EXPEDITED REVIEW
Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT)
A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath
Alan Maisel, MD*,*,
Judd E. Hollander, MD ,
David Guss, MD ,
Peter McCullough, MD, MPH ,
Richard Nowak, MD||,
Gary Green, MD¶,
Mitchell Saltzberg, MD#,
Stefanie R. Ellison, MD, FACEP,
Meenakshi Awasthi Bhalla, MD*,
Vikas Bhalla, MD*,
Paul Clopton, MS*,
Robert Jesse, MD** REDHOT Investigators
* University of California-San Diego, Veterans Affairs Medical Center, San Diego, California, USA
University of Pennsylvania, Philadelphia, Pennsylvania, USA
University of California at San Diego and Thornton Medical Center, San Diego, California, USA
University of Missouri–Kansas City School of Medicine, Truman Medical Center, Elmwood Hospital, and Edwards Hospitals, Kansas City, Missouri, USA
|| Henry Ford Hospital, Detroit, Michigan, USA
¶ The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
# Good Samaritan Hospital, Heart Failure Program at Midwest Heart Specialists, Downers Grove, Illinois, USA
** Medical College of Virginia, Richmond Veterans Affairs Medical Center, Richmond, Virginia, USA
Manuscript received February 12, 2004;
revised manuscript received June 1, 2004,
accepted June 8, 2004.
* Reprint requests and correspondence: Dr. Alan Maisel, VAMC Cardiology 111-A, 3350 La Jolla Village Drive, San Diego, California 92161, USA.
amaisel{at}ucsd.edu
OBJECTIVES: The purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes of the CHF patients presenting to emergency department (ED).
BACKGROUND: Since BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine.
METHODS: The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge.
RESULTS: Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels <200 pg/ml (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (CHF visits or admissions and mortality) in the group of patients admitted with BNP <200 pg/ml and >200 pg/ml was 9% and 29%, respectively (p = 0.006).
CONCLUSIONS: In patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.
|
Abbreviations and Acronyms
| | BNP | = B-type natriuretic peptide | | CHF | = congestive heart failure | | ED | = emergency department | | NYHA | = New York Heart Association | | REDHOT | = Rapid Emergency Department Heart failure Outpatient Trial | | SOB | = shortness of breath |
|
Related Article
-
Heart failure in the emergency department: Is B-type natriuretic peptide a better prognostic indicator than clinical assessment?
- Torbjørn Omland
J. Am. Coll. Cardiol. 2004 44: 1334-1336.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
J. George, D. Jack, G. Mackle, T. S. Callaghan, L. Wei, C. C. Lang, E. Dow, and A. D. Struthers
High sensitivity troponin T provides useful prognostic information in non-acute chest pain
QJM,
February 1, 2012;
105(2):
159 - 166.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Luchner, M. Mockel, E. Spanuth, J. Mocks, D. Peetz, H. Baum, C. Spes, C. E. Wrede, J. Vollert, R. Muller, et al.
N-terminal pro brain natriuretic peptide in the management of patients in the medical emergency department (PROMPT): correlation with disease severity, utilization of hospital resources, and prognosis in a large, prospective, randomized multicentre trial
Eur J Heart Fail,
January 25, 2012;
(2012)
hfr171v2.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. A. Halim, L. K. Newby, and E. M. Ohman
Biomarkers in Cardiovascular Clinical Trials: Past, Present, Future
Clin. Chem.,
January 1, 2012;
58(1):
45 - 53.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Maisel
Biomonitoring and biomarker-guided therapy the next step in heart failure and biomarker research.
J. Am. Coll. Cardiol.,
October 25, 2011;
58(18):
1890 - 1892.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. A. Lurati Buse, M. T. Koller, C. Burkhart, M. D. Seeberger, and M. Filipovic
The Predictive Value of Preoperative Natriuretic Peptide Concentrations in Adults Undergoing Surgery: A Systematic Review and Meta-Analysis
Anesth. Analg.,
May 1, 2011;
112(5):
1019 - 1033.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. S. Maisel, N. Katz, H. L. Hillege, A. Shaw, P. Zanco, R. Bellomo, I. Anand, S. D. Anker, N. Aspromonte, S. M. Bagshaw, et al.
Biomarkers in kidney and heart disease
Nephrol. Dial. Transplant.,
January 1, 2011;
26(1):
62 - 74.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Shah, P. R. Taub, and A. Maisel
Chapter 35 Biomarkers in acute heart failure
The ESC Textbook of Acute and Intensive Cardiac Care,
December 1, 2010;
1(1):
med-9780199584314-chapter - med-9780199584314-chapter.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. L. Weintraub, S. P. Collins, P. S. Pang, P. D. Levy, A. S. Anderson, C. Arslanian-Engoren, W. B. Gibler, J. K. McCord, M. B. Parshall, G. S. Francis, et al.
Acute Heart Failure Syndromes: Emergency Department Presentation, Treatment, and Disposition: Current Approaches and Future Aims: A Scientific Statement From the American Heart Association
Circulation,
November 9, 2010;
122(19):
1975 - 1996.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. F. Peacock, E. Braunwald, W. Abraham, N. Albert, J. Burnett, R. Christenson, S. Collins, D. Diercks, G. Fonarow, J. Hollander, et al.
National Heart, Lung, and Blood Institute Working Group on Emergency Department Management of Acute Heart Failure: Research Challenges and Opportunities
J. Am. Coll. Cardiol.,
July 27, 2010;
56(5):
343 - 351.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Ronco, P. McCullough, S. D. Anker, I. Anand, N. Aspromonte, S. M. Bagshaw, R. Bellomo, T. Berl, I. Bobek, D. N. Cruz, et al.
Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative
Eur. Heart J.,
March 2, 2010;
31(6):
703 - 711.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W.-C. Chen, K. D. Tran, and A. S. Maisel
Biomarkers in heart failure
Heart,
February 1, 2010;
96(4):
314 - 320.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Maisel
Natriuretic Peptide-Guided Therapy for Heart Failure: Ready for "Battle" or Too "Scarred" by the Challenges of Trial Design?
J. Am. Coll. Cardiol.,
January 5, 2010;
55(1):
61 - 64.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Kanoupakis, E. G. Manios, and P. E. Vardas
Predicting future shocks in implantable cardioverter defibrillator recipients: the role of biomarkers
Europace,
November 1, 2009;
11(11):
1434 - 1439.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. J. Singer, R. H. Birkhahn, D. Guss, A. Chandra, C. D. Miller, B. Tiffany, P. Levy, R. Dunne, A. Bastani, H. C. Thode Jr, et al.
Rapid Emergency Department Heart Failure Outpatients Trial (REDHOT II): A Randomized Controlled Trial of the Effect of Serial B-Type Natriuretic Peptide Testing on Patient Management
Circ Heart Fail,
July 1, 2009;
2(4):
287 - 293.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. R.J. van Kimmenade, J. L. Januzzi Jr, J. A. Bakker, A. J. Houben, R. Rennenberg, A. A. Kroon, H. J.G.M. Crijns, M. P. van Dieijen-Visser, P. W. de Leeuw, and Y. M. Pinto
Renal Clearance of B-Type Natriuretic Peptide and Amino Terminal Pro-B-Type Natriuretic Peptide: A Mechanistic Study in Hypertensive Subjects
J. Am. Coll. Cardiol.,
March 10, 2009;
53(10):
884 - 890.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Mangat, C. Carter, G. Riley, Y. Foo, and M. Burch
The clinical utility of brain natriuretic peptide in paediatric left ventricular failure
Eur J Heart Fail,
January 1, 2009;
11(1):
48 - 52.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Ronco, M. Haapio, A. A. House, N. Anavekar, and R. Bellomo
Cardiorenal Syndrome
J. Am. Coll. Cardiol.,
November 4, 2008;
52(19):
1527 - 1539.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Maisel, C. Mueller, K. Adams Jr., S. D. Anker, N. Aspromonte, J. G.F. Cleland, A. Cohen-Solal, U. Dahlstrom, A. DeMaria, S. Di Somma, et al.
State of the art: Using natriuretic peptide levels in clinical practice
Eur J Heart Fail,
September 1, 2008;
10(9):
824 - 839.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. S. Maisel, W. F. Peacock, N. McMullin, R. Jessie, G. C. Fonarow, J. Wynne, and R. M. Mills
Timing of Immunoreactive B-Type Natriuretic Peptide Levels and Treatment Delay in Acute Decompensated Heart Failure: An ADHERE (Acute Decompensated Heart Failure National Registry) Analysis
J. Am. Coll. Cardiol.,
August 12, 2008;
52(7):
534 - 540.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. B. Daniels, G. A. Laughlin, P. Clopton, A. S. Maisel, and E. Barrett-Connor
Minimally Elevated Cardiac Troponin T and Elevated N-Terminal Pro-B-Type Natriuretic Peptide Predict Mortality in Older Adults: Results From the Rancho Bernardo Study
J. Am. Coll. Cardiol.,
August 5, 2008;
52(6):
450 - 459.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A L Baggish, D M Lloyd-Jones, J Blatt, A M Richards, J Lainchbury, M O'Donoghue, R Sakhuja, A A Chen, and J L Januzzi
A clinical and biochemical score for mortality prediction in patients with acute dyspnoea: derivation, validation and incorporation into a bedside programme
Heart,
August 1, 2008;
94(8):
1032 - 1037.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. W Yip
B-type natriuretic peptide: a treatment, not a diagnostic marker
Heart,
May 1, 2008;
94(5):
542 - 544.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. N. Kirkpatrick, S. N. Ghani, and K. T. Spencer
Hand carried echocardiography screening for LV systolic dysfunction in a pulmonary function laboratory
Eur Heart J Cardiovasc Imaging,
May 1, 2008;
9(3):
381 - 383.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. M. Green, A. Martinez-Rumayor, S. A. Gregory, A. L. Baggish, M. L. O'Donoghue, J. A. Green, K. B. Lewandrowski, and J. L. Januzzi Jr
Clinical Uncertainty, Diagnostic Accuracy, and Outcomes in Emergency Department Patients Presenting With Dyspnea
Arch Intern Med,
April 14, 2008;
168(7):
741 - 748.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Ryder, N. F. Murphy, D. McCaffrey, C. O'Loughlin, M. Ledwidge, and K. McDonald
Outpatient intravenous diuretic therapy; potential for marked reduction in hospitalisations for acute decompensated heart failure
Eur J Heart Fail,
March 1, 2008;
10(3):
267 - 272.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. B. Daniels and A. S. Maisel
Natriuretic Peptides
J. Am. Coll. Cardiol.,
December 18, 2007;
50(25):
2357 - 2368.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Maisel
Biomarkers in Heart Failure: Does Prognostic Utility Translate to Clinical Futility?
J. Am. Coll. Cardiol.,
September 11, 2007;
50(11):
1061 - 1063.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Breidthardt, K. Laule, A.-H. Strohmeyer, C. Schindler, S. Meier, M. Fischer, A. Scholer, M. Noveanu, M. Christ, A. P. Perruchoud, et al.
Medical and Economic Long-term Effects of B-Type Natriuretic Peptide Testing in Patients with Acute Dyspnea
Clin. Chem.,
August 1, 2007;
53(8):
1415 - 1422.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. C. Fonarow, W. F. Peacock, C. O. Phillips, M. M. Givertz, M. Lopatin, and for the ADHERE Scientific Advisory Committee and I
Admission B-Type Natriuretic Peptide Levels and In-Hospital Mortality in Acute Decompensated Heart Failure
J. Am. Coll. Cardiol.,
May 15, 2007;
49(19):
1943 - 1950.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. H. Zou, A. J. O'Malley, and L. Mauri
Receiver-Operating Characteristic Analysis for Evaluating Diagnostic Tests and Predictive Models
Circulation,
February 6, 2007;
115(5):
654 - 657.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Le Jemtel, M. Padeletti, and S. Jelic
Diagnostic and Therapeutic Challenges in Patients With Coexistent Chronic Obstructive Pulmonary Disease and Chronic Heart Failure
J. Am. Coll. Cardiol.,
January 16, 2007;
49(2):
171 - 180.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Abroug, L. Ouanes-Besbes, N. Nciri, N. Sellami, F. Addad, K. B. Hamda, A. B. Amor, M. F. Najjar, and J. Knani
Association of Left-Heart Dysfunction with Severe Exacerbation of Chronic Obstructive Pulmonary Disease: Diagnostic Performance of Cardiac Biomarkers
Am. J. Respir. Crit. Care Med.,
November 1, 2006;
174(9):
990 - 996.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Cortes, M. Portoles, A. Salvador, V. Bertomeu, F. G. de Burgos, L. Martinez-Dolz, E. R. Lleti, V. Climent, A. Jordan, R. Paya, et al.
Diagnostic and prognostic value of urine NT-proBNP levels in heart failure patients
Eur J Heart Fail,
October 1, 2006;
8(6):
621 - 627.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. F. Price, A. K. Thomas, M. Grenier, B. W. Eidem, E. O. Smith, S. W. Denfield, J. A. Towbin, and W. J. Dreyer
B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Events in Pediatric Outpatients With Chronic Left Ventricular Systolic Dysfunction
Circulation,
September 5, 2006;
114(10):
1063 - 1069.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. S. Jaffe, L. Babuin, and F. S. Apple
Biomarkers in Acute Cardiac Disease: The Present and the Future
J. Am. Coll. Cardiol.,
July 4, 2006;
48(1):
1 - 11.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. V. St. Peter, G. G. Hartley, M. M. Murakami, and F. S. Apple
B-Type Natriuretic Peptide (BNP) and N-Terminal Pro-BNP in Obese Patients without Heart Failure: Relationship to Body Mass Index and Gastric Bypass Surgery
Clin. Chem.,
April 1, 2006;
52(4):
680 - 685.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. van Kimmenade, F. van Dielen, J. Bakker, J. Nijhuis, H. Crijns, W. Buurman, M. van Dieijen-Visser, J.-W. Greve, and Y. Pinto
Is Brain Natriuretic Peptide Production Decreased in Obese Subjects?
J. Am. Coll. Cardiol.,
February 21, 2006;
47(4):
886 - 887.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Januzzi Jr, R. Sakhuja, M. O'Donoghue, A. L. Baggish, S. Anwaruddin, C. U. Chae, R. Cameron, D. G. Krauser, R. Tung, C. A. Camargo Jr, et al.
Utility of amino-terminal pro-brain natriuretic Peptide testing for prediction of 1-year mortality in patients with dyspnea treated in the emergency department.
Arch Intern Med,
February 13, 2006;
166(3):
315 - 320.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Januzzi, R. van Kimmenade, J. Lainchbury, A. Bayes-Genis, J. Ordonez-Llanos, M. Santalo-Bel, Y. M. Pinto, and M. Richards
NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: The International Collaborative of NT-proBNP Study
Eur. Heart J.,
February 1, 2006;
27(3):
330 - 337.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Maisel
The Coming of Age of Natriuretic Peptides: The Emperor Does Have Clothes!
J. Am. Coll. Cardiol.,
January 3, 2006;
47(1):
61 - 64.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Gheorghiade, F. Zannad, G. Sopko, L. Klein, I. L. Pina, M. A. Konstam, B. M. Massie, E. Roland, S. Targum, S. P. Collins, et al.
Acute Heart Failure Syndromes: Current State and Framework for Future Research
Circulation,
December 20, 2005;
112(25):
3958 - 3968.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. S. Ginsburg, M. P. Donahue, and L. K. Newby
Prospects for Personalized Cardiovascular Medicine: The Impact of Genomics
J. Am. Coll. Cardiol.,
November 1, 2005;
46(9):
1615 - 1627.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Mockel, R. Muller, J. O. Vollert, C. Muller, A. Carl, D. Peetz, F. Post, J. K. Kohse, and K. J. Lackner
Role of N-Terminal Pro-B-Type Natriuretic Peptide in Risk Stratification in Patients Presenting in the Emergency Room
Clin. Chem.,
September 1, 2005;
51(9):
1624 - 1631.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Does BNP Testing Beat Clinical Assessment for Predicting CHF Outcomes?
Journal Watch Emergency Medicine,
November 24, 2004;
2004(1124):
7 - 7.
[Full Text]
|
|
|
|
|
|
|
BNP Testing for Heart Failure Triage in the ED?
Journal Watch Cardiology,
November 5, 2004;
2004(1105):
6 - 6.
[Full Text]
|
|
|
|
