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J Am Coll Cardiol, 2003; 41:2010-2017, doi:10.1016/S0735-1097(03)00405-4
© 2003 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: BIOMARKERS IN HEART DISEASE

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

Alan S. Maisel, MD, FACC*, James McCord, MD, Richard M. Nowak, MD, Judd E. Hollander, MD, Alan H. B. Wu, PhD, MD, MBA, Philippe Duc, MD, Torbjørn Omland, MD, PhD, Alan B. Storrow, MD, Padma Krishnaswamy, MD, William T. Abraham, MD, FACC, Paul Clopton, MS, Gabriel Steg, MD, Marie Claude Aumont, MD, Arne Westheim, MD, PhD, MPH, Cathrine Wold Knudsen, MD, Alberto Perez, MD, Richard Kamin, MD, Radmila Kazanegra, MD, Howard C. Herrmann, MD, FACC, Peter A. McCullough, MD, MPH, FACC Breathing Not Properly Multinational Study Investigators*

Manuscript received June 1, 2002; revised manuscript received October 21, 2002, accepted November 19, 2002.

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

OBJECTIVES: This study examines B-type natriuretic peptide (BNP) levels in patients with systolic versus non-systolic dysfunction presenting with shortness of breath.

BACKGROUND: Preserved systolic function is increasingly common in patients presenting with symptoms of congestive heart failure (CHF) but is still difficult to diagnose.

METHODS: The Breathing Not Properly Multinational Study was a seven-center, prospective study of 1,586 patients who presented with acute dyspnea and had BNP measured upon arrival. A subset of 452 patients with a final adjudicated diagnosis of CHF who underwent echocardiography within 30 days of their visit to the emergency department (ED) were evaluated. An ejection fraction of greater than 45% was defined as non-systolic CHF.

RESULTS: Of the 452 patients with a final diagnosis of CHF, 165 (36.5%) had preserved left ventricular function on echocardiography, whereas 287 (63.5%) had systolic dysfunction. Patients with non-systolic heart failure (NS-CHF) had significantly lower BNP levels than those with systolic heart failure (S-CHF) (413 pg/ml vs. 821 pg/ml, p < 0.001). As the severity of heart failure worsened by New York Heart Association class, the percentage of S-CHF increased, whereas the percentage of NS-CHF decreased. When patients with NS-CHF were compared with patients without CHF (n = 770), a BNP value of 100 pg/ml had a sensitivity of 86%, a negative predictive value of 96%, and an accuracy of 75% for detecting abnormal diastolic dysfunction. Using Logistic regression to differentiate S-CHF from NS-CHF, BNP entered first as the strongest predictor followed by oxygen saturation, history of myocardial infarction, and heart rate.

CONCLUSIONS: We conclude that NS-CHF is common in the setting of the ED and that differentiating NS-CHF from S-CHF is difficult in this setting using traditional parameters. Whereas BNP add modest discriminatory value in differentiating NS-CHF from S-CHF, its major role is still the separation of patients with CHF from those without CHF.

Abbreviations and Acronyms
  AUC
  area under the curve
  BNP
  B-type natriuretic peptide
  CHF
  congestive heart failure
  ED
  emergency department
  EF
  ejection fraction
  LV
  left ventricular
  NS-CHF
  non-systolic congestive heart failure
  NYHA
  New York Heart Association
  ROC
  receiver operating characteristic
  S-CHF
  systolic congestive heart failure




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