Annabel A. Chen

A clinical and biochemical critical pathway for the evaluation of patients with suspected acute congestive heart failure: The ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) algorithm.

Dyspnea is a primary clinical manifestation of acute congestive heart failure (CHF) among patients presenting to the emergency department (ED). Unfortunately, other critical illnesses, including acute coronary syndromes, pulmonary embolism, chronic obstructive pulmonary disease, and pneumonia, may present with clinical symptoms and signs similar to acute CHF. N-terminal pro-brain natriuretic peptide (NT-proBNP) has proven to be a powerful tool in the diagnostic assessment of dyspnea as a result of its ability to confirm or exclude the presence of acute CHF. However, many of the disorders that mimic acute CHF may result in elevated NT-proBNP levels as well. Results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study recently demonstrated that a strategy integrating NT-proBNP testing into routine clinical assessment demonstrated a better diagnostic yield than each strategy used in isolation. We present a diagnostic algorithm integrating NT-proBNP testing with clinical assessment for use in routine clinical practice.

A clinical and biochemical score for mortality prediction in patients with acute dyspnoea: derivation, validation and incorporation into a bedside programme

Background: Risk stratification for patients with acute dyspnoea is a challenging task. No quantitative tool for mortality prediction among patients with acute dyspnoea is available. Methods: 595 dyspnoeic subjects were enrolled in an emergency department. Clinical and biochemical factors independently predictive of death by 1 year were used to develop a mortality risk prediction tool. Results: Seven factors comprised the final tool: age (×0.3), heart rate (×0.2), blood urea nitrogen (×0.3), New York Heart Association class (×5), amino-terminal pro-B-type natriuretic peptide (NT-proBNP) ⩾986 pg/ml (18 points), systolic blood pressure <100 mm Hg (11 points) and presence of a murmur (11 points). A continuous rise in mortality was seen from 1.7% in the lowest score quintile (n = 118; score ⩽48.5) to 43.1% in the highest quintile (n = 116, score ⩾85.5; p<0.001 for trend). Receiver operating characteristic curve analysis of the score’s accuracy produced an area under the curve (AUC) of 0.82 (95% CI 0.78 to 0.85) with similar AUCs in subjects with acutely destabilised heart failure (AUC = 0.73, 95% CI 0.67 to 0.79) and those without (AUC = 0.83, 95% CI 0.77 to 0.85, p for the comparison = NS). The score was validated in a separate population of dyspnoeic patients (AUC = 0.73, 95% CI 0.64 to 0.82; p<0.001) and was incorporated into a computer program suitable for near-patient calculation. Conclusion: A new risk stratification tool for acutely dyspnoeic patients has been derived and validated.

Combination of D-dimer and amino-terminal pro-B-type natriuretic Peptide testing for the evaluation of dyspneic patients with and without acute pulmonary embolism.

CONTEXT D-dimer concentration can be used to exclude a diagnosis of acute pulmonary embolism. However, clinicians frequently order unnecessary supplemental testing in patients with low concentrations of D-dimer. Elevations in natriuretic peptides have also been described in the setting of pulmonary embolism. OBJECTIVE We investigated the integrative role of D-dimer with amino-terminal pro-B-type natriuretic peptide for the evaluation of patients with and without acute pulmonary embolism. DESIGN Patients were selected for analysis from a previous study in which levels of D-dimer and amino-terminal pro-B-type natriuretic peptide were measured. The presence of pulmonary embolism was determined by computed tomographic angiography. RESULTS The median levels of D-dimer were significantly higher in patients with acute pulmonary embolism. Similarly, the median levels of amino-terminal pro-B-type natriuretic peptide were higher in patients with pulmonary embolism. CONCLUSIONS The Roche Tina-quant D-Dimer immunoturbidimetric assay provides a high negative predictive value and can be used to exclude acute pulmonary embolism in patients with dyspnea. Measurement of amino-terminal pro-B-type natriuretic peptide in addition to D-dimer improves specificity for acute pulmonary embolism without sacrificing negative predictive value. A combination of both markers may offer reassurance for excluding acute pulmonary embolism, and thus avoid redundant, expensive confirmatory tests.