Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
Division of Cardiology, Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada.
J Am Coll Cardiol. 2018 Mar 20;71(11):1191-1200. doi: 10.1016/j.jacc.2018.01.021.
Contemporary reconsideration of diagnostic N-terminal pro-B-type natriuretic peptide (NT-proBNP) cutoffs for diagnosis of heart failure (HF) is needed.
This study sought to evaluate the diagnostic performance of NT-proBNP for acute HF in patients with dyspnea in the emergency department (ED) setting.
Dyspneic patients presenting to 19 EDs in North America were enrolled and had blood drawn for subsequent NT-proBNP measurement. Primary endpoints were positive predictive values of age-stratified cutoffs (450, 900, and 1,800 pg/ml) for diagnosis of acute HF and negative predictive value of the rule-out cutoff to exclude acute HF. Secondary endpoints included sensitivity, specificity, and positive (+) and negative (-) likelihood ratios (LRs) for acute HF.
Of 1,461 subjects, 277 (19%) were adjudicated as having acute HF. The area under the receiver-operating characteristic curve for diagnosis of acute HF was 0.91 (95% confidence interval [CI]: 0.90 to 0.93; p < 0.001). Sensitivity for age stratified cutoffs of 450, 900, and 1,800 pg/ml was 85.7%, 79.3%, and 75.9%, respectively; specificity was 93.9%, 84.0%, and 75.0%, respectively. Positive predictive values were 53.6%, 58.4%, and 62.0%, respectively. Overall LR+ across age-dependent cutoffs was 5.99 (95% CI: 5.05 to 6.93); individual LR+ for age-dependent cutoffs was 14.08, 4.95, and 3.03, respectively. The sensitivity and negative predictive value for the rule-out cutoff of 300 pg/ml were 93.9% and 98.0%, respectively; LR- was 0.09 (95% CI: 0.05 to 0.13).
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.
有必要重新考虑当代诊断 N 末端前 B 型利钠肽（NT-proBNP）截断值以诊断心力衰竭（HF）。
本研究旨在评估 NT-proBNP 对急诊科（ED）呼吸困难患者急性 HF 的诊断性能。
北美 19 家 ED 收治的呼吸困难患者入院并抽取血液进行后续 NT-proBNP 测量。主要终点是年龄分层截断值（450、900 和 1800 pg/ml）对急性 HF 的阳性预测值以及排除急性 HF 的排除截断值的阴性预测值。次要终点包括急性 HF 的敏感性、特异性和阳性（+）和阴性（-）似然比（LR）。
在 1461 名受试者中，277 名（19%）被判定为急性 HF。急性 HF 诊断的受试者工作特征曲线下面积为 0.91（95%置信区间：0.90 至 0.93；p<0.001）。年龄分层截断值为 450、900 和 1800 pg/ml 的敏感性分别为 85.7%、79.3%和 75.9%；特异性分别为 93.9%、84.0%和 75.0%。阳性预测值分别为 53.6%、58.4%和 62.0%。年龄依赖性截断值的总体 LR+为 5.99（95%置信区间：5.05 至 6.93）；年龄依赖性截断值的个体 LR+分别为 14.08、4.95 和 3.03。300 pg/ml 排除截断值的敏感性和阴性预测值分别为 93.9%和 98.0%；LR-为 0.09（95%置信区间：0.05 至 0.13）。
在 ED 环境中出现急性呼吸困难的患者中，年龄分层的 NT-proBNP 截断值可能有助于诊断急性 HF。NT-proBNP<300 pg/ml 强烈排除急性 HF 的存在。
