Use Of B-type Natriuretic Peptide Research Articles

Prognostic value of B-type natriuretic peptide for nursing- and healthcare-associated pneumonia and aspiration pneumonia in comparison with procalcitonin and A-DROP score: a prospective cohort study.

Pneumonia in elderly patients who require nursing care is becoming more and more common among the aging populations of developed countries, and treatment is an important topic worldwide. A simpler prognostic indicator would be expected to improve the treatment of pneumonia. This single-center, prospective cohort study aimed to compare the usefulness of B-type natriuretic peptide (BNP), procalcitonin (PCT), and the A-DROP score, which have been reported to correlate with pneumonia prognoses, such as aspiration pneumonia (AP). We included patients who were admitted to the Kanazawa Medical University Himi Municipal Hospital with a diagnosis of either nursing- and healthcare-associated pneumonia (NHCAP) or AP between January 1, 2012 and July 31, 2019. We collected demographic, clinical, and laboratory characteristics and outcome data from electronic medical records, and calculated A-DROP scores. The primary outcome was 30-day mortality. We evaluated correlations with the primary outcome using the chi-square test, Fisher exact test, t-test, Cox-regression analysis, and receiver operating characteristic curve analysis. Of the 1,215 patients with pneumonia, 297 were eligible for the study, of whom 37 (12%) died whin 30 days. After univariate analysis, we performed Cox proportional-hazards analysis for BNP, PCT, A-DROP score, albumin, C-reactive protein, and disseminated intravascular coagulation, which were significantly correlated with the primary outcome in univariate analysis. As a result, only BNP showed a significant correlation (P=0.008, 95% CI: 1.30-6.06). No significant correlation was obtained in PCT (P=0.529) and A-DROP score (P=0.107). Furthermore, we generated receiver operating characteristic curve to estimate the prognostic cut-off values of BNP for the primary outcome of NHCAP and AP. The optimal cut-off value of BNP for predicting death was 179.3 pg/mL (sensitivity 62.2%, specificity 76.2%, negative likelihood ratio 0.50%, positive likelihood ratio 2.61%). And, BNP yielded the highest area under the curve (0.72) in comparison with PCT (0.67) and A-DROP score (0.69). BNP may be a more clinically useful prognostic factor for NHCAP and AP than PCT or A-DROP score, and should be considered as a routine test at the beginning of these treatments.

Use of B-Type Natriuretic Peptide as a Quantitative Marker of Fluid Overload in Neonatal Renal Replacement Therapy

Use of B-Type Natriuretic Peptide as a Quantitative Marker of Fluid Overload in Neonatal Renal Replacement Therapy

B-type natriuretic peptide testing in the emergency setting for managing acute dyspnea.

The performance of B-type natriuretic peptide to accurately diagnose dyspnea of cardiac origin has been widely proved. However, its impact in clinical practice is less clear. We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We identified two systematic reviews including five studies overall, of which all were randomized trials. We concluded the use of B-type natriuretic peptide for the management of acute dyspnea in the emergency setting probably leads to a small reduction in the need for hospitalization. Additionally, it may slightly reduce mortality and intensive care unit admission, but the certainty of the evidence is low.

Plasma B-type natriuretic peptide levels are poorly related to the occurrence of ischemia or ventricular arrhythmias during symptom-limited exercise in low-risk patients.

IntroductionThe usefulness of B-type natriuretic peptide (BNP) as a marker of ischemia is controversial. BNP levels have predicted arrhythmias in various settings, but it is unknown whether they are related to exercise-induced ischemic ventricular arrhythmias.Material and methodsWe analyzed in 63 patients (64 ±14 years, 65% male, 62% with known coronary disease) undergoing exercise stress single-photon emission computed tomography (SPECT) the association between plasma BNP values (before and 15 min after exercise) and the occurrence of ischemia or ventricular arrhythmias during the test.ResultsExercise test (8.1 ±2.7 min, 7.4 ±8.1 metabolic equivalents, 82 ±12% of maximal predicted heart rate) induced reversible perfusion defects in 23 (36%) patients. Eight (13%) patients presented significant arrhythmias (≥ 7 ventricular premature complexes/min, couplets, or non-sustained ventricular tachycardia during exercise or in the first minute of recovery). Median baseline BNP levels were 17.5 (12.4–66.4) pg/ml in patients developing scintigraphic ischemia and 45.6 (13.2–107.4) pg/ml in those without ischemia (p = 0.137). The BNP levels increased after exercise (34.4 (15.3–65.4)% increment over baseline, p < 0.001), but the magnitude of this increase was not related to SPECT positivity (35.7 (18.8–65.4)% vs. 27.9 (5.6–64.0)% in patients with and without ischemia, respectively, p = 0.304). No significant association was found between BNP values (at baseline or their change during the test) and ventricular arrhythmias.ConclusionsPlasma BNP values – at baseline or after exercise – were not associated with myocardial ischemia or with ventricular arrhythmia during exercise SPECT. These results highlight the limited usefulness of this biomarker to assess acute ischemia.

Diagnostic utility of contemporary echo and BNP assessment in patients with acute heart failure during early hospitalization

BackgroundThe use of B-type natriuretic peptide (BNP) and echocardiography in acute heart failure (AHF) diagnosis is poorly employed in the Emergency Department. The aim of the present study is to evaluate relation among BNP levels systolic and diastolic dysfunction during early phases of AHF hospitalization. MethodsWe performed contemporary echocardiographic and BNP assessment in 310 patients with AHF within 12h since hospital admission. We studied the correlation among BNP and degree of diastolic dysfunction evaluated by pulsed Doppler transmitral flow and Tissue Doppler flow. Finally we investigated the relation among BNP and the right systolic longitudinal ventricular function (TAPSE) and the systolic pulmonary arterial pressure (PAPs). ResultsBNP levels were 1417±1126, 1081±955, 894±901pg/mL, for patients with EF≤25%, EF 25–40% and EF 40–50% (p=0.005), respectively. “BNP levels linearly correlate with the degree of diastolic dysfunction: 582±406pg/mL in altered relaxation pattern, 712±557pg/mL in pseudonormal pattern and 1694±805 in restrictive filling pattern (p<0.001 for all patterns).” BNP levels were significantly increased in patients with right systolic ventricular dysfunction (TAPSE<18mm; p=0.006) and in patients with PAPs≥40mmHg (p=0.001). ROC curve and logistic regression analysis highlighted the power of BNP to detect severe systolic dysfunction, right ventricular (RV) overload and dysfunction and diastolic dysfunction patterns. ConclusionsBNP levels correlate linearly with LV systolic dysfunction as well as with impaired degree of diastolic dysfunction. Significant PAP increase is a further factor influencing BNP elevation in patients with AHF during early hospitalization phase.

Validation of the use of B-type natriuretic peptide point-of-care test platform in preliminary recognition of cardioembolic stroke patients in the ED

AimThe aim of the study is to validate of the use of plasma B-type natriuretic peptide (BNP) point-of-care test platform in preliminary recognition of cardioembolic stroke patients in the emergency department (ED). MethodsIn our ED, emergency physicians prospectively assessed consecutive adult patients with acute phase of ischemic stroke and measured plasma BNP by point-of-care test platform on admission. The included patients with plasma BNP concentration more than 66.50 pg/mL were presumed to be classified as the cardioembolism (CE) subtype and were then followed up. Stroke neurologists evaluated patients' functional outcome at hospital discharge and also made discharge diagnosis and stroke etiologic subtypes according to Trial of ORG 10172 in Acute Stroke Treatment criteria: large artery atherosclerosis, CE, small artery occlusion, stroke of other determined etiology, and stroke of other undetermined etiology. ResultsIn this study, 172 of 262 acute ischemic stroke patients met the study criteria (mean age, 71.18 ± 11.65 years; 53.49% female). Of the 172 patients, 38.95% were diagnosed with large artery atherosclerosis at discharge; 26.16%, with CE; 24.42%, with small artery occlusion; and 10.47%, with stroke of other determined etiology or stroke of other undetermined etiology. Age, previous cardiac disease, atrial fibrillation, length of hospital stays, Scandinavian Stroke Scale score on admission less than or equal to 25, and modified Rankin Scale greater than or equal to 3 or death at discharge were all significantly higher in the CE patients compared to other subtypes (P < .01). The mean BNP concentration was significantly higher in the CE group than in other 3 subtypes (P < .01). The plasma BNP level greater than 66.50 pg/mL had good corresponding diagnostic performance in preliminary recognition of cardioembolic stroke patients (sensitivity, 75.56%; specificity, 87.40%). ConclusionsIn this study, we found that the plasma BNP level greater than 66.50 pg/mL as a reference index had good corresponding diagnostic performance in preliminary recognition of cardioembolic stroke patients. However, the single BNP biomarker panel cannot be used to confidently identify CE subtype as a diagnosis and must be taken in context with clinical assessment and judgment before making management decisions.

Soluble ST2 in Ventricular Dysfunction.

Heart failure is a commonly encountered condition associated with increased morbidity, mortality, and healthcare cost. For years, its management has been strongly influenced by the use of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide biomarkers. In some cases, this approach does not always identify patients with heart failure accurately and may not provide the best prognostic assessment, particularly in the presence of comorbidities. Biomarkers that help refine diagnosis and risk stratification are needed. Soluble ST2, a peptide belonging to the interleukin-1 receptor family, is secreted when cardiomyocytes and cardiac fibroblasts are subjected to mechanical strain. Although preliminary results on this novel biomarker are encouraging, additional and more comprehensive studies are clearly needed to establish its role in the management of patients with heart failure. The purpose of this chapter is to provide an overview of data currently available.

B-type natriuretic peptide-guided therapy for perioperative medicine?

The recent guideline from the European Society of Cardiology and European Society of Anesthesiology recommended the use of B-type natriuretic peptide (BNP) as preoperative testing for high-risk cardiac patients undergoing...

Prediction of clinical outcomes using B-type natriuretic peptides in the general population: a systematic review.

The use of B-type natriuretic peptides to predict outcomes in general populations has been investigated in a number of primary studies. A previous systematic review considering natriuretic peptides in cardiovascular disease included a subgroup of general population studies, which suggested an association with a number of clinical outcomes. We electronically searched Medline, Embase, AMED, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL for English-language articles published between 1989 and mid-2012. We utilized trained reviewers and standardized forms to screen articles for inclusion and extract data from included articles. All included studies (n=7) were summarized in narrative and tabular form. A general population was defined as one that was randomly selected from a community setting where no specific inclusion or exclusion criteria were specified. The seven included studies all used FDA approved assays for NT-proBNP. The range of clinical outcomes and heterogeneity did not allow for meta-analysis. The hazard ratios for predicting outcomes in the included studies ranged from 1.0 to 4.1 (all p values <0.05). The discrimination statistics reported in four studies all demonstrated statistically significant improvements in predicting outcomes. NT-proBNP is associated with heart failure, all-cause and cardiovascular mortality, and other combined cardiovascular events in a general unselected population. The discrimination statistics suggest modest improvements in risk stratification. No prospective studies exist to demonstrate the clinical utility of using B-type natriuretic peptides to predict clinical outcomes in a general population.

Usefulness of plasma B-type natriuretic peptide as a prognostic marker of cardiac function in senile systemic amyloidosis and in familial amyloidotic polyneuropathy

Objective: In senile systemic amyloidosis (SSA), a common age-related amyloidosis, wild-type transthyretin accumulates in tissues, with a primary result being cardiac dysfunction. Here, we aimed to clarify the usefulness of B-type natriuretic peptide (BNP) as a prognostic marker of cardiac function in SSA and in familial amyloidotic polyneuropathy (FAP).Methods and results: We studied 13 patients with severe SSA and 14 patients with FAP. SSA patients, but not FAP patients, demonstrated a significant correlation of log BNP with the echocardiographic diastolic marker E/e′ ratio (r = 0.78, p < 0.01). SSA patients also showed significant correlations between log BNP and log C-reactive protein or log high-sensitive troponin T (r = 0.70, p < 0.01; r = 0.64, p < 0.05). FAP patients, however, had significant correlations between log BNP and left ventricular wall thickness (intraventricular septum thickness diastole and posterior wall thickness diastole) (r = 0.73, p < 0.01; r = 0.77, p < 0.01). The mean log BNP level in the follow-up period was significantly higher than that in the diagnostic period in SSA patients (2.65 ± 0.45 versus 2.36 ± 0.40, p < 0.01) but not in FAP patients (1.91 ± 0.56 versus 1.93 ± 0.45, p = 0.87). An especially notable phenomenon was the high plasma BNP level (≥180 pg/ml) in SSA patients.Conclusion: Plasma BNP levels may be a useful prognostic marker of cardiac function in SSA.

B‐type natriuretic peptide in the evaluation and management of dyspnoea in primary care

The rapid and accurate diagnosis of heart failure in primary care is a major unmet clinical need. We evaluated the additional use of B-type natriuretic peptide (BNP) levels. A randomized controlled trial. Twenty-nine primary care physicians in Switzerland and Germany coordinated by the University Hospital Basel, Switzerland. A total of 323 consecutive patients presenting with dyspnoea. Assignment in a 1 : 1 ratio to a diagnostic strategy including point-of-care measurement of BNP (n = 163) or standard assessment without BNP (n = 160). The total medical cost at 3 months was the primary end-point. Secondary end-points were diagnostic certainty, time to appropriate therapy, functional capacity, hospitalization and mortality. The final diagnosis was adjudicated by a physician blinded to the BNP levels. Heart failure was the final diagnosis in 34% of patients. The number of hospitalizations, functional status and total medical cost at 3 months [median $1655, interquartile range (IQR), 850-3331 vs. $1541, IQR 859-2827; P = 0.68] were similar in both groups. BNP increased diagnostic certainty as defined by the need for further diagnostic work-up (33% vs. 45%; P = 0.02) and accelerated the initiation of the appropriate treatment (13 days vs. 25 days; P = 0.01). The area under the receiver-operating characteristics curve for BNP to identify heart failure was 0.87 (95% confidence interval, 0.81-0.93). The use of BNP levels in primary care did not reduce total medical cost, but improved some of the secondary end-points including diagnostic certainty and time to initiation of appropriate treatment.

Abstract 331: Elevated Pre-discharge B-type Natriuretic Peptide Predicts 30-day Heart Failure-specific Rehospitalization

Background: Studies support the use of B-type natriuretic peptide (BNP) to guide both the diagnosis and treatment of heart failure. However the variation in clinical use of BNP, and its impact on outcomes outside the clinical trial setting, has not been well characterized. Our aim was to evaluate the clinical use of BNP across the Veterans Affairs (VA) Health Care System, and to identify factors associated with 30-day rehospitalization. Methods: We determined both the frequency and timing of BNP and amino-terminal pro-B-type natriuretic peptide (NT-proBNP). We examined all hospital discharges with the diagnosis of heart failure in the VA Health Care System from 2006 - 2009 (n=109,875). The relationship between pre-discharge BNP and 30 day rehospitalization was evaluated using generalized estimating equations that adjusted for covariates and clustering of patients within facilities. Results: There were 59,720 out of 109,875 patients (54%) with a BNP (50%) or NT-ProBNP (4%) obtained during admission. Use of a BNP or NT-ProBNP test increased from 41% in 2006 to 60% in 2009. Patients evaluated with a BNP test had an older mean age (71 vs, 68 years, p&lt;0.001). Black patients were less likely to have a BNP (50%) compared to non-black patients (58%, p&lt;0.001). There were 125 VA hospitals with at least 80 heart failure discharges in the time period studied. Among these hospitals, the use of BNP (or NT-proBNP) during admission ranged from 0% to 83% of heart failure hospitalizations (median 57%, interquartile range 42% to 72%). BNP within 2 days of discharge (pre-discharge) was measured in 25,988 (24%) heart failure admissions. Higher pre-discharge BNP was associated with a greater risk for rehospitalization with heart failure as the principal diagnosis (Table; p&lt;0.001 for trend). Risk for heart failure readmission tripled from a pre-discharge BNP of 200 to 1000 pg/ml. Pre-discharge BNP was not a significant predictor of other causes of readmission. There were too few NT-proBNP values for comparison. Similar findings were seen after adjustment for patient characteristics. Conclusions: There is significant variability in BNP usage across the VA Health Care System, although use of the test is growing. Pre-discharge BNP is a strong predictor of heart failure readmission but not of other causes of rehospitalization. These data may help clinicians identify high-risk patients prior to hospital discharge, and perhaps indicate a need for more aggressive heart failure-specific therapy and outpatient monitoring.

The Usefulness of B-Type Natriuretic Peptide in the Early Diagnosis of Right Ventricular Infarction

PURPOSE: 19-51% of inferior acute myocardial infarction(AMI) patients combine with right ventricular infarction(RVI). RVI is associated with a highly increased in-hospital mortality. Therefore, early diagnosis of RVI in inferior acute myocardial infarction is very important. This study was planned to investigate the usefulness of B-type natriuretic peptide(BNP) in the early diagnosis of RVI.

Biomonitors of cardiac injury and performance: B-type natriuretic peptide and troponin as monitors of hemodynamics and oxygen transport balance

Serum biomarkers, such as B-type natriuretic peptide and troponin, are frequently measured in the cardiac intensive care unit. A review of the evidence supporting monitoring of these biomarkers is presented. A search of MEDLINE, PubMed, and the Cochrane Database was conducted to find literature regarding the use of B-type natriuretic peptide and troponin in the cardiac intensive care setting. Adult and pediatric data were considered. Both B-type natriuretic peptide and troponin have demonstrated utility in the intensive care setting but there is no conclusive evidence at this time that either biomarker can be used to guide inpatient management of children with cardiac disease. Although B-type natriuretic peptide and troponin concentrations can alert clinicians to myocardial stress, injury, or hemodynamic alterations, the levels can also be elevated in a variety of clinical scenarios, including sepsis. Observational studies have demonstrated that perioperative measurement of these biomarkers can predict postoperative mortality and complications. (class IIb, level of evidence B): The use of B-type natriuretic peptide and/or troponin measurements in the evaluation of hemodynamics and postoperative outcome in pediatric cardiac patients may be beneficial.

Use of B-type natriuretic peptide as a screening tool for left ventricular diastolic dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease.

Patients with rheumatoid arthritis (RA) are at an increased risk for heart failure and left ventricular diastolic dysfunction (LVDD). B-type natriuretic peptide (BNP) may be useful to screen for LVDD in the general population. We compared the effectiveness of BNP as a screening tool for LVDD in RA and non-RA subjects without cardiovascular disease (CVD). Study subjects were recruited from population-based samples with and without RA, excluding subjects with CVD. LVDD was assessed by 2-dimensional and Doppler echocardiography and categorized as none, mild, moderate/severe, or indeterminate. Linear regression and proportional odds models evaluated the association between LVDD and BNP, adjusting for age, sex, and body mass index. Among 231 RA and 1,730 non-RA subjects without CVD, BNP was significantly higher in subjects with moderate/severe LVDD compared to those with no or mild LVDD (P = 0.02 for RA and P < 0.001 for non-RA subjects). More RA subjects had elevated BNP than non-RA subjects (16% versus 9%; P < 0.001). Positive predictive value (25% in RA and 18% in non-RA subjects) and sensitivity (40% in RA and 26% in non-RA subjects) were similarly low in both cohorts, but specificity was significantly lower in RA than in non-RA subjects (89% versus 94%; P = 0.02). While RA subjects were more likely to have elevated BNP, few RA patients with elevated BNP actually have LVDD. Also, normal BNP levels are less likely to rule out LVDD in RA than in non-RA subjects. Therefore, BNP may be less effective for screening in RA subjects compared to the general population.

2011 Update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006

Chronic heart failure (CHF) is a complex and lethal clinical syndrome accounting for an increasing number of Australian hospital separations and more than 2700 Australian deaths in 2008. In 2006, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand published Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Results from recently published clinical trials provide additional information to be considered in the prevention, detection and management of CHF. In some cases, this new evidence strengthens recommendations previously made in the 2006 guidelines; in others, it provides new approaches to current recommended practice. Areas in which there have been significant new developments include: Use of B-type natriuretic peptide (BNP) or N-terminal proBNP plasma level measurement in guiding treatment of CHF; New pharmacological approaches to the treatment of systolic heart failure; Drugs to avoid or use with caution in CHF; Treatment of cardiac arrhythmias in patients with CHF; Multidisciplinary care and post-discharge management programs. While patient circumstances and clinical judgement should guide the interpretation of these findings in the clinical context, this update, together with the 2006 guidelines, provides current clinical guidance on CHF.

Use of B‐type natriuretic peptide in the management of hypoxaemic respiratory failure

Evaluation and management of patients with hypoxaemic respiratory failure in the intensive care unit (ICU) are difficult. The use of B-type natriuretic peptide (BNP), a quantitative marker of cardiac stress and heart failure (HF), may be helpful. The purpose of this study is to describe the prevalence of causative disorders of hypoxaemic respiratory failure in the ICU and to determine the impact of a BNP-guided diagnostic strategy. This prospective, multi-centre, randomized, single-blind, controlled trial included 314 ICU patients with hypoxaemic respiratory failure: 159 patients were randomly assigned to a diagnostic strategy involving the measurement of BNP and 155 were assessed in a standard manner. The time to discharge and the total cost of treatment were the primary endpoints. Hypoxaemic respiratory failure was multi-causal in 27% of the patients. Heart failure was the most common diagnosis in both groups. The use of BNP levels, in conjunction with other clinical information, significantly increased the detection of HF in combination with an additional diagnosis (32 vs. 16%, P = 0.001) and also increased the application of HF-specific medical therapy (nitrates: 32 vs. 23%, P < 0.05 and diuretics: 65 vs. 50%, P < 0.01). Time to discharge (median, 13 vs.14 days, P = 0.50) and total cost of treatment (median, US-$6190 vs. 7155, P = 0.24) were comparable in both groups. Hypoxaemic respiratory failure in the ICU is often a multi-causal disorder. The use of BNP increased the detection of HF, but did not significantly improve patient management as quantified by time to discharge or treatment cost. ClinicalTrials.gov Identifier: NCT00130559.

Usefulness of B-Type Natriuretic Peptide to Predict Outcome of Patients Treated by Transcatheter Aortic Valve Implantation

B-type natriuretic peptide (BNP) has been shown to predict outcomes after conventional aortic valve replacement. The aim of the present study was to investigate whether BNP also predicts the outcomes after transcatheter aortic valve implantation (TAVI). A total of 58 patients (36 men, age 84 ± 5 years) underwent TAVI in our institution for severe aortic stenosis (aortic valve area 0.6 ± 0.1 cm², mean gradient 41 ± 15 mm Hg) at high risk of surgery (logistic European System for Cardiac Operative Risk Evaluation 34 ± 17%). BNP was measured before and 24 hours after TAVI. The 30-day survival rate was 91%. Although the baseline clinical and hemodynamic characteristics were similar among the 30-day survivors (n = 53) and nonsurvivors (n = 5), the BNP levels were significantly lower in the 30-day survivors, at both baseline (463 ± 265 vs 1,067 ± 655 pg/ml; p = 0.005) and 24 hours after TAVI (488 ± 238 vs 1,632 ± 1,028 pg/ml; p <0.0001). The BNP levels were significantly greater in patients experiencing one major adverse event at 30 days. On multivariate analysis, only BNP levels (baseline value and change at 24 hours) were independent predictors of 30-day survival. Kaplan-Meier analysis showed that 30-day survival was significantly lower in patients with than in those without both a baseline BNP level >428 mg/dl (p = 0.04) and a significant BNP increase of >170 pg/ml at 24 hours after TAVI (p = 0.001). In conclusion, BNP is a strong predictor of 30-day outcomes after transcatheter aortic valve implantation, at both baseline and 24 hours after the procedure.

Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis

Purposes The aim of the study was to assess the usefulness of systematic natriuretic peptide testing in the management of patients presenting with acute dyspnea to emergency departments (EDs). Methods We performed a systematic review and meta-analysis of randomized controlled trials assessing the usefulness of B-type natriuretic peptide (BNP) or its N-terminal fragment (NT-proBNP) in the management of patients presenting with dyspnea into ED. We searched Medline, Embase, and conference proceedings without restriction on neither language nor publication year. Selection of studies, data collection, and assessment of risk of bias were performed by 2 reviewers independently and in duplicate. Outcomes included hospital admission rate, time to discharge, and length of hospital stay, mortality and rehospitalization rates, and total direct medical costs. Combined risk ratios were estimated using fixed or random effects model. Duration and cost data were not combined. Findings Four randomized controlled trials, representing 2041 patients, were selected. In 4 trials, there was a tendency for hospital admission to be reduced in the intervention group (combined risk ratio, 0.95; 95% confidence interval, 0.89-1.01). Time to discharge was significantly reduced in 2 trials, whereas there was no significant reduction in hospital length of stay in 3 trials. There was no significant effect on in-hospital and 30-day mortality rates or rehospitalization rates (3 trials reporting each outcome). Two trials found significant reduction in direct costs. Conclusions The current evidence remains inconclusive on whether systematic natriuretic peptide testing is useful for the management of patients presenting to ED with acute dyspnea.

Diagnostic accuracy and clinical relevance of brain natriuretic peptide assay in pediatric patients with congenital heart diseases

The clinical usefulness of B-type natriuretic peptide (BNP) assay in congenital heart diseases is still controversial. We evaluated the diagnostic accuracy and clinical relevance of this assay in different cardiovascular hemodynamic conditions in pediatric patients with congenital heart diseases. BNP was measured in 173 healthy individuals and in 382 pediatric patients with congenital heart diseases. We identified five subgroups of hemodynamic conditions: left ventricular volume overload, right ventricular volume overload, left ventricular pressure overload, right ventricular pressure overload, and biventricular volume overload. BNP was higher (P<0.0001) in patients (median 49.0 ng/l, range 0.45-14363 ng/l) than in the reference population (median 6.1 ng/l, range 1.0-29.7 ng/l). BNP assay showed a good diagnostic accuracy in discriminating between healthy individuals and patients (area under the receiver operating characteristic curve 0.95, SE 0.009). Lower BNP values were found in right ventricular pressure overload than in left ventricular pressure overload, left ventricular volume overload, or biventricular volume overload. In the left ventricular volume overload subgroup, BNP significantly correlated with peak systolic gradients (rho=0.622, P<0.001) and left ventricular dilatation (rho=0.35, P=0.03). In the right ventricular volume overload subgroup, BNP correlated with right ventricular pressure (rho=0.622, P<0.001) and right ventricular dilatation (rho=0.377, P=0.0077). Moreover, in cyanotic defects, BNP showed a significant correlation with O2 saturation (rho=0.204 P=0.0128). BNP assay showed a good diagnostic accuracy in discriminating between healthy individuals and patients. Congenital heart disease with left ventricular pressure overload and biventricular volume overload has higher BNP values than that with right ventricular pressure overload.