Btype Natriuretic Peptide BNP in the Diagnosis of Acute Congestive Heart Failure CHF - PowerPoint PPT Presentation

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Btype Natriuretic Peptide BNP in the Diagnosis of Acute Congestive Heart Failure CHF

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Title: Btype Natriuretic Peptide BNP in the Diagnosis of Acute Congestive Heart Failure CHF


1
B-type Natriuretic Peptide(BNP) in the Diagnosis
of Acute Congestive Heart Failure (CHF)
  • Scott M Silvers, MD
  • 1st Annual Pan American Conference
  • Emergency Medicine Clinical Policies
  • November 6 7, 2003

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Lecture Outline
  • Introduction to BNP
  • Case
  • Critical Question
  • Literature Search
  • Critical Literature Evaluation
  • Evidence-based Recommendations

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Introduction to BNP
  • 32-aa polypeptide
  • Found in heart ventricles
  • Produced with ? ventricular stretch and volume
  • Results in vasodilation, natriuresis, diuresis,
    and reduced preload
  • Increases with worsening heart failure

8
Introduction to BNP
Maisel AS, et al. N Engl J Med.
2002347(3)161-167.
9
Introduction to BNP
Morrison LK, et al. J American Coll of Card.
200239(2)202-209.
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Case
  • Current History
  • Ms. GM is a 76 yo woman with a history only of
    obstructive lung disease who presents to the
    emergency department with 2 days of progressively
    worsening shortness of breath.
  • Physical Examination
  • T 37C HR 110 BP 170/90 RR 40 SO2
    (air) 87
  • She is unable to speak long sentences.
  • Neck veins difficult to assess
  • Heart difficult to hear over her lung sounds
  • Lungs diffuse wheezing with decreased breath
    sounds and rales at the bases
  • Abdomen normal
  • Extremities warm with moderate pitting edema

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Chest X-ray
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Critical Question
  • What is the utility of a B-type natriuretic
    peptide (BNP) measurement in the diagnosis of
    congestive heart failure among patients
    presenting to an emergency department
    with shortness of breath?

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Curiosity Poll
  • How many people have a BNP assay available to
    them where they practice?

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Literature Search
  • Medline January 1995 Present
  • Keywords
  • Brain natriuretic peptide, B-type natriuretic
    peptide, B natriuretic peptide, or BNP
  • 1, 745 papers
  • Limits
  • Human subjects, clinical trials, meta-analyses
  • 164 papers

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Literature Search
  • Abstracts of clinical studies reviewed
  • Patients presenting with shortness of breath to
    acute care centers
  • 5 papers
  • Reviews and clinical policies 2000 - present
    (references crosschecked)

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Typical Study Methodology
  • Inclusion Criteria
  • Adult patients presenting to an acute care
    facility
  • Primary complaint shortness of breath

Exclusion Criteria
  • Obvious non-CHF cause of shortness of breath
  • Renal Failure
  • Acute myocardial infarction

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Typical Study Methodology
  • Evaluation by an emergency physician
  • Assessment of clinical probability of CHF
  • BNP assay sent
  • Results not revealed to emergency physician
  • Patient treated and dispositioned
  • Physician team blinded to BNP measurement assign
    final diagnosis after evaluation of case

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Typical Study Methodology
  • CHF Gold Standard
  • Clinical findings
  • Chest x-ray
  • Echocardiography
  • Nuclear cardiology
  • Cardiac Catheterization
  • Framingham and NHANES scores
  • Clinical response to therapies

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Critical Literature EvaluationBNP in Diagnosing
CHF
  • 5 published studies to date
  • 2 report data from the same sample

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Critical Literature EvaluationBNP in Diagnosing
CHF
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Critical Literature EvaluationBNP in Diagnosing
CHF
  • Maisel et al, (NEJM 2002)
  • Prospective, multinational N 1,586
  • All clinical risk patients evaluated as one
    sample
  • BNP
  • Sensitivity 90 Specificity 76
  • NPV 89 PPV 79
  • BNP
  • Sensitivity 97 Specificity 62
  • NPV 96 PPV 71
  • Study Grade 1

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Critical Literature EvaluationBNP in Diagnosing
CHF
  • McCullough et al, (Circulation 2002)
  • Prospective, multinational N 1,538
  • Excluded 48 patients without clinical risk
    assessement
  • BNP
  • Low and Intermediate clinical probability (0
    79)
  • Sensitivity 94 Specificity 70
  • NPV 93 PPV 74
  • High clinical probability (80 100)
  • Sensitivity 49 Specificity 96
  • NPV 68 PPV 91
  • Study Grade 2 (Post-study Analysis)

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Critical Literature Evaluation
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Critical Literature Evaluation
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Critical Literature Evaluation
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Critical Literature Evaluation
Maisel AS, et al. N Engl J Med.
2002347(3)161-167.
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Critical Literature Evaluation
  • Possible Limitation of BNP
  • Among rats given acute CHF, BNP may take over 1
    hour to rise.

Nakagawa O, et al. J Clin Invest.
1995961280-1287.
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Evidenced-based Recommendations
  • Includes
  • Patients presenting to an emergency department
  • Primary complaint shortness of breath

Excludes
  • Obvious non-CHF cause of shortness of breath
  • Renal Failure
  • Acute myocardial infarction

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Evidenced-based Recommendations
  • Level A Recommendations
  • A BNP rule-out the diagnosis of congestive heart
    failure when the diagnosis is uncertain.
    (Probability

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Evidenced-based Recommendations
  • Level B Recommedations
  • Among low and intermediate clinical probability
    patients, a BNP used to help rule-out the diagnosis of congestive
    heart failure. (Probability
  • Among patients without a history of CHF, a BNP
    88 pmol/L (400 pg/ml) may be used to rule-in the
    diagnosis of CHF when the diagnosis is uncertain.
    (Probability 95)
  • A BNP 220 pmol/L (1,000 pg/ml) may be used to
    rule-in the diagnosis of acute CHF among patients
    presenting with a history of CHF. (Probability
    95)

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Evidenced-based Recommendations
  • Level C Recommendations
  • When evaluating a patient who presents with
    possible CHF within 1 hour from symptom onset,
    use caution in the interpretation of a low BNP
    level as BNP may take over 1 hour to rise.

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Key References
  • Davis M, et al. Plasma brain natriuretic peptide
    in assessment of acute dyspnea. Lancet.
    1994343440-444.
  • Dao Q, et al. Utility of B-type natriuretic
    peptide in the diagnosis of congestive heart
    failure in an urgent-care setting. J Amer Coll
    Card. 200137(2)379-385.
  • Morrison LK, et al. Utility of a rapid
    B-natriuretic peptide assay in differentiating
    congestive heart failure from lung disease in
    patients presenting with dyspnea. J Amer Coll
    Card. 200239(2)202-209.
  • Maisel AS, et al. Rapid measurement of B-type
    natriuretic peptide in the emergency diagnosis of
    heart failure. New Eng J Med.
    2002347(3)161-167.
  • McCullough PA, et al. B-typenatriuretic peptide
    and clinical judgement in emergency diagnosis of
    heart failure Analysis from breathing not
    properly (BNP) multinational study. Circulation.
    2002106416-422.
  • Nakagawa O, et al. Rapid transcriptional
    activation and early mRNA turnover of brain
    natriuretic peptide in cardiocyte hypertrophy. J
    Clin Invest. 1995961280-1287.

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