BNP in acute Dyspnea - 365heart · Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic...
Transcript of BNP in acute Dyspnea - 365heart · Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic...
Prof. Dr. Christian MuellerUniversity Hospital Basel
Lisboa, June 13th, 2005
BNP in Acute DyspneaBNP in Acute Dyspnea
BNP in Acute DyspneaBNP in Acute Dyspnea
Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?
BNP in Acute DyspneaBNP in Acute Dyspnea
Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?
Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic uncertainty
Initial diagnosis correct in only 25-50% of pts.(Eur Heart J 1991;12:315, Lancet 1997;350:1349)
CHF false positive, CHF false negative
Heart or Lung?Heart or Lung?
0
50
100
150
200
250
300
350
400Pa
tient
(n)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
CHF Probability
uncertainuncertain
McCullough et al., Circulation 2002 106:416-422
Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic uncertainty
BNP in Acute DyspneaBNP in Acute Dyspnea
Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?
Physiology
ANPBNP
CNPVolume ↑Pressure ↑
Maisel A, et al. N Engl J Med 2002;347:161-7.
Acute Dyspnea: BNP
McCullough et al., Circulation 2002 106:416-422
Acute Dyspnea: BNP ROC Curve
BNP in Acute DyspneaBNP in Acute Dyspnea
Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?
Supported by:Swiss National Science Foundation
Swiss Heart FoundationKrokus Foundation
University BaselBiosite
B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation
(BASEL) Study:
BASEL StudyBASEL Study
BNP group
Pts with acute dyspnea
Start of specific treatment
Control group
Further evaluation recommended: Echo & spirometry
randomized
History, physical exam, ECG, chest X-ray, blood tests, SaO2
Rapid BNP Test
Hospital Discharge
Tim
e to
dis
char
ge
30 day outcome
Study Algorithm
Base-Line Characteristics
Medical History – no. (%)
Smoking status – no. (%)
Sex – no. %
Age – yrCharacteristic
22 (10)19 (8)Deep-vein thrombosis56 (25)56 (25)Chronic kidney disease49 (22)40 (18)Stroke or PVD21 (9)15 (7)Depressive disorder
107 (47)119 (53)Any pulmonary disorder26 (11)20 (9)Other pulmonary disease13 (6)18 (8)Pulmonary embolism28 (12)30 (13)Pneumonia12 (5)17 (8)Asthma65 (29)75 (33)COPD56 (25)47 (21)Diabetes mellitus
124 (55)113 (50)Arterial hypertension112 (49)113 (50)Coronary artery disease68 (30)60 (27)Previous smoker45 (20)64 (28)Current smoker
114 (50)101 (45)Never smoked97 (43)93 (41)Female
130 (57)132 (59)Male21 - 9619 – 97Range
68.9 – 72.768.2 – 72.495% Confidence interval70.870.3Mean
Control Group (N=227)
BNP Group (N=225)
Results
BNP groupClinical group
Tim
e to
ade
quat
e th
erap
y (m
in)
100
90
80
70
60
50
40
30
20
10
0
63
90p=0.029
Time to adequate therapy
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
Time to Discharge
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
BNP groupClinical group
Hos
pita
l adm
issi
on (%
)
100
90
80
70
60
50
40
30
20
10
0
75
85
p=0.008
Hospital Admissions
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
BNP groupClinical group
Tota
l tre
atm
ent c
ost (
$)
8000
7000
6000
5000
4000
3000
2000
1000
0
5410
7264 p=0.006
-26%
Total Treatment Costs
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
BNP groupClinical group
In-H
ospi
tal M
orta
lity
(%)
10
9
8
7
6
5
4
3
2
1
0
6
9 p=0.212
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
In-Hospital Mortality
BASEL: Conclusion
Used in conjunction with other clinical information, rapid measurement of BNP in the ED improved the evaluation and treatment of pts with acute dyspnea and thereby reduced the time to discharge and the total cost of treatment.
Mueller Ch. et al. N Engl J Med 2004;350:647-54.
<100pg/ml* >400pg/ml100-400pg/ml
Clinical evaluationNo CHF CHF
Always in conjunction with other clinical information
No CHF CHF DiureticsNitratesACE-I*if Creatinine Clearance > 60ml/min
Interpretation of BNP Values in Patientspresenting with Acute Dyspnea
BNP in Acute DyspneaBNP in Acute Dyspnea
Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?
BASEL: Elderly
Mueller Ch et al. J Intern Med 2005; in press.
BASEL: Elderly
Mueller Ch et al. J Intern Med 2005; in press.
BASEL: Elderly
Mueller Ch et al. J Intern Med 2005; in press.
BASEL: Elderly
BNP in Acute DyspneaBNP in Acute Dyspnea
We really need it!It is good!We can do a better job in the ED with BNP!It also works in the elderly!