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J Am Coll Cardiol, 2002; 39:202-209
© 2002 by the American College of Cardiology Foundation
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CLINICAL STUDY: HEART FAILURE

Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea

L. Katherine Morrison, BS*, Alex Harrison, BS*, Padma Krishnaswamy, MD*, Radmila Kazanegra, MD*, Paul Clopton, MS* and Alan Maisel, MD, FACC*,*

* Division of Cardiology, Veteran’s Affairs Medical Center, and the Department of Medicine, University of California, San Diego, California, USA

Manuscript received June 18, 2001; revised manuscript received October 4, 2001, accepted October 26, 2001.

* Reprint requests and correspondence: Dr. Alan Maisel, Veterans Affairs Medical Center, Cardiology 111-A, 3350 La Jolla Village Drive, San Diego, California 92161, USA.
amaisel{at}ucsd.edu

OBJECTIVES: Since B-type natriuretic peptide (BNP) is secreted by the left ventricle (LV) in response to volume elevated LV pressure, we sought to assess whether a rapid assay for BNP levels could differentiate cardiac from pulmonary causes of dyspnea.

BACKGROUND: Differentiating congestive heart failure (CHF) from pulmonary causes of dyspnea is very important for patients presenting to the emergency department (ED) with acute dyspnea.

METHODS: B-natriuretic peptide levels were obtained in 321 patients presenting to the ED with acute dyspnea. Physicians were blinded to BNP levels and asked to give their probability of the patient having CHF and their final diagnosis. Two independent cardiologists were blinded to BNP levels and asked to review the data and evaluate which patients presented with heart failure. Patients with right heart failure from cor pulmonale were classified as having CHF.

RESULTS: Patients with CHF (n = 134) had BNP levels of 758.5 ± 798 pg/ml, significantly higher than the group of patients with a final diagnosis of pulmonary disease (n = 85) whose BNP was 61 ± 10 pg/ml. The area under the receiver operating curve, which plots sensitivity versus specificity for BNP levels in separating cardiac from pulmonary disease, was 0.96 (p < 0.001). A breakdown of patients with pulmonary disease revealed: chronic obstructive pulmonary disease (COPD): 54 ± 71 pg/ml (n = 42); asthma: 27 ± 40 pg/ml (n = 11); acute bronchitis: 44 ± 112 pg/ml (n = 14); pneumonia: 55 ± 76 pg/ml (n = 8); tuberculosis: 93 ± 54 pg/ml (n = 2); lung cancer: 120 ± 120 pg/ml (n = 4); and acute pulmonary embolism: 207 ± 272 pg/ml (n = 3). In patients with a history of lung disease but whose current complaint of dyspnea was seen as due to CHF, BNP levels were 731 ± 764 pg/ml (n = 54). The group with a history of CHF but with a current COPD diagnosis had a BNP of 47 ± 23 pg/ml (n = 11).

CONCLUSIONS: Rapid testing of BNP in the ED should help differentiate pulmonary from cardiac etiologies of dyspnea.

Abbreviations and Acronyms
  BNP
  B-type natriuretic peptide
  CHF
  congestive heart failure
  COPD
  chronic obstructive pulmonary disease
  CV
  coefficient of variation
  ED
  emergency department
  EDTA
  ethylene diamine tetra acetic acid
  LV
  left ventricle or left ventricular
  PEF
  peak expiratory flow
  ROC
  receiver-operating characteristic




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Diagnostic Accuracy and Prognostic Relevance of the Measurement of Cardiac Natriuretic Peptides: A Review
Clin. Chem., January 1, 2004; 50(1): 33 - 50.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
E. C. Vourvouri, A. F.L. Schinkel, J. R.T.C. Roelandt, F. Boomsma, G. Sianos, M. Bountioukos, F. B. Sozzi, V. Rizzello, J. J. Bax, H. I. Karvounis, et al.
Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device
Eur J Heart Fail, December 1, 2003; 5(6): 767 - 774.
[Abstract] [Full Text] [PDF]

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 HeartHome page
R Senior, G Galasko, J V McMurray, and J Mayet
Screening for left ventricular dysfunction in the community: role of hand held echocardiography and brain natriuretic peptides
Heart, November 1, 2003; 89(90003): iii24 - 28.
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 Eur Respir JHome page
P. Pruszczyk, M. Kostrubiec, A. Bochowicz, G. Styczynski, M. Szulc, M. Kurzyna, A. Fijalkowska, A. Kuch-Wocial, I. Chlewicka, and A. Torbicki
N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism
Eur. Respir. J., October 1, 2003; 22(4): 649 - 653.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
K. Hryniewicz, A. S. Androne, A. Hudaihed, and S. D. Katz
Comparative Effects of Carvedilol and Metoprolol on Regional Vascular Responses to Adrenergic Stimuli in Normal Subjects and Patients With Chronic Heart Failure
Circulation, August 26, 2003; 108(8): 971 - 976.
[Abstract] [Full Text] [PDF]

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 HeartHome page
A S Androne, K Hryniewicz, R Goldsmith, A Arwady, and S D Katz
Acetylcholinesterase inhibition with pyridostigmine improves heart rate recovery after maximal exercise in patients with chronic heart failure
Heart, August 1, 2003; 89(8): 854 - 858.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
D. Mariano-Goulart, M.-C. Eberle, V. Boudousq, A. Hejazi-Moughari, C. Piot, C. C. de Kerleau, R. Verdier, M.-L. Barge, F. Comte, N. Bressot, et al.
Major increase in brain natriuretic peptide indicates right ventricular systolic dysfunction in patients with heart failure
Eur J Heart Fail, August 1, 2003; 5(4): 481 - 488.
[Abstract] [Full Text] [PDF]

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 J Am Board Fam MedHome page
R. Cardarelli and T. G. Lumicao Jr
B-type Natriuretic Peptide: A Review of Its Diagnostic, Prognostic, and Therapeutic Monitoring Value in Heart Failure for Primary Care Physicians
J Am Board Fam Med, July 1, 2003; 16(4): 327 - 333.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
A. S. Maisel, J. McCord, R. M. Nowak, J. E. Hollander, A. H. B. Wu, P. Duc, T. Omland, A. B. Storrow, P. Krishnaswamy, W. T. Abraham, et al.
Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction: Results from the Breathing Not Properly Multinational Study
J. Am. Coll. Cardiol., June 4, 2003; 41(11): 2010 - 2017.
[Abstract] [Full Text] [PDF]

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 Endocr. Rev.Home page
H. Ruskoaho
Cardiac Hormones as Diagnostic Tools in Heart Failure
Endocr. Rev., June 1, 2003; 24(3): 341 - 356.
[Abstract] [Full Text] [PDF]

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 NEJMHome page
M. Jessup and S. Brozena
Heart Failure
N. Engl. J. Med., May 15, 2003; 348(20): 2007 - 2018.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
R. Shabetai
Monitoring heart failure hemodynamics with an implanted device:its potential to improve outcome
J. Am. Coll. Cardiol., February 19, 2003; 41(4): 572 - 573.
[Full Text] [PDF]

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 CirculationHome page
B. G. Angeja and W. Grossman
Evaluation and Management of Diastolic Heart Failure
Circulation, February 11, 2003; 107(5): 659 - 663.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
D. Logeart, C. Saudubray, P. Beyne, G. Thabut, P.-V. Ennezat, C. Chavelas, C. Zanker, E. Bouvier, and A. C. Solal
Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea
J. Am. Coll. Cardiol., November 20, 2002; 40(10): 1794 - 1800.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
P. A. McCullough, R. M. Nowak, J. McCord, J. E. Hollander, H. C. Herrmann, P. G. Steg, P. Duc, A. Westheim, T. Omland, C. W. Knudsen, et al.
B-Type Natriuretic Peptide and Clinical Judgment in Emergency Diagnosis of Heart Failure: Analysis From Breathing Not Properly (BNP) Multinational Study
Circulation, July 23, 2002; 106(4): 416 - 422.
[Abstract] [Full Text] [PDF]

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 NEJMHome page
A. S. Maisel, P. Krishnaswamy, R. M. Nowak, J. McCord, J. E. Hollander, P. Duc, T. Omland, A. B. Storrow, W. T. Abraham, A. H.B. Wu, et al.
Rapid Measurement of B-Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure
N. Engl. J. Med., July 18, 2002; 347(3): 161 - 167.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
I. I. Tulevski, B. J. M. Mulder, and D. J. van Veldhuisen
Utility of a BNP as a marker for RV dysfunction in acute pulmonary embolism
J. Am. Coll. Cardiol., June 19, 2002; 39(12): 2080 - 2080.
[Full Text] [PDF]

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 CirculationHome page
A. Maisel
B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure: What's Next?
Circulation, May 21, 2002; 105(20): 2328 - 2331.
[Full Text] [PDF]

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 Journal Watch CardiologyHome page
BNP Differentiates Heart Failure from Pulmonary Disease
Journal Watch Cardiology, March 15, 2002; 2002(315): 4 - 4.
[Full Text]

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 JWatch Emergency Med.Home page
B-Type Natriuretic Peptide: A Promising Test for CHF
Journal Watch Emergency Medicine, March 13, 2002; 2002(313): 1 - 1.
[Full Text]

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 JWatch GeneralHome page
BNP Differentiates Heart Failure from Pulmonary Disease
Journal Watch (General), February 8, 2002; 2002(208): 3 - 3.
[Full Text]


 
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