Role of BNP Levels in Diagnosis of Heart Failure in ED Settings

Although substantial advances have been made in the understanding ofthe pathophysiology and treatment of heart failure, diagnosis of the disease remains difficult. For the acutely ill patient presenting to the ED with dyspnea, an incorrect diagnosis carries the consequence of higher risk of morbidity and mortality (11). Therefore, the diagnosis of heart failure in emergency settings must be rapid and accurate. Unfortunately, the signs and symptoms of heart failure are nonspecific (12). Dyspnea may also be a nonspecific finding in the elderly or obese patient in whom comorbidity with respiratory disease and physical deconditioning are common (13). Routine laboratory results, electrocardiograms (ECGs), and X-rays are also often insufficient to make the appropriate diagnosis (13-16).

Strong and consistent data establish the value of BNP for facilitating the diagnosis of heart failure in patients presenting with dyspnea. Davis et al. (17) first measured levels of the natriuretic hormones ANP and BNP in 52 patients presenting with acute dyspnea and found that the plasma concentration of BNP more accurately reflected the final diagnosis than did ejection fraction or the plasma concentration of ANP. Dao et al. (18) were the first to use a rapid POC BNP assay to evaluate patients presenting to an urgent-care center with dyspnea (n = 250). The evaluating physicians were asked to make an assessment of the probability of heart failure (low, medium, or high) for each patient and were blinded to the results of BNP measurements. The finding that the BNP results were the strongest predictor of the diagnosis of heart failure was the basis for the design of the Breathing Not Properly study, the first large-scale, prospective study using BNP testing to evaluate the cause of dyspnea.

The Breathing Not Properly Multinational Study enrolled 1586 patients who presented to the ED with acute dyspnea (19). The blood concentration of BNP was measured on arrival. On completion of their evaluation, the ED physicians (blinded to BNP) were asked to assess the probability of the patient having heart failure. In addition, two independent cardiologists also blinded to the BNP levels later reviewed all clinical data and standardized scores to produce a clinical diagnosis that was used as the "gold standard" for this study. In the analysis of diagnostic performance, the concentration of BNP used

Table 1

Clinically Available Assays for BNP

Table 1

Clinically Available Assays for BNP

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