Adam Bystrzycki

B-Type Natriuretic Peptide Testing, Clinical Outcomes, and Health Services Use in Emergency Department Patients With Dyspnea: A Randomized Trial

Context Serum levels of B-type natriuretic peptide (BNP) increase in patients with decompensated heart failure, and BNP testing is commonly done to distinguish cardiac from noncardiac causes of dyspnea. Contribution In this randomized trial, BNP testing did not reduce health services use or improve health outcomes for dyspneic patients who visited emergency departments. Caution Patients were sick enough that the test itself was unlikely to change treatment decisions or outcomes. Implication The practice of measuring BNP in all dyspneic patients to see if heart failure is a cause of their symptoms may not be justified. The Editors A total of 10% to 15% of all emergency department presentations are due to shortness of breath, secondary to heart failure or lung disease. Approximately 80% of patients with acute heart failure syndromes present through the emergency department (1), with dyspnea as the chief symptom (2). The incidence of heart failure is reaching epidemic proportions in the Western world (3). In Europe, up to 2% of the population has symptomatic heart failure (4) (1.5% to 2% in Australia [5]). The incidence of heart failure increases with age; approximately 10% of persons older than 65 years and more than 50% of those older than 85 years have heart failure (6, 7). With an aging population and greater survival from disease processes leading to heart failure, the burden of this disease on the health care system will only increase. Plasma B-type natriuretic peptide (BNP) measurement in patients who present with shortness of breath could improve diagnosis and management. B-type natriuretic peptide is a 32 AA peptide hormone released from the cardiac muscle cells in response to increased ventricular filling pressure and volume expansion (8). Some observational studies have suggested excellent sensitivity and specificity for this test in diagnosing heart failure (915). However, only 1 trial of moderate size (450 patients) has randomly assigned patients to undergo BNP testing or not (16). In the study, investigators in Switzerland reported that the use of the BNP test reduced hospital and intensive care unit (ICU) admissions by 10% and further reduced the median time to discharge. Death and readmissions of these patients were not altered. B-type natriuretic peptide testing markedly reduced costs (

Complications of intercostal catheter insertion using EMST techniques for chest trauma.

1800 per patient), mainly because of the reduction in hospital and ICU admissions. The U.S. Food and Drug Administration approved the BNP test, and it is widely marketed throughout the United States and Europe. Swiss emergency care systems differ from Anglo-American health systems, and it is not known whether this influences the extent to which BNP testing may affect the decision to admit patients. It is not known how the test will affect patient management and admission rates when it is done in the central laboratory and patients are assessed with results of chest radiography, electrocardiography, and laboratory testing, which are all available to the treating emergency physician. We investigated whether patients who presented with shortness of breath would be managed differently and hospitalization rates would be altered if BNP was measured. We did a randomized, controlled trial of BNP testing in 2 busy, university-based, teaching hospital emergency departments. Methods Design Overview This study on BNP in shortness of breath was a randomized, controlled, single-blind trial investigating the effect of BNP testing on admission rates, length of hospital stay, and management of patients who presented to the emergency department with shortness of breath as the main symptom. We blinded patients to the intervention but did not blind clinicians or those who assessed trial outcomes. Setting and Participants We conducted the study in the emergency departments of The Alfred (Prahan, Victoria, Australia; a tertiary referral center with 45000 patient attendances per year), and The Northern Hospital (Epping, Victoria, Australia; a metropolitan hospital with 70000 patient attendances per year). We enrolled patients who presented with severe shortness of breath as the main symptom from August 2005 to March 2007. We included only patients who presented with the primary symptom of shortness of breath and were triaged to category 1 to 3 (severe illness acuity requiring assessment by a physician immediately to within 30 minutes after arrival). Exclusion criteria were age younger than 40 years, dyspnea secondary to trauma, cardiogenic shock, and a creatinine level greater than 250 mol/L (>2.82 mg/dL). We further excluded patients who were transferred to another hospital within 24 hours of presentation because of difficulty with follow-up. A registrar or consultant clinically assessed all patients in the emergency department. Routine investigations included blood tests, chest radiography, and electrocardiography. We ordered transthoracic echocardiography and pulmonary function tests within 30 days of presentation when possible. Randomization and Interventions Emergency department staff enrolled patients in the study at presentation. Patients were randomly assigned to have BNP tested (BNP group) or not tested (control group) before consent. Consent for use of patient data and follow-up and further involvement in the trial was obtained within 24 hours. We blinded patients to the intervention. Allocation to the BNP and control group was by random numbers (from computer-generated, random-number tables) in a sealed envelope. The randomization was stratified by site. We collected 10 mL of the patients blood in tubes containing EDTA and sent it to the hospital laboratory. Patients randomly assigned to the BNP group had BNP analyzed, and the result was provided with other blood test results within 60 minutes. We measured BNP by using the Abbott AxSYM MEIA Automated Immunoassay (Abbott, Chicago, Illinois). The measurable range of the BNP assay is 15 to 4000 ng/L. The assay has a functional sensitivity of 20 ng/L (coefficient of variation, 20%) and is calibrated against the Triage B-Type Natriuretic Peptide test (Biosite, San Diego, California) (9). The diagnostic value of detecting heart failure by using this BNP assay has been documented (17). Four education sessions during the study period familiarized emergency department staff with BNP, its role in the diagnosis of heart failure, and the current literature in the field. The BNP test had been done at the main study hospital for 5 years if requested from the cardiology department; but if other physicians requested the test, a chemical pathologist needed to approve it. Each physician who treated an enrolled patient received a written guideline on the treatment of acute heart failure and chronic obstructive pulmonary disease, as well as the BNP nomogram published by McCullough and coworkers (10). We advised physicians that a BNP level less than 100 ng/L made the diagnosis of heart failure unlikely, whereas a BNP level greater than 500 ng/L made heart failure likely. Outcomes and Follow-up Primary outcomes were hospital admission rate, length of stay, and change in patient management. Secondary outcomes were 30-day mortality and readmission rates. We contacted all patients or next of kin after 30 days about readmission and death. We achieved complete follow-up of all study participants. Trained research assistants, who were not blinded to the group assignment, collected baseline demographic characteristics, admission rates, length of hospital stay, and clinical information from hospital records. Two physicians made the final diagnosis of heart failure; one was a cardiologist. The physicians had access to additional information, including case notes; results of blood tests; electrocardiography and chest radiography reports; and clinical course during inpatient stay, including response to treatment, transthoracic echocardiography results, and pulmonary function test results. We did not blind physicians to the group assignment, but we did blind them to the BNP results. Reviewers defined heart failure on the basis of the definition from the European Society of Cardiology working group on heart failure diagnostic criteria (18), as well as an algorithm for the diagnosis of heart failure. The reviewers determined whether heart failure caused the presentation to the emergency department with dyspnea or not. If the 2 independent reviewers agreed, their diagnoses were taken as the final diagnosis. When they disagreed, a third physician reviewed all available data and made the final diagnosis. The degree of agreement between the 2 reviewers was substantial in both the BNP and control groups (= 0.79 [95% CI, 0.78 to 0.83] and 0.82 [CI, 0.78 to 0.86], respectively). Statistical Analysis Prespecified outcomes were the hospital admission rate, the length of hospital stay, and any change in management in the 2 groups. With a sample size of 300 patients in each group, we calculated an 80% power to detect an absolute reduction of 10 percentage points (80% to 70%) in hospital admission rates and a relative reduction of 20% (8.0 to 6.4 days) in hospital length of stay, assuming tests were 2-sided and P values were 0.05. Statistical analysis was done by intention to treat in all patients who consented after randomization. Demographic characteristics, clinical characteristics, and baseline vital signs in the BNP and control groups are reported in counts and percentages or means (SDs), as appropriate. We compared admission rates by using Pearson chi-square and Fisher exact tests. We used the MantelHaenszel test to compare admission rates with and without the BNP test and stratified by hospital site. We compared length of admission between the 2 groups by using the 2-sample Wilcoxon rank-sum (MannWhitney) test. In addition, we did multivariate logistic regression to investigate the probability of hospital admission and length of stay. Covariates included a history of hypertension, history of heart failure, and hos

Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma

Background:  The purpose of the present study was to determine the complication rates associated with intercostal catheter insertion (ICI) performed using Early Management of Severe Trauma (EMST) guidelines on trauma patients admitted through The Alfred Trauma Centre.

B-Type Natriuretic Peptide Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department

Objective:  Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with ‘unexpected survival’. This study used TRISS analysis to identify ‘unexpected survivors’ suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to ‘unexpected survival’.

BNP Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department

Background—It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. Methods and Results—Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. Conclusion—In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration—clinicaltrials.gov. Identifier: NCT00163709.

TRAUMA RECEPTION AND RESUSCITATION

Background—It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnea to the emergency department (ED). This study assessed whether B-type natriuretic peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. Methods and Results—Patients presenting to the Alfred and the Northern Hospital EDs with a chief complaint of dyspnea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic gold standard for HF was determined by 1 cardiologist and 1 emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non-BNP group showed a sensitivity, specificity, and accuracy of 65%, 92%, and 81%, respectively. The BNP group had a similar sensitivity, specificity, and accuracy of 66%, 90%, and 78%, respectively, for the diagnosis of HF in the ED. There was no significant difference between the BNP and non-BNP groups in any of the measures of diagnostic accuracy for HF. Conclusion—In the clinical setting of EDs, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF. Clinical Trial Registration—clinicaltrials.gov. Identifier: NCT00163709.

P-27 B-Type Natriuretic Peptide Testing in Patients with Shortness of Breath in the Emergency Department to Improve Patient Outcome

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision‐making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point‐of‐care computer technology linked to real‐time decision‐making and trauma team coordination may achieve error reduction through standardized decision‐making and a corresponding reduction in preventable mortality and morbidity.

Use of ultrasound for non-trauma patients in the emergency department

the control group using standard ED care. The clinicians making the diagnosis had in addition to patients’ presentation and history also access to laboratory tests and chest X-ray. The final diagnosis of HF was determined by one cardiologist and one emergency physician independently reviewing all available information while being blinded to the BNP result. Results: In the control group, the diagnosis of HF had a sensitivity of 65%, a specificity of 92% and an accuracy of 81%. In the BNP group, the diagnosis had a higher sensitivity of 66%, but a lower specificity and accuracy at 90% and 78% respectively. There was no significant difference between the BNP and non BNP groups in any of the measures of accuracy. Conclusion: In the clinical setting of Australian emergency departments, availability of BNP levels do not significantly improve the accuracy of a diagnosis of HF.