heart failure is a main cause of mortality and morbidity worldwide. Assessment of the case is essential to determine the etiology and the best treatment strategy. For the assessment of HF patients, a variety of imaging techniques are used, each with advantages and disadvantages. For its accessibility, affordability, and utility, echocardiography remains the preferred method. It offers the majority of the data necessary it has been improved with the addition of 3DE and strain for the management and follow-up of patients with HF. In particular cases like ischemic heart disease, other methods may be helpful. It should be noted that the right imaging choice can assist in the management of the patient with HF.

Bedside lung ultrasonography by emergency department residents as an aid for identifying heart failure in patients with acute dyspnea after a 2-h training course

BackgroundUltrasonographic B-lines have recently emerged as a bedside imaging tool for the differential diagnosis of acute dyspnea in the Emergency Department (ED). However, despite its simplicity, LUS has not fully penetrated emergency department. This study aimed to assess the accuracy and reproducibility of ultrasonographic B-lines performed by emergency medicine (EM) residents for the diagnosis of congestive heart failure (CHF) in patients admitted to ED for acute dyspnea.Patients and methodsThis is a cross-sectional prospective study conducted between January 2016 and October 2017 including patients aged over 18 years admitted to ED for acute dyspnea. At admission, two consecutive bedside LUS study were performed by a pair of EM residents who received a 2-h course for recognition of sonographic B-lines to determine independently B-lines score and B-profile pattern. All participating sonographers were blinded to patients’ clinical data. B-lines score ≥ 15 or a B-profile pattern was considered as suggestive of CHF. The final leading diagnosis was assessed by two expert sonographers, who were blinded to the residents’ interpretations, based on clinical findings, chest X-ray, brain natriuretic peptide, cardiac and lung ultrasound testing. Accuracy and agreement of B-lines score and B-profile pattern were calculated.ResultsWe included 700 patients with a mean age of 68 ± 12.6 years and a sex ratio (M/F) of 1.43. The diagnosis of CHF was recorded in 371 patients (53%). The diagnostic performance of B-lines score at a cut-off 15 and B-profile pattern was, respectively, 88% and 82.5% for sensitivity, 75% and 84% for specificity, 80% and 85% for positive predictive value, 84% and 81% for negative predictive value. The area under receiver operating characteristic curve was 0.86 [0.83–0.89] and 0.83 [0.80–0.86], respectively, for B-lines score and B-profile pattern. There was an excellent agreement between residents for the diagnosis of CHF using both scores (kappa = 0.81 and 0.85, respectively, for ordinal scale B-lines score and B-profile pattern).ConclusionLung ultrasound B-lines assessment has a good accuracy and an excellent reproducibility in the diagnosis of CHF in the hand of EM residents following a short training program.Trial registration Name of the registry: clinicaltrials.gov; Trial registration number: NCT03717779; Date of registration: October 24, 2018 ‘Retrospectively registered’; URL of trial registry record: clinicaltrials.gov

Diagnostic accuracy of inferior vena cava ultrasound for heart failure in patients with acute dyspnoea: a systematic review and meta-analysis

BackgroundDyspnoea is the most common sign of heart failure (HF). Patients accessing the ED for HF-related symptoms require fast diagnosis and early treatment. Transthoracic echocardiography has a crucial role in...

Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology.

Acute heart failure is one of the main diagnostic and therapeutic challenges in clinical practice due to a non-specific clinical manifestation and the urgent need for timely and tailored management at the same time. In this position statement, the Heart Failure Association aims to systematize the use of various imaging methods in accordance with the timeline of acute heart failure care proposed in the recent guidelines of the European Society of Cardiology. During the first hours of admission the point-of-care focused cardiac and lung ultrasound examination is an invaluable tool for rapid differential diagnosis of acute dyspnoea, which is highly feasible and relatively easy to learn. Several portable and stationary imaging modalities are being increasingly used for the evaluation of cardiac structure and function, haemodynamic and volume status, precipitating myocardial ischaemia or valvular abnormalities, and systemic and pulmonary congestion. This paper emphasizes the central role of the full echocardiographic examination in the identification of heart failure aetiology, severity of cardiac dysfunction, indications for specific heart failure therapy, and risk stratification. Correct evaluation of cardiac filling pressures and accurate prognostication may help to prevent unscheduled short-term readmission. Alternative advanced imaging modalities should be considered to assist patient management in the pre- and post-discharge phase, including cardiac magnetic resonance, computed tomography, nuclear studies, and coronary angiography. The Heart Failure Association addresses this paper to the wide spectrum of acute care and heart failure specialists, highlighting the value of all available imaging techniques at specific stages and in common clinical scenarios of acute heart failure.

Vocal Cord Dysfunction a differential diagnosis of acute dyspnea

Vocal Cord Dysfunction a differential diagnosis of acute dyspnea

Cardiac imaging in patients with dyspnea.

Acute dyspnea is a frequent cause of access to the Emergency Department. Differentiation between cardiogenic and respiratory causes does not always seem simple and certain, causing a delay in initiating targeted therapies and prolonging the patient's stay in the emergency department. The basic elements for the diagnosis remain the history and the objective examination, supplemented by the execution of an electrocardiogram, a determination of blood parameters and the execution of a chest X-ray. The limits of radiological semeiotics, related to a low sensitivity to high specificity, promote other methods available to the first aid physician. Specifically, the determination of the natriuretic B-type peptide and transthoracic ultrasound is proposed as a method, recognized and validated by the recent letter on the patient bed, relatively easy to execute, fast learning, fast execution and non-invasive (referring to "ultrasound"). The sensitivity and specificity of both methods are high (86.7% and 93%, respectively) in the diagnosis of alveolus-interstitial syndrome, simplifying and accelerating the differential diagnosis of acute dyspnea.

Diagnostic performance of multi-organ ultrasound with pocket-sized device in the management of acute dyspnea

BackgroundThe availability of ultra-miniaturized pocket ultrasound devices (PUD) adds diagnostic power to the clinical examination. Information on accuracy of ultrasound with handheld units in immediate differential diagnosis in emergency department (ED) is poor. The aim of this study is to test the usefulness and accuracy of lung ultrasound (LUS) alone or combined with ultrasound of the heart and inferior vena cava (IVC) using a PUD for the differential diagnosis of acute dyspnea (AD).MethodsWe included 68 patients presenting to the ED of “Maurizio Bufalini” Hospital in Cesena (Italy) for AD. All patients underwent integrated ultrasound examination (IUE) of lung-heart-IVC, using PUD. The series was divided into patients with dyspnea of cardiac or non-cardiac origin. We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive value and negative predictive value of the three ultrasonic methods and their various combinations for the diagnosis of cardiogenic dyspnea (CD), comparing with the final diagnosis made by an independent emergency physician.ResultsLUS alone exhibited a good sensitivity (92.6%) and specificity (80.5%). The highest accuracy (90%) for the diagnosis of CD was obtained with the combination of LUS and one of the other two methods (heart or IVC).ConclusionsThe IUE with PUD is a useful extension of the clinical examination, can be readily available at the bedside or in ambulance, requires few minutes and has a reliable diagnostic discriminant ability in the setting of AD.

Valsalva manoeuvre‐mediated Hamman's Syndrome in a parturient

SummaryHamman's syndrome is the presence of subcutaneous emphysema associated with pneumomediastinum. We describe a case occurring postpartum caused by high intra‐alveolar pressures developed during valsalva manoeuvre. Spontaneous resolution occurred over several days with conservative management. This case report highlights an unusual complication as a differential diagnosis of acute dyspnoea and chest pain postpartum and we discuss its subsequent management.

Diagnostic value of natriuretic peptides in pediatrics

Natriuretic peptide hormones are the family of vasoactive substanses produced by cardiomyocytes in response to the expansion and increased pressure in the heart chambers. The review of the literature focuses on the diagnostic role of natriuretic peptides in pediatrics. The most important clinical effects of natriuretic peptides, brief history of their discovery and studying, age-related changes of serum levels are analyzed. Data of their use in the diagnosis and cardiac function monitoring in various forms of cardiomyopathy, myocardial inflammatory diseases, Kawasaki disease in children are presented. The results of studies examining the natriuretic peptides levels in children with congenital heart defects and heart transplantation in pre-and postoperative period are reviewed. The review involved the diagnostic use of natriuretic peptides in neonates, including high pulmonary hypertension and hemodynamically significant patent ductus arteriosus diagnosis in preterm infants. The possibility of the natriuretic peptides use for assessing the cardiotoxic complications risk in anti-tumor chemotherapy and for differential diagnosis of acute dyspnea due to heart failure or pulmonary diseases are discussed.

Visualization of Cardiac Thrombus by Bedside Ultrasound

A 85-year-old man with sudden onset of dyspnea and chest pain with an history of immobilization due to right tibia plateau fracture after traffic accident 2 months ago was admitted to our emergency department. He was hypotensive (70/50 mmHg), tachycardic (166 beats/minute), tachypneic (26/minute) on admission. A 12-lead electrocardiogram showed atrial fibrillation with rapid ventricular response, arterial blood gas analysis revealed a hypoxic and hypocarbic profile together with an increased alveolar arterial oxygen. His physical examination was unremarkable except cold extremities, delayed capillary refilling time and bilateral decreased breath sounds with rhoncus, abdominal respiration and increased in diameter of right calf 3 cm more than left. Focused cardiac ultrasonography (FOCUS) performed by the emergency physician (EP) using a Mindray M7® model ultrasound machine with a 3.6 mHz microconvex transducer (M7, Mindray Bio-medical Electronics CO., Shenzen, China) revealed enlarged right ventricle (RV), hypokinetic lateral wall and hyperkinetic apex of RV (McConnell’s sign)1 and also a large, mobile serpentine thrombus in the right atrium. The thrombus also extended into the inferior vena cava and protruded into the RV through the tricuspid valve during diastole (Video). Computerized tomography angiography of the thorax revealed filling defects in both main pulmonary arteries (Figure). The patient received alteplase treatment with a dose of 100 mg over 2 hours in the intensive care unit. The patient was discharged from the intensive care unit with oral anticoagulation after three days with symptomatic relief. Figure. Blue arrow heads show filling defects in both main pulmonary arteries in computerized tomographic angiography of the thorax. Pulmonary emboli (PE) is one of the crucial considerations in the differential diagnosis of acute dyspnea and hypotension. Multiple prospective studies reveal a low sensitivity (41–70%) of FOCUS for specifically identifying PE.2,3 As experience with emergency ultrasound grows, EPs will be expected to fully understand and exploit the power of FOCUS to meet the evolving standards of care in emergency medicine. Video. Focused cardiac sonography shows dilated right ventricle and also a mobile thrombus in the right atrium. Click here to view.(2.1M, m4v)

The importance of admission and discharge BNP assessment in patients hospitalized for acutely decompensated chronic systolic heart failure

IntroductionThe assessment of B-type natriuretic peptide (BNP) plasma levels is not only useful for the differential diagnosis of acute dyspnea, but also for the prognostic stratification of patients with heart failure. However, available studies that have addressed monitoring of hospitalized patients are burdened with significant limitations: (1) measurement of plasma BNP levels only at admission or at discharge, (2) lack of details regarding the cause of heart failure, and (3) small sample size. Therefore, we conducted a prospective study of all patients presenting to our hospital with acutely decompensated chronic systolic heart failure. AimTo determine the importance of admission and discharge values of BNP and its changes during hospitalization for identification of patients with acutely decompensated chronic systolic heart failure at higher risk of unfavorable course of the disease. MethodsA prospective monocentric study determining plasma BNP levels at admission and at discharge in patients hospitalized for acutely decompensated chronic systolic heart failure. Patients: 130 consecutive patients, 77% men, mean age 70 years, body mass index (BMI) 27.8kg/m2; etiology of chronic heart failure—65.9% ischemic heart disease, 29.5% dilated cardiomyopathy, 4.6% others; signs and symptoms at admission—peripheral edema 58.9%, pulmonary rates 88.3%, orthopnea 53.1%, median of admission BNP 1101pg/ml, median of discharge BNP 650pg/ml, median left ventricular ejection fraction 26.5%, average length of hospitalization 9 days. ResultsDuring the follow-up (mean 15 months) the total mortality rate reached almost 40% and the annual mortality of our cohort was 29%. The most common causes of death included progression of heart failure and acute coronary syndromes. To evaluate the long-term risk of mortality, we used time-dependent ROC curves for the definition of cut-off values of BNP at admission and discharge. The relationship of BNP levels and the survival of patients was assessed using the hazard ratio (HR) calculated by the Cox proportional hazards model. BNPs at admission and at discharge with a cut-off value of 1699pg/ml and 434.5pg/ml are significant prognostic factors for patients hospitalized for acutely decompensated chronic systolic heart failure with a HR 2.79 and 3.29, respectively. During the follow-up, more than half of the patients required readmission to the hospital. The most common reasons for rehospitalization were cardiovascular causes. ConclusionBNP levels at admission and at discharge are an important predictive factor of survival in patients with acutely decompensated chronic systolic heart failure.

Differentiation of Cardiac and Noncardiac Dyspnea Using Bioelectrical Impedance Vector Analysis (BIVA)

BackgroundThere is no gold standard for the differential diagnosis of acute dyspnea despite the usefulness of N-terminal pro–B-type natriuretic peptide (NT-proBNP) and lung ultrasound. No study has evaluated the contribution of bioelectrical impedance vector analysis (BIVA) in discriminating between cardiac and noncardiac dyspnea. We sought to determine whether a relationship exists between ultrasound detection of lung congestion, NT-proBNP, and BIVA in patients with acute dyspnea. Methods and ResultsEligible patients were between 50 and 95 years, with an estimated glomerular filtration rate of ≥30 mL min−1 1.73 m−2, who presented to an emergency department with dyspnea. Dyspnea was classified by reviewers blinded to BIVA as cardiac or noncardiac based on physical examination, electrocardiogram, chest X-ray, NT-proBNP, and B-lines of lung congestion on ultrasound. Overall, 315 patients were enrolled (median age 77 years, 48% male). An adjudicated diagnosis of cardiac dyspnea was established in 169 (54%). Using BIVA, vector positions below −1 SD of the Z-score of reactance were associated with peripheral congestion (χ2 = 115; P < .001). BIVA measures were reasonably accurate in discriminating cardiac and noncardiac dyspnea (69% sensitivity, 79% specificity, 80% area under the receiver operating characteristic curve). ConclusionsIn patients presenting with acute dyspnea, the combination of BIVA and lung ultrasound may provide a rapid noninvasive method to determine the cause of dyspnea.

Bedeutung der Surfactant-Proteine B und D in der Differentialdiagnostik der akuten Dyspnoe

The basis for an optimal therapy of cardiopulmonary diseases is the assessment of an early diagnosis. This implies an evaluation of possible differential diagnoses of acute dyspnea. In numerous studies, natriuretic peptides were characterized as additional, meaningful parameters for the assessment of left ventricular function. Current studies could demonstrate that surfactant proteins B (SP-B) and D (SP-D) are of importance for the differentiation of patients with acute dyspnea. The aim of this study was to compare the values of NT-proBNP (N-terminal brain natriuretic peptide) and surfactant proteins for the assessment of a final diagnosis in patients with acute dyspnea. NT-proBNP, SP-B and SP-D were measured in 81 patients with acute dyspnea in the emergency room and were correlated with clinical and echocardiographic parameters with respect to the final diagnosis. For this, patients were classified with respect to clinical and echocardiographic parameters in different subgroups concerning the final diagnosis of acute dyspnea. In patients with a cardiac origin of acute dyspnea, plasma levels of NT-proBNP were significantly higher as compared to patients with a noncardiac diagnosis (p = 0.04). SP-D was highest in patients with a cardiac origin of acute dyspnea, but after performing regression analysis it seems to be of less importance for the differential diagnosis of acute dyspnea as compared to NT-proBNP. SP-B plasma levels were not different between the four subgroups. NT-proBNP is of importance for the differential diagnosis of acute dyspnea. Although SP-D shows similar changes of plasma levels between the four subgroups, it seems to be of less importance for the differential diagnosis of acute dysnea. SP-B occurs to be of no relevance for the differentiation between cardiac and noncardiac origin of acute dyspnea.

BNP/NT‐ProBNP and Cardiac Pacing: A Review

Natriuretic peptide (NP) levels (B-type natriuretic peptide [BNP] and N-terminal proBNP) are now widely used in clinical practice and cardiovascular research all over the world and have been incorporated into many cardiovascular guidelines for heart failure (HF). The roles of NP levels are evolving rapidly not only in diagnosis, therapy monitoring, and risk stratification of HF, but also in differential diagnosis of acute dyspnea, predicting death and rehospitalization in HF patients. NP assays have been applied in permanent cardiac pacing in recent years, whereas it is still not well known how NP levels change and whether NP levels can predict HF in permanent cardiac pacing. Therefore, this article reviews the role of NP levels in permanent cardiac pacing, mainly including NP changes in different cardiac pacing modes and cardiac resynchronization therapy.

Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.

Natriuretic Peptides and Cardiovascular Events

IN PATIENTS WITH KNOWN OR SUSPECTED CARDIOVASCUlar disease, biomarkers are increasingly being explored as indicators of disease presence, severity, or activity; prognosis; and therapeutic efficacy. A biomarker may be a by-product of the disease state and may also directly participate in its pathogenesis or modulation. The cardiac natriuretic peptides (secreted in response to myocardial stretch) promote vasodilation and natriuresis and are believed to mitigate adverse cardiovascular remodeling. Circulating levels of these peptides have proved useful in gauging the severity of heart failure and in assessing the differential diagnosis of acute dyspnea. N-terminal fragment of the prohormone brain-type natriuretic peptide (NT-proBNP) is an inactive cleavage product with much slower clearance than the biologically active BNP. Its plasma concentration, therefore, principally reflects myocardial secretion over a prolonged time. Prior investigations have identified plasma BNP and NT-proBNP levels as independent predictors of mortality or cardiovascular events in populations with chronic heart failure, acute coronary syndromes, prior myocardial infarction, established vascular disease or elevated coronary risk, and in community-based samples. In this issue of JAMA, the study by Bibbins-Domingo and colleagues extends these observations within a population of patients with stable coronary artery disease (CAD) and further clarifies the utility of NT-proBNP level as a predictor of a variety of subsequent cardiovascular events. The authors observe that plasma NT-proBNP concentration remains an independent predictor of all-cause mortality, CAD mortality, stroke, and events related to heart failure, even after sequentially adjusting for known measures of cardiac risk, left ventricular remodeling and function, inducible ischemia, functional capacity, inflammation, myocyte necrosis, and symptoms. Furthermore, plasma NT-proBNP concentration approaches significance as an independent predictor of myocardial infarction. These findings challenge the conventional view of the natriuretic peptide levels as mere hemodynamic markers of worsening heart failure or left ventricular dysfunction. Furthermore, these findings provoke reconsideration of the value of these markers as diagnostic tools and potentially as triggers for therapeutic intervention. How can a marker of myocardial stretch, measured at a single time point within a stable population, predict such a wide variety of cardiovascular events? Levels of NTproBNP may reflect a variety of adverse factors, all potentially resulting in increased hormonal release from stretched myocardium. However, to the extent that levels denote myocardial stretch, it seems likely that their value in predicting cardiovascular events would diminish after accounting for numerous known biochemical, echocardiographic, and functional markers of myocardial injury, ventricular remodeling, and active or inducible ischemia. The value of NTproBNP in predicting stroke, also observed for BNP in an analysis of the Framingham cohort, could be linked to its role as a marker of cardiac dilation with a predisposition to atrial fibrillation. However, the preserved predictive value for stroke after correction for multiple covariates, including echocardiographic measures of left ventricular function, supports consideration of alternative mechanisms responsible for the linkage between NT-proBNP levels and vascular events, including stroke. Along with myocardial stretch, a variety of other factors have been found to stimulate or enhance secretion of BNP in vitro, including myocardial ischemia and paracrine or endocrine agents such as endothelin A, angiotensin II, and tumor necrosis factor . Cardiac fibroblasts, as well as cardiac myocytes, secrete BNP, and its secretion modulates fibrosis through induction of matrix metalloproteinases. These observations suggest that the predictive value of plasma NT-proBNP concentration, particularly in a stable population without clinical heart failure, results not merely from its relationship with acute myocardial stretch but to

NT-proBNP in the differential diagnosis of acute dyspnea in the emergency department

Objectives: The purpose of this study was to verify the usefulness of NT-proBNP in the differential diagnosis of dyspnea in a population of patients presenting in the ER with breathlessness. Design and methods: In samples from 122 patients presenting in the ER with acute-severe dyspnea and from 25 subjects enrolled as a “comparison group” (NORM), NT-proBNP levels were measured. Patients have been classified on the basis of discharge diagnosis: pulmonary disease (PD, n = 23), pulmonary concomitant to cardiac disease (MIXED, n = 17), pulmonary embolism (EMB, n = 8), cardiac disease (CARD, n = 56), acute myocardial infarction (AMI, n = 11) and other disease (OTHER, n = 7). Results: A significant difference in NT-proBNP values ( P ≤ 0.05) was found in CARD vs. PD as well as vs. NORM and OTHER groups. 1760 ng/L was the best cut-off value calculated from ROC analysis (AUC ± SE 0.815 ± 0.041). Comparing NT-proBNP values and ER diagnosis, a disagreement in 24 patients was observed. Using the discharge diagnosis as the “gold standard,” four cases (17%) were found to be FP and 11 cases (46%) were FN according to ER diagnosis, while 2 patients showed false positive and 7 false negative NT-proBNP values. Conclusions: NT-proBNP measurement represents a useful biochemical tool helping the ER physician in the rapid and reliable recognition of cardiac involvement in patients presenting in the ER with acute-severe dyspnea.

The Role of Plasma B-type Natriuretic Peptide Measurements in the Differential Diagnosis of Acute Dyspnea

Background : The B-type natriuretic peptide (BNP) is a cardiac neurohormone that is specifically secreted from the ventricles in response to volume expansion and a pressure overload. Differentiating congestive heart failure from the pulmonary causes of dyspnea is very important for patients presenting with acute dyspnea. Methods : A retrospective study was carried out on 261 patients who were admitted to the emergency department of Hanyang University Hospital due to acute dyspnea from March to July 2004. The serum BNP levels of the patients were measured using the ELISA method. Results : The BNP levels were 382, 111-1140 pg/ml (median, interquartile range) in the heart failure group (n=119) and 29, 7-81 pg/ml in the non-heart failure group (n=142). The BNP levels according to the subgroups of heart failure were 820, 354-1620 pg/ml, 1650, 239-1990 pg/ml, and 378, 106-1120 pg/ml for the chronic obstructive pulmonary disease (COPD) with combined left heart failure (n=5), cor pulmonale (n=3), and left heart failure groups (n=111), respectively. The BNP levels according to the subgroups of non-heart failure were 39, 21-101 pg/ml, 59, 10-129 pg/ml, and 15, 6-47 pg/ml for the COPD (n=20), other pulmonary diseases (n=56), and other causes groups (n=66), respectively. The BNP levels were significantly different according to the underlying etiology (p