N-Terminal Pro–B-Type Natriuretic Peptide in the Emergency Department

Januzzi, James L.; Chen‐Tournoux, Annabel; Christenson, Robert H.; Doros, Gheorghe; Hollander, Judd E.; Levy, Phillip D.; Nagurney, John Tobias; Nowak, Richard M.; Pang, Peter S.; Patel, Devendra D.; Peacock, W. Franklin; Rivers, E. Joy; Walters, Elizabeth L.; Gaggin, Hanna K.; Investigators, Icon-Reloaded

doi:10.1016/j.jacc.2018.01.021

Cited by 173 publications

(162 citation statements)

References 25 publications

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“…These findings extend and corroborate previous work on the best possible clinical use of natriuretic peptides in the early diagnosis of AHF . First, natriuretic peptides should be interpreted as quantitative markers of haemodynamic cardiac stress and heart failure.…”

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Cosupporting

confidence: 88%

“…Accordingly, the diagnostic use of natriuretic peptides has received a class I recommendation in both the European and the American practice guidelines . While the cut‐off concentrations of B‐type natriuretic peptide (BNP) recommended in current guidelines were validated in a large, multicentre study, only recently, the performance of the N‐terminal proBNP (NT‐proBNP) cut‐off concentrations has been tested in a North American and an Asian cohort of relatively young patients with low prevalence of AHF and less co‐morbidities as compared to those observed in European patients . We therefore aimed to address this major gap in knowledge and prospectively validate NT‐proBNP cut‐off concentrations in the diagnosis of AHF in the European multicentre cohort Basics in Acute Shortness of Breath EvaLuation (BASEL V) (NCT01831115) study.…”

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

“…Specificity, positive predictive value, and the percentage of patients triaged towards rule‐in were the primary outcome measures for the age‐dependent NT‐proBNP rule‐in cut‐off concentrations (450 pg/mL if < 50 years, 900 pg/mL if 50–75 years, and 1800 pg/mL if > 75 years) . Sensitivity, negative predictive value, and the percentage of patients triaged towards rule‐out were the primary outcome measures for the universal NT‐proBNP rule‐out cut‐off concentration (300 pg/mL) . The relevant 95% confidence intervals (CIs) were defined using the Wilson score method without continuity correction.…”

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

“…For patients presenting with acute dyspnoea in the ED, concentrations < 300 ng/L for NT‐proBNP and < 100 ng/L for BNP balance the safety and efficacy of rule‐out well. High concentrations provide a high positive predictive value for AHF and allow triaging patients towards rule‐in . Second , while patients with BNP or NT‐proBNP plasma concentration in the ‘grey zone’ have a broad differential diagnosis and usually require full clinical work‐up, most of them will finally be found to have mild heart failure .…”

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

“…Second , while patients with BNP or NT‐proBNP plasma concentration in the ‘grey zone’ have a broad differential diagnosis and usually require full clinical work‐up, most of them will finally be found to have mild heart failure . Third, even in the presence of renal dysfunction the utility of NT‐proBNP in the rapid triage of dyspnoeic patients in the ED remains high …”

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

See 4 more Smart Citations

Prospective validation of N‐terminal pro B‐type natriuretic peptide cut‐off concentrations for the diagnosis of acute heart failure

Kozhuharov

Sabti

Wussler

et al. 2019

European J of Heart Fail

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Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Cosupporting

confidence: 88%

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

Section: Optimal N‐terminal Pro B‐type Natriuretic Peptide Cut‐off Comentioning

confidence: 99%

See 3 more Smart Citations

Prospective validation of N‐terminal pro B‐type natriuretic peptide cut‐off concentrations for the diagnosis of acute heart failure

Kozhuharov

Sabti

Wussler

et al. 2019

European J of Heart Fail

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Heart Failure With Reduced Ejection Fraction

Murphy

Ibrahim

Januzzi

2020

JAMA

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496

325

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ImportanceWorldwide, the burden of heart failure has increased to an estimated 23 million people, and approximately 50% of cases are HF with reduced ejection fraction (HFrEF).ObservationsHeart failure is a clinical syndrome characterized by dyspnea or exertional limitation due to impairment of ventricular filling or ejection of blood or both. HFrEF occurs when the left ventricular ejection fraction (LVEF) is 40% or less and is accompanied by progressive left ventricular dilatation and adverse cardiac remodeling. Assessment for heart failure begins with obtaining a medical history and physical examination. Also central to diagnosis are elevated natriuretic peptides above age- and context-specific thresholds and identification of left ventricular systolic dysfunction with LVEF of 40% or less as measured by echocardiography. Treatment strategies include the use of diuretics to relieve symptoms and application of an expanding armamentarium of disease-modifying drug and device therapies. Unless there are specific contraindications, patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor–neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms. Ivabradine and hydralazine/isosorbide dinitrate also have a role in the care of certain patients with HFrEF. More recently, sodium-glucose cotransporter 2 (SGLT2) inhibitors have further improved disease outcomes, significantly reducing cardiovascular and all-cause mortality irrespective of diabetes status, and vericiguat, a soluble guanylate cyclase stimulator, reduces heart failure hospitalization in high-risk patients with HFrEF. Device therapies may be beneficial in specific subpopulations, such as cardiac resynchronization therapy in patients with interventricular dyssynchrony, transcatheter mitral valve repair in patients with severe secondary mitral regurgitation, and implantable cardiac defibrillators in patients with more severe left ventricular dysfunction particularly of ischemic etiology.Conclusions and RelevanceHFrEF is a major public health concern with substantial morbidity and mortality. The management of HFrEF has seen significant scientific breakthrough in recent decades, and the ability to alter the natural history of the disease has never been better. Recent developments include SGLT2 inhibitors, vericiguat, and transcatheter mitral valve repair, all of which incrementally improve prognosis beyond foundational neurohormonal therapies. Disease morbidity and mortality remain high, with a 5-year survival rate of 25% after hospitalization for HFrEF.

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Associations of High-Sensitivity Troponin and Natriuretic Peptide Levels With Outcomes After Intensive Blood Pressure Lowering

et al. 2021

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IMPORTANCE Elevated high-sensitivity cardiac troponin T (hscTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) levels are associated with risk of heart failure (HF) and mortality among individuals in the general population. However, it is unknown if this risk is modifiable.OBJECTIVE To test the hypothesis that elevated hscTnT and NTproBNP levels would identify individuals with the greatest risk for mortality and HF and the largest benefit associated with intensive systolic blood pressure (SBP) lowering.DESIGN, SETTING, AND PARTICIPANTS This is a nonprespecified post hoc analysis of the multicenter, prospective, randomized clinical Systolic Blood Pressure Intervention Trial (SPRINT), conducted from October 20, 2010, to August 20, 2015. A total of 9361 patients without diabetes with increased risk for cardiovascular disease were randomized to receive intensive vs standard SBP lowering. Statistical analysis was performed on an intention-to-treat basis from September 30, 2019, to July 29, 2021.INTERVENTIONS Participants were randomized to undergo intensive (<120 mm Hg) or standard (<140 mm Hg) SBP lowering. High-sensitivity cardiac troponin T and NTproBNP levels were measured from stored specimens collected at enrollment, with elevated levels defined as 14 ng/L or more for hscTnT (to convert to micrograms per liter, multiply by 0.001) and 125 pg/mL or more for NTproBNP (to convert to nanograms per liter, multiply by 1.0). MAIN OUTCOMES AND MEASURESThe primary outcome of this ancillary study was HF and mortality. RESULTSOf the 9361 participants enrolled in SPRINT, 8828 (5578 men [63.2%]; mean [SD] age, 68.0 [9.5] years) had measured hscTnT levels and 8836 (5585 men [63.2%]; mean [SD] age, 68.0 [9.5] years) had measured NTproBNP levels; 2262 of 8828 patients (25.6%) had elevated hscTnT levels, 3371 of 8836 patients (38.2%) had elevated NTproBNP, and 1411 of 8828 patients (16.0%) had both levels elevated. Randomization to the intensive SBP group led to a 4.9% (95% CI, 1.7%-7.5%) absolute risk reduction (ARR) over 4 years in death and HF (421 events) for those with elevated hscTnT and a 1.7% (95% CI, 0.7%-2.5%) ARR for those without elevated levels. Similarly, for those with elevated NTproBNP, the ARR for death and HF over 4 years was 4.6% (95% CI, 2.3%-6.5%) vs 1.8% (95% CI, 0.9%-2.5%) in those without elevated levels. For those with elevated levels of both biomarkers, the ARR for death and HF over 4 years was 7.8% (95% CI, 3.3%-11.3%) vs 1.7% (95% CI, 0.8%-2.3%) in those with neither biomarker elevated. No significant treatment group by biomarker category interactions were detected. CONCLUSIONS AND RELEVANCEIntensive SBP control led to large absolute differences in death and HF among patients with abnormal hscTnT and NTproBNP levels. These findings demonstrate that risk associated with elevation of these biomarkers is modifiable with intensive BP control. A prospective, randomized clinical trial is needed to evaluate whether these biomarkers may help guide selection of patients for intensive SBP lowering.

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N-Terminal Pro–B-Type Natriuretic Peptide in the Emergency Department

Abstract: In acutely dyspneic patients seen in the ED setting, age-stratified NT-proBNP cutpoints may aid in the diagnosis of acute HF. An NT-proBNP <300 pg/ml strongly excludes the presence of acute HF.

Cited by 173 publications

References 25 publications

Prospective validation of N‐terminal pro B‐type natriuretic peptide cut‐off concentrations for the diagnosis of acute heart failure

Prospective validation of N‐terminal pro B‐type natriuretic peptide cut‐off concentrations for the diagnosis of acute heart failure

Heart Failure With Reduced Ejection Fraction

Associations of High-Sensitivity Troponin and Natriuretic Peptide Levels With Outcomes After Intensive Blood Pressure Lowering

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