N-terminal Pro-brain Natriuretic Peptide In Group Research Articles

Prognostic implications of N-terminal pro-brain natriuretic peptide in patients with Non-ST segment elevation myocardial infarction

Abstract Background Limited data exist regarding prognostic implications of N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) in patients with non-ST segment elevation myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI). Objectives The current study sought to evaluate the prognostic implications of NT-proBNP in patients with NSTEMI who underwent PCI. Methods Among a total of 13,104 patients from a nationwide, multicenter, and prospective registry of the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH), a total of 3,083 patients with NSTEMI who underwent PCI were selected. The selected patients were classified according to the initial NT-proBNP value (cut-off value of NT-proBNP, 700 pg/ml). Primary endpoint was major adverse cardiovascular events (MACE) at 3 years, a composite of all-cause death, recurrent myocardial infarction (MI), unplanned repeat revascularization, and admission for heart failure. Results Among the study population, 1,813 patients (58.8%) were in the low NT-proBNP group (<700 pg/ml) and 1,270 patients (41.2%) were in the high NT-proBNP group (≥700 pg/ml). The high NT-proBNP group showed significantly higher risk of MACE than the low NT-proBNP group (29.5% vs 12.3%; adjusted hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.39-2.07; P<0.001), mainly driven by higher risk of cardiac death or admission for heart failure (15.6% vs. 2.2%; adjusted HR, 2.98; 95% CI, 2.03-4.40; P<0.001). These results were consistent after confounder adjustment by propensity score matching (HR, 1.56; 95% CI, 1.21-2.02; P=0.001) and inverse probability weighting analysis (HR, 1.54; 95% CI, 1.19-2.00; P=0.001). Conclusion In patients with NSTEMI who underwent PCI, elevated initial NT-proBNP level was associated with higher risk of MACE at 3 years, mainly driven by the higher risk of cardiac death or admission for heart failure. The current results suggest that the initial NT-proBNP level may have a clinically significant prognostic value in NSTEMI patients undergoing PCI.

Peripheral Venous Pressure And NT-proBNP Phenotypes as Surrogates for Invasive Fontan Haemodynamics in Adults

We hypothesized that phenotyping patients using a combination of resting peripheral venous pressure (PVP) and N-terminal pro–brain natriuretic peptide (NT-proBNP) would predict invasive Fontan haemodynamics. Accordingly, 35 adults with a history of Fontan palliation were categorized into 3 groups according to PVP and NT-proBNP values: normal, ↑NT-proBNP (≥300 pg/dL) or ↑PVP (≥15 mm Hg), and ↑PVP+↑NT-proBNP. Those in the normal values group universally had normal resting pulmonary artery wedge and Fontan pressures, with a single patient having abnormal exercise values; conversely, all patients in the ↑PVP+↑NT-proBNP group had increased resting Fontan or pulmonary artery wedge pressures, with those in the ↑NT-proBNP or ↑PVP group constituting an intermediate group.

Excess long-term risk of adverse outcomes in heart failure patients with high and low levels of NT-proBNP: A 7-year follow-up study (NorthStar Trial)

BackgroundThis study investigated excess risk in patients with heart failure with reduced left ventricular ejection fraction (HFrEF) with or without elevated levels of NT-proBNP (N-terminal pro-brain natriuretic peptide). MethodsPatients with HFrEF from the NorthStar cohort (n = 1120) were matched on age, sex, and presence of AF (atrial fibrillation/flutter) to five controls without HFrEF from The Danish National Patient Registries. Patients were compared with controls before and after stratification according to baseline NT-proBNP levels, with cutoffs defined as </≥ 600 pg/ml in patients with sinus rhythm and </≥ 900 pg/ml in patients with AF. The primary composite endpoint was a 7-year risk of cardiovascular death or HF admission. ResultsIn the HFrEF cohort, 704 patients had high NT-proBNP (median age, 73; mean left ventricular ejection fraction (LVEF), 33%). 416 patients had low NT-proBNP (median age, 65; LVEF, 30%). Patients from both groups were in NYHA class I-III. The primary endpoint occurred in 531 patients (75.4%) with HFrEF and elevated NT-proBNP, and 748 controls (21.3%) (risk difference, 54.2%; 95% confidence interval (CI) 50.7–57.6%). In comparison, it occurred in 199 patients (47.9%) with HFrEF and without elevated NT-proBNP, and 185 controls (8,9%) (risk difference, 38.9%; 95% CI 34.0–43.9%). Risk differences for all secondary endpoints were significant, except for overall mortality in the low NT-proBNP group (risk difference, 3.8%; 95% CI, −0.4–8.0%). ConclusionThis study identified a significant excess risk in patients with HFrEF across various endpoints, which persisted after stratification into high and low levels of NT-proBNP.

Predictive potential of age-group cut-off values of N-terminal pro-brain natriuretic peptide in Kawasaki disease.

The relationship between serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and the clinical features of patients with Kawasaki disease (KD) has been the subject of research. Recent studies have revealed that serum NT-proBNP levels vary with age. We therefore aimed to determine the utility of age-stratified cut-off values for NT-proBNP in predicting coronary artery lesions (CALs) in patients with KD. We retrospectively assessed the electronic medical records of patients who were hospitalized for KD or incomplete KD between January 1, 2015, and August 31, 2019. The patients were divided into high and normal NT-proBNP groups using age-stratified cut-off based on serum NT-proBNP levels measured immediately before KD treatment initiation. The study comprised 242 cases, including 71 and 171 cases in high and normal NT-proBNP groups, respectively. Thirty-seven of them (15.3%) were resistant to treatment; 15 (6.2%) had CALs, with a higher incidence in the high NT-proBNP group than in the normal NT-proBNP group. On multivariate logistic regression analysis, high serum NT-proBNP levels were significantly correlated to CALs (OR, 9.76; 95% CI, 2.64-36.2). On logistic regression analysis to compare the predictive accuracy of the age-stratified and fixed cut-off for CALs, the age-stratified cut-off values showed a larger area under the receiver operating characteristic curve than fixed cut-off value. Based on age-stratified cut-off values for serum NT-proBNP, high NT-proBNP levels at the time of diagnosis were significantly associated with CALs in patients with KD. Higher predictive accuracy for CALs of the age-stratified cut-off values was also suggested.

Potential impacts of high-sensitivity creatine kinase-MB on long-term clinical outcomes in patients with stable coronary heart disease

This study aimed to investigate the prognostic value of high-sensitivity creatine kinase-myocardial band or fraction (hsCK-MB) in comparison with other well-established biomarkers including heart type-fatty acid binding protein (H-FABP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with stable coronary heart disease (SCHD). A total of 1,785 patients were enrolled and followed for 36 months. The primary outcome was all-cause mortality. The secondary outcomes included cardiovascular (CV) death, acute myocardial infarction (AMI), angina-related hospitalizations, and hospitalizations for heart failure. The all-cause mortality rate was significantly higher in the high hsCK-MB group compared to the low hsCK-MB group (4.64% vs. 1.88%, p = 0.0026). After adjusting for baseline covariates, there were no significant differences for the secondary outcomes. H-FABP (≥4.226 ng/mL) was the best predictor for all-cause mortality (HR = 2.68, 95% CI = 1.28–5.62, p = 0.009) and CV death (HR = 6.84, 95% CI = 1.89–22.14, p = 0.003). The high NT-proBNP group had a higher AMI-related hospitalization rate (HR = 1.91, 95% CI = 1.00–3.65, p = 0.05). Neither the addition of hsCK-MB to any other markers nor combinations of the three markers improved the prognostic significance of CV outcomes. In conclusion, hsCK-MB was an independent predictor for all-cause mortality but not CV outcomes in patients with SCHD. Combination of hsCK-MB, H-FABP and NT-proBNP failed to improve the prognostic power for all-cause mortality or CV outcomes.

P6366High blood pressure cut-off by 130/80 mmHg in middle-ages may be valid for predicting heart failure in ages of seventies

Abstract Background ESC/ESH Guidelines (2018) recommended that treated BP values should be targeted to 130/80 mmHg or lower in most patients. However, it remains unclear whether this target in middle-aged population is associated with future development of heart failure. Purpose We conducted a retrospective analysis to determine whether high blood pressure cut-off by 130/80 mmHg in the middle-age predicts the risk of heart failure, detected by high N-terminal pro-brain natriuretic peptide (NT-proBNP) level, in the elderly in a cohort in which longitudinal blood pressure records exist. Methods The cohort consists of health check examinee who consulted the examination institute between 2015 and 2018 (n=8513), aged 70 years or older, and had previous institution-visit record at least once from 50 to 69 years old. We measured serum NT-proBNP level in the all examinee and defined the group of high NT-proBNP as ≥144 pg/ml [defined as the highest quartile, n=2135 (25%)]. The number of participants whose previous blood pressure records exists was 8123 (95%) for 65–69 years old, 6980 (82%) for 60–64 years old, 5233 (61%) for 55–59 years old, and 3018 (35%) for 50–54 years old, respectively. The each generation subgroups were divided into the three gradual categories according to the blood pressure records: SBP ≥140 and/or DBP ≥90, SBP130–139 and/or DBP80–89, and SBP &lt;130 and DBP &lt;80 mmHg. Results Categorization to high NT-proBNP group in ages of 70 or more was significantly associated with the categorization to high blood pressure, which was not only the SBP ≥140 and/or DBP ≥90 mmHg but also the SBP130–139 and/or DBP80–89 mmHg at any time points of previous blood pressure measurements. The multivariable adjusted odds ratios for having high NT-proBNP level in the elderly against the two high blood pressure categories based on the previous blood pressure measurements were shown in the Table. Table 1. Multivariable adjusted OR for high NT-proBNP level in elderly Age N SBP 130–139 and/or DBP 80–89 SBP ≥140 and/or DBP ≥90 OR P OR P 65–69 8123 1.30 &lt;0.001 1.68 &lt;0.001 60–64 6980 1.26 0.002 1.55 &lt;0.001 55–59 5233 1.25 0.013 1.41 &lt;0.001 50–54 3018 1.32 0.023 1.58 &lt;0.001 Model included age, gender, BMI, serum creatinine, hemoglobin, and presence of antihypertensive medications, and cardiac disease. Conclusion High blood pressure cut-off by 130/80 mmHg in the middle-age may be valid to predict the risk of heart failure in the elderly.

A health economic evaluation of using N-terminal pro brain natriuretic peptide for the management of acute heart failure: A pilot study in an Indonesian tertiary referral hospital

Heart failure represents a major health problem and economic burden also in development countries such as Indonesia. Based on current guidelines, the use of natriuretic peptides can improve diagnosis, risk stratification, and decrease in hospital length of stay. However, mostly due to the related high costs, many Indonesian physicians currently do not routinely use these biomarkers in their daily clinical practice. By comparing the results of guidance with N-terminal pro brain natriuretic peptide (NT-proBNP) and without NT-proBNP, this pilot study was aimed to determine the clinical effectiveness and costs of using natriuretic peptides in the management of acute heart failure (AHF) patients admitted at National Cardiovascular Center Harapan Kita Hospital, a tertiary referral hospital in Jakarta, Indonesia. This was a health economic evaluation using a single-blind, randomized controlled trial. AHF patients adjudicated following European Society of Cardiology guidelines were randomly assigned to the 2 groups: NT-proBNP group (group A) and control group (group B). In the group A, NT-proBNP level was obtained at admission and pre-discharge, with the target of achieving a decrease of ≥30%. Randomised patients were followed up to 90 days post-discharge to assess short-term outcomes and costs. In total, one hundred and twelve patients were enrolled, of whom 56 were randomized in group A and 56 patients in group B. Compared to Group B, in Group A the total costs of patients management resulted to be significantly higher (P&lt;0.05), while no significant difference between the 2 groups was observed for inhospital length of stay, total mortality rate, rehospitalization, and emergency department visits within 90 days post-discharge. In this pilot study for the management of AHF at an Indonesian National Cardiovascular Center, the routine use of NT-proBNP compared to the non use, at hospital admission and discharge resulted into a significant increase of medical cost without any evident favourable impact on patients outcomes. Larger study in greater Asia Pacific populations should be performed to confirm these preliminary results.

Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial.

The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.

Value of red blood cell distribution width on evaluation of severity of acute heart failure in children

Objective To investigate the correlation between red blood cell distribution width (RDW) and the cardiac function in children with acute heart failure, and to explore the clinical value in evaluating the degree of heart failure. Methods From July 2013 to October 2015, 75 cases of children with acute heart failure who were hospitalized in Chengdu Women and Children′s Central Hospital were collected and assigned as 3 groups.Heart function classification was done by using a modified Ross scoring system, and each group included 25 cases of class Ⅱ, Ⅲ, Ⅳ.Indices of red blood cell, haemoglobin, RDW, concentration of plasma N-terminal pro brain natriuretic peptide (NT-proBNP), and left ventricular ejection fraction (LVEF) were recorded.SPSS 17.0 software was statistically used for comparing each index among groups and correlation analysis. Results Red blood cells and haemoglobin were not statistically different among groups(F=0.802, 1.372, all P>0.05). RDW, NT-proBNP concentration and LVEF were significantly different among groups(F=31.388, 29.300, χ2=56.952, all P class Ⅲ group>class Ⅱ group[RDW: (16.6±1.3)%>(15.4±1.1)%>(13.9±1.3)%, NT-proBNP: (506.6±190.2) ng/L>(1 028.1±356.8) ng/L>(1 884.1±358.6) ng/L, all P<0.01]. According to LVEF=50% as the cut-off point, children with acute heart failure were divided into LVEF decreased group and LVEF retention group, former group′s RDW and NT-proBNP were significantly higher than the latter group[RDW: (16.7±1.3)% vs.(13.9±1.1)%, NT-proBNP: (1 787.4±368.6) ng/L vs.(657.4±291.1) ng/L, all P<0.01]. According to NT-proBNP levels, the children with acute heart failure were divided into low, medium, and high NT-proBNP group, and RDW in the high NT-proBNP group[(17.3±0.9)%] was significantly higher than that of medium[(15.4±0.7)%], and that of low level group[(13.7±1.2)%](all P<0.01). The correlation analysis between RDW, NT-proBNP as well as LVEF showed that RDW was significantly positive correlated with NT-proBNP (r=0.869, P<0.01), and negatively related with LVEF(r=- 0.962, P< 0.01). Conclusions RDW is closely related to the cardiac function in children with acute heart failure.RDW is increased with the aggravating of acute heart failure, which can indirectly reflect the NT-proBNP concentration and LVEF change and suggests that RDW can be used as a convenient and useful index monitoring the level of cardiac function in children with acute heart failure, and the assessment of the severity of acute heart failure. Key words: Red blood cell distribution width; Acute heart failure; N-terminal pro brain natriuretic peptide; Child

N-terminal pro-brain natriuretic peptide is a useful marker to identify latent heart failure patients in older adults in a rural outpatient clinic.

Although measurement of natriuretic peptides including N-terminal pro-brain natriuretic peptide (NT-proBNP) has been recommended for identifying heart failure (HF) patients, the prevalence of elderly patients with latent HF who are attending an outpatient clinic is unknown. We measured NT-proBNP levels in 393 patients (aged 75±9years) in a rural outpatient clinic. Patients with a diagnosis of heart disease were excluded. The patients were divided into two groups by the values of NT-proBNP: high NT-proBNP group (>400pg/mL) and low NT-proBNP group (≤400pg/mL) according to Japanese guidelines. Patients with a high NT-proBNP value underwent echocardiography including tissue Doppler examination. A total of 43 (11%) patients had high NT-proBNP values. Those patients were older, and larger percentages of those patients were male, had atrial fibrillation, history of stroke and dementia. Echocardiography was carried out in 39 of the 43 patients with high NT-proBNP values, and there were four patients with left ventricular systolic dysfunction, two with hypertrophic cardiomyopathy and one with aortic regurgitation. In the remaining 32 patients, 27 patients had diastolic HF in accordance with Japanese guidelines. A diagnosis of HF according to the guidelines was finally made in 34 (87%) of the 39 patients. A large number of elderly patients without a diagnosis of HF who were attending an outpatient clinic showed high levels of NT-proBNP, and measurement of NT-proBNP is useful to identify patients with latent HF. Geriatr Gerontol Int 2017; 17: 1648-1653.

Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro-Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial.

Outpatient treatment of pulmonary embolism (PE) may lead to improved patient satisfaction and reduced healthcare costs. However, trials to assess its safety and the optimal method for patient selection are scarce. To validate the utility and safety of selecting patients with PE for outpatient treatment by the Hestia criteria and to compare the safety of the Hestia criteria alone with the Hestia criteria combined with N-terminal pro-brain natriuretic peptide (NT-proBNP) testing. We performed a randomized noninferiority trial in 17 Dutch hospitals. We randomized patients with PE without any of the Hestia criteria to direct discharge or additional NT-proBNP testing. We discharged the latter patients as well if NT-proBNP did not exceed 500 ng/L or admitted them if NT-proBNP was greater than 500 ng/L. The primary endpoint was 30-day adverse outcome defined as PE- or bleeding-related mortality, cardiopulmonary resuscitation, or intensive care unit admission. The noninferiority margin for the primary endpoint was 3.4%. We randomized 550 patients. In the NT-proBNP group, 34 of 275 (12%) had elevated NT-proBNP values and were managed as inpatients. No patient (0 of 34) with an elevated NT-proBNP level treated in hospital (0%; 95% confidence interval [CI], 0-10.2%), versus no patient (0 of 23) with a post hoc-determined elevated NT-proBNP level from the direct discharge group (0%; 95% CI, 0-14.8%), experienced the primary endpoint. In both trial cohorts, the primary endpoint occurred in none of the 275 patients (0%; 95% CI, 0-1.3%) subjected to NT-proBNP testing, versus in 3 of 275 patients (1.1%; 95% CI, 0.2-3.2%) in the direct discharge group (P = 0.25). During the 3-month follow-up, recurrent venous thromboembolism occurred in two patients (0.73%; 95% CI, 0.1-2.6%) in the NT-proBNP group versus three patients (1.1%; 95% CI, 0.2-3.2%) in the direct discharge group (P = 0.65). Outpatient treatment of patients with PE selected on the basis of the Hestia criteria alone was associated with a low risk of adverse events. Given the low number of patients with elevated NT-proBNP levels, this trial was unable to draw definite conclusions regarding the incremental value of NT-proBNP testing in patients who fulfill the Hestia criteria. Clinical trial registered with www.trialregister.nl/trialreg/admin/rctview.asp?TC=2603 (NTR2603).

The prognostic value of the plasma N-terminal pro-brain natriuretic peptide level on all-cause death and major cardiovascular events in a community-based population.

BackgroundDespite growing evidence that N-terminal pro-brain natriuretic peptide (NT-proBNP) has an important prognostic value for patients with cardiovascular disease, chronic kidney disease, etc, the prognostic significance of NT-proBNP levels in the general population has not been established. The aim of this study was to evaluate the clinical significance of NT-proBNP in a community population.MethodsThis is a community-based prospective survey of residents from two communities in Beijing conducted for a routine health status checkup. Out of 1,860 individuals who were eligible for inclusion from 2007 to 2009, 1,499 completed a follow-up and were assessed for the prognostic value of NT-proBNP in 2013. A questionnaire was used for end point events. Anthropometry and blood pressure were measured. Plasma NT-proBNP, creatinine, lipids, and glucose were determined.ResultsA total of 1,499 subjects with complete data were included in the analysis. Participants were divided into four groups according to baseline NT-proBNP levels (quartile 1, <19.8 pg/mL; quartile 2, 19.8–41.6 pg/mL; quartile 3, 41.7–81.8 pg/mL; quartile 4, ≥81.9 pg/mL). During a median 4.8-year follow-up period, the all-cause mortality rate rose from 0.8% in the lowest concentration NT-proBNP group (<19.8 pg/mL) to 7.8% in the highest NT-proBNP group (≥81.9 pg/mL; P<0.001). The incidence of major adverse cardiovascular events (MACEs) increased from 3.1% in the lowest NT-proBNP group to 18.9% in the highest group (P<0.001). Individuals in the highest NT-proBNP group (≥81.9 pg/mL) were associated with higher risk of all-cause death and MACEs compared with the lowest NT-proBNP group using Kaplan–Meier survival curves and the Cox proportional hazard model after adjusting for age, sex, and traditional risk factors.ConclusionThe plasma NT-proBNP level is a strong and independent prognosis factor for all-cause death and MACEs in the community population. The NT-proBNP cut-point for the prognostic value remains to be further studied. NT-proBNP is a strong and independent prognostic factor for all-cause death and MACEs in individuals older than 65 years and MACEs in individuals younger than 65 years.

Age-adjusted plasma N-terminal pro-brain natriuretic peptide level in Kawasaki disease.

PurposeRecent reports showed that plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) could be a useful biomarker of intravenous immunoglobulin (IVIG) unresponsiveness and coronary artery lesion (CAL) development in Kawasaki disease (KD). The levels of these peptides are critically influenced by age; hence, the normal range and upper limits for infants and children are different. We performed an age-adjusted analysis of plasma NT-proBNP level to validate its clinical use in the diagnosis of KD.MethodsThe data of 131 patients with KD were retrospectively analyzed. The patients were divided into 2 groups—group I (high NT-proBNP group) and group II (normal NT-proBNP group)—comprising patients with NT-proBNP concentrations higher and lower than the 95th percentile of the reference value, respectively. We compared the laboratory data, responsiveness to IVIG, and the risk of CAL in both groups.ResultsGroup I showed significantly higher white blood cell count, absolute neutrophil count, C-reactive protein level, aspartate aminotransferase level, and troponin-I level than group II (P<0.05). The risk of CAL was also significantly higher in group I (odds ratio, 5.78; P=0.012). IVIG unresponsiveness in group I was three times that in group II (odds ratio, 3.35; P= 0.005).ConclusionAge-adjusted analysis of plasma NT-proBNP level could be helpful in predicting IVIG unresponsiveness and risk of CAL development in patients with KD.

Sensitive troponin and N-terminal probrain natriuretic peptide in stable angina

High-sensitivity cardiac troponin (hs-TnT) and N-terminal probrain natriuretic peptide (NT-proBNP) are powerful predictors of mortality in patients with stable coronary artery disease. Whether their combined use may further improve mortality prediction in these patients is unknown. The study included 869 patients with stable coronary artery disease who underwent percutaneous coronary intervention. Hs-TnT and NT-proBNP were measured before angiography. Using median values of hs-TnT (0·008 μg L(-1)) and NT-proBNP (250·0 ng L(-1)) as cut-off points, patients were divided into four groups: low hs-TnT/low NT-proBNP group (293 patients with hs-TnT and NT-proBNP < median); low hs-TnT/high NT-proBNP group (142 patients with hs-TnT < median and NT-proBNP ≥ median); high hs-TnT/low NT-proBNP group (142 patients with hs-TnT ≥ median and NT-proBNP < median) and high hs-TnT/high NT-proBNP group (292 patients with hs-TnT and NT-proBNP ≥ median). The primary end point was all-cause mortality. The 4-year follow-up was complete in 90·7% of the patients. There were 76 deaths during the follow-up: seven in low hs-TnT/low NT-proBNP, 8 in low hs-TnT/high NT-proBNP, 10 in high hs-TnT/low NT-proBNP and 51 in high hs-TnT/high NT-proBNP groups (mortality estimates, 2·5%, 5·9%, 7·4% and 18·1%, respectively; odds ratio = 8·64, 95% confidence interval 3·85-19·4, P < 0·001 for high hs-TnT/high NT-proBNP vs. low hs-TnT/low NT-proBNP). Inclusion of hs-TnT and NT-proBNP in the multivariable model increased the discriminatory power of the model regarding mortality prediction compared with the model without biomarkers (absolute and relative integrated discrimination improvement 0·039 and 26·0%, P = 0·0015). Combined use of hs-TnT and NT-proBNP improves long-term risk prediction of mortality in patients with stable coronary heart disease.

N-terminal pro–brain natriuretic peptide testing in the emergency department: Beneficial effects on hospitalization, costs, and outcome

N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. Assessment of this biomarker in patients with acute dyspnea presenting to the emergency department (ED) may aid diagnostic decision-making, resulting in improved patient care and reduced costs. In a prospective clinical trial, patients presenting with acute dyspnea to the ED of the Erasmus Medical College, Rotterdam, the Netherlands, were randomized for either rapid measurement or no measurement of NT-proBNP. For ruling out heart failure, cutoff values of 93 pg/mL in male and 144 pg/mL in female patients were used, and for ruling in heart failure, a cutoff value of 1,017 pg/mL was used. Time to discharge from the hospital and costs related to hospital admission were primary end points. Bootstrap analysis was used for comparison of costs and 30-day mortality between the NT-proBNP and control group. A total of 477 patients (54% male) was enrolled. The mean age was 59 years, with 44% of patients having a history of cardiac disease. Median time to discharge from the hospital was 1.9 days (interquartile range [IQR], 0.12-8.4 days) in the NT-proBNP group (n = 241) compared with 3.9 days (IQR, 0.16-11.0 days) in the control group (n = 236) (P = .04). Introduction of NT-proBNP testing resulted in a trend toward reduction in costs related to hospital admission and diagnostic investigations of $1,364 per patient (95% CI $-246 to $3,215), whereas 30-day mortality was similar (15 patients in the NT-proBNP and 18 patients in the control group). Introduction of NT-proBNP testing for heart failure in the ED setting reduces the time to discharge and is associated with a trend toward cost reduction.