Usman Ali

A systematic review of BNP and NT-proBNP in the management of heart failure: overview and methods

B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) levels are increased in persons with heart failure (HF); low levels of these peptides rule out HF. We systematically reviewed the literature to assess the use of BNP and NT-proBNP in the diagnosis, prognosis, and treatment for HF. We also examined the biological variation of these peptides in persons with and without HF. We searched Medline, Embase, AMED, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL for English-language studies published between January 1989 and June 2012. Supplemental searches involved the gray literature and the reference lists of included studies. Trained reviewers used standardized forms to screen articles for inclusion in the review and to extract data from included papers. We examined the risk of bias with QUADAS-2 for diagnosis studies, the Hayden criteria for prognosis studies, and the Jadad scale for treatment studies. We assessed the strength of evidence in four domains (risk of bias, consistency, directness, and precision) for the diagnosis and treatment studies. Results were reported as narrative syntheses. Additional meta-analyses were conducted for the diagnosis studies. Three hundred ten articles passed through screening and were included in the review. One hundred four articles applied to diagnostic accuracy, 190 papers pertained to prognosis, and nine articles addressed BNP- or NT-proBNP-guided treatment. Each individual paper in this series reports, summarizes, and discusses the evidence regarding diagnosis, prognosis, or treatment.

Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review

National and international guidelines have been published recommending the use of natriuretic peptides as an aid to the diagnosis of heart failure (HF) in acute settings; however, few specific recommendations exist for governing the use of these peptides in primary care populations. To summarize the available data relevant to the diagnosis of HF in primary care patient population, we systematically reviewed the literature to identify original articles that investigated the diagnostic accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in primary care settings. The search yielded 25,864 articles in total: 12 investigating BNP and 20 investigating NT-proBNP were relevant to our objective and included in the review. QUADAS-2 and GRADE were used to assess the quality of the included articles. Diagnostic data were pooled based on three cutpoints: lowest and optimal, as chosen by study authors, and manufacturers’ suggested. The effect of various determinants (e.g., age, gender, BMI, and renal function) on diagnostic performance was also investigated. Pooled sensitivity and specificity of BNP and NT-proBNP using the lowest [0.85 (sensitivity) and 0.54 (specificity)], optimal (0.80 and 0.61), and manufacturers’ (0.74 and 0.67) cutpoints showed good performance for diagnosing HF. Similar performance was seen for NT-proBNP: lowest (0.90 and 0.50), optimal (0.86 and 0.58), and manufacturers’ (0.82 and 0.58) cutpoints. Overall, we rated the strength of evidence as high because further studies will be unlikely to change the estimates diagnostic performance.

Screening for depression: a systematic review and meta-analysis

BACKGROUND The Canadian Task Force on Preventive Health Care has a guideline on screening for depression among adults 18 years of age or older at average or high risk for depression. To provide evidence for an update of this guideline, we evaluated the literature on the effectiveness of screening for depression in adults. METHODS For the period 1994 to May 23, 2012, we searched the following electronic databases: MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Randomized controlled trials, observational studies and systematic reviews with evidence for the benefits or harms of screening for depression were eligible for inclusion. We performed screening for relevance, extraction of data, analysis of risk of bias and quality assessments in duplicate. We used the generic inverse variance method to conduct a meta-analysis. To determine confidence in the effect, we analyzed the results according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Five quasi-experimental studies (before-after design with a nonrandomized control group) met the inclusion criteria for this review. These studies reported on the effect of community-based screening for depression, with follow-up on the risk of suicide completion, for older residents in regions of rural Japan with high suicide rates. Meta-analysis showed that the screening program had a protective effect on the overall incidence of suicide completion (ratio of rate ratios [RRR] 0.50, 95% confidence interval [CI], 0.32-0.78). When sex was considered, the RRR indicated a significantly lower rate of suicide among women (RRR 0.37, 95% CI 0.21-0.66) but not among men (RRR 0.67, 95% CI 0.35-1.27). The overall GRADE rating applied to this evidence indicated very low quality. No studies addressing the harms of screening for depression met the inclusion criteria for the review. INTERPRETATION There is very limited research evidence allowing conclusions about the effectiveness of screening for depression in either average-risk or high-risk populations.

Erratum to: Conflict of interest declaration

The conflict of interest declaration for these four articles (for which the author group is same) should read as follows. Conflict of interest Mark Oremus, Robert McKelvie, Pasqualina L. Santaguida, Usman Ali, Cynthia Balion, Stephen Hill, Judy A. Brown, Amy Bustamam, Nazmul Sohel, and Parminder Raina have no conflicts of interest or financial ties to disclose. Andrew C. DonWauchope has received clinical trial support from AMGEN. Ronald A. Booth has received honoraria from INOVA Diagnostics Inc. and is a member of the Health Technology Expert Review Panel of the Canadian Agency for Drugs and Technologies in Health (CADTH).