Randomized comparison between clinical evaluation plus N-terminal pro–B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin

Plasma B-type natriuretic peptide levels are poorly related to the occurrence of ischemia or ventricular arrhythmias during symptom-limited exercise in low-risk patients

“…NT-proBNP has also been shown to contain prognostic information in patients with suspected non-ST-segment elevation acute coronary syndrome [ 21 ] and in those arriving in the emergency room with a normal or nearly normal ECG and no troponin elevation [ 22 , 23 ]. However, BNP and NT-proBNP mainly predict long-term events [ 21 , 23 ]; it is unclear that they are useful to drive patients’ management [ 24 , 25 ], and their value in the chest pain unit has been challenged when high-sensitive assays are used for troponin detection [ 26 ].…”

Systematic review of the effects of care provided with and without diagnostic clinical prediction rules

“…Eleven of the 27 included studies were considered to have evaluated a diagnostic CPR or strategy designed to replace the existing approach [18, 24, 28, 33, 34, 37, 40, 41, 44–46], 12 assessed the impact of adding a CPR to the usual diagnostic pathway in order to evaluate the benefit of extra information to diagnostic decision-making [19, 23, 25, 27, 30–32, 36, 38, 39, 42, 43], while three studies evaluated CPRs as a triage test. In the triage studies, the CPR was used before the existing test to determine which patients undergo the existing test [26, 29, 35].…”

“…In 19 of 27 studies, the CPR was introduced as a stand-alone tool [20, 23, 24, 26–34, 36, 38, 39, 41, 43–45]. The diagnostic CPRs and strategies tested were directive in 25 of the 27 studies, making a recommendation regarding treatment or disposition in 10 studies [19, 24, 27, 30, 31, 37, 40, 41, 44, 45], further diagnostic testing in 8 studies [23, 26, 29, 35, 36, 38, 39, 43] and both further testing and treatment in 7 studies [18, 25, 28, 32–34, 46].…”

“…Patient outcomes were considered the primary outcome in 3 [18, 28, 35] of the 27 studies, and process of care outcomes (e.g. length of stay) were the primary study outcome in 5 [25–27, 36, 37]. A clinical decision was the primary outcome in 12 studies [19, 21, 23, 29, 32, 38, 39, 41, 43–45, 47], and the appropriateness of the decision was the primary outcome in 3 [34, 40, 42].…”

Natriuretic peptides in acute chest pain and acute coronary syndrome

“…A strategy combining clinical evaluation and NT-proBNP, rather than an exercise test, reduced initial emergency hospitalization in patients with chest pain and was simpler [28]. A strategy combining clinical evaluation and NT-proBNP, rather than an exercise test, reduced initial emergency hospitalization in patients with chest pain and was simpler [28].…”