Maisel Alan, Hollander Judd E, Guss David, McCullough Peter, Nowak Richard, Green Gary, Saltzberg Mitchell, Ellison Stefanie R, Bhalla Meenakshi Awasthi, Bhalla Vikas, Clopton Paul, Jesse Robert
University of California-San Diego, Veterans Affairs Medical Center, San Diego, California 92161, USA.
J Am Coll Cardiol. 2004 Sep 15;44(6):1328-33. doi: 10.1016/j.jacc.2004.06.015.
The purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes of the CHF patients presenting to emergency department (ED).
Since BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine.
The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge.
Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels <200 pg/ml (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (CHF visits or admissions and mortality) in the group of patients admitted with BNP <200 pg/ml and >200 pg/ml was 9% and 29%, respectively (p = 0.006).
In patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.
本研究旨在探讨诊断范围内B型利钠肽（BNP）水平、感知到的充血性心力衰竭（CHF）严重程度、临床决策以及急诊室（ED）中CHF患者的结局之间的关系。
由于BNP与CHF的存在、疾病严重程度和预后相关，我们假设诊断范围内的BNP水平在急诊医学中对于关键结局具有独立于医生决策的价值。
快速急诊室心力衰竭门诊试验（REDHOT）研究是一项10中心试验，在该试验中，因呼吸急促到急诊室就诊的患者在到达时同意检测BNP水平。入选标准包括BNP水平>100 pg/ml。医生对实际BNP水平及后续BNP测量结果不知情。患者出院后随访90天。
464例患者中，90%住院。三分之二的患者被认为是纽约心脏协会（NYHA）功能分级III级或IV级。从急诊室出院回家的患者与入院患者的BNP水平无显著差异（976 vs. 766，p = 0.6）。使用逻辑回归分析，急诊医生收治或出院患者的意向对90天结局无影响，而BNP水平是90天结局的有力预测指标。入院患者中，11%的BNP水平<200 pg/ml（其中66%被认为是NYHA功能分级III级或IV级）。BNP<200 pg/ml和>200 pg/ml入院的患者组中，90天联合事件发生率（CHF就诊或入院及死亡率）分别为9%和29%（p = 0.006）。
在因心力衰竭到急诊室就诊的患者中，急诊医生感知到的CHF严重程度与BNP水平所确定的严重程度之间存在脱节。BNP水平可预测未来结局，因此可能有助于医生做出关于患者收治或出院的分诊决策。新出现的临床数据将有助于进一步完善涉及BNP的生物标志物指导的门诊治疗和监测策略。
