Copeptin and risk stratification in patients with acute dyspnea

Introduction

The identification of patients at highest risk for adverse outcome who are presenting with acute dyspnea to the emergency department remains a challenge. This study investigates the prognostic value of Copeptin, the C-terminal part of the vasopressin prohormone alone and combined to N-terminal pro B-type natriuretic peptide (NT-proBNP) in patients with acute dyspnea.

Methods

We conducted a prospective, observational cohort study in the emergency department of a university hospital and enrolled 287 patients with acute dyspnea.

Results

Copeptin levels were elevated in non-survivors (n = 29) compared to survivors at 30 days (108 pmol/l, interquartile range (IQR) 37 to 197 pmol/l) vs. 18 pmol/l, IQR 7 to 43 pmol/l; P < 0.0001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.83 (95% confidence interval (CI) 0.76 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for Copeptin, NT-proBNP and BNP, respectively (Copeptin vs. NTproBNP P = 0.21; Copeptin vs. BNP P = 0.002). When adjusted for common cardiovascular risk factors and NT-proBNP, Copeptin was the strongest independent predictor for short-term mortality in all patients (HR 3.88 (1.94 to 7.77); P < 0.001) and especially in patients with acute decompensated heart failure (ADHF) (HR 5.99 (2.55 to 14.07); P < 0.0001). With the inclusion of Copeptin to the adjusted model including NTproBNP, the net reclassification improvement (NRI) was 0.37 (P < 0.001). An additional 30% of those who experienced events were reclassified as high risk, and an additional 26% without events were reclassified as low risk.

Conclusions

Copeptin is a new promising prognostic marker for short-term mortality independently and additive to natriuretic peptide levels in patients with acute dyspnea.     

Value of arterial blood gas analysis in patients with acute dyspnea: an observational study

Introduction

The diagnostic and prognostic value of arterial blood gas analysis (ABGA) parameters in unselected patients presenting with acute dyspnea to the Emergency Department (ED) is largely unknown.

Methods

We performed a post-hoc analysis of two different prospective studies to investigate the diagnostic and prognostic value of ABGA parameters in patients presenting to the ED with acute dyspnea.

Results

We enrolled 530 patients (median age 74 years). ABGA parameters were neither useful to distinguish between patients with pulmonary disorders and other causes of dyspnea nor to identify specific disorders responsible for dyspnea. Only in patients with hyperventilation from anxiety disorder, the diagnostic accuracy of pH and hypoxemia rendered valuable with an area under the receiver operating characteristics curve (AUC) of 0.86. Patients in the lowest pH tertile more often required admission to intensive care unit (28% vs 12% in the first tertile, P < 0.001) and had higher in-hospital (14% vs 5%, P = 0.003) and 30-day mortality (17% vs 7%, P = 0.002). Cumulative mortality rate was higher in the first (37%), than in the second (28%), and the third tertile (23%, P = 0.005) during 12 months follow-up. pH at presentation was an independent predictor of 12-month mortality in multivariable Cox proportional hazard analysis both for patients with pulmonary (P = 0.043) and non-pulmonary disorders (P = 0.038).

Conclusions

ABGA parameters provide limited diagnostic value in patients with acute dyspnea, but pH is an independent predictor of 12 months mortality.     

Usefulness of B-type natriuretic peptide in elderly patients with acute dyspnea

Objective Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is particularly difficult in elderly patients. The aim of our study was to evaluate B-type natriuretic peptide (BNP) in patients older than 65 years presenting with acute dyspnea.Design Prospective study.Setting Medical emergency department of a 2000-bed urban teaching hospital.Patients Patients aged over 65 years presenting with acute dyspnea and a respiratory rate more than 25/min or a PaO₂ below 70 mmHg, SpO₂ less than 92%, PaCO₂ higher than 45 mmHg with pH less than 7.35, were included. BNP levels, measured blind at admission were compared with the final diagnosis (CPE or no CPE) as defined by experts.Intervention None.Measurements and results Three hundred eight patients (mean age of 80 years) were enrolled in the study. The median BNP was 575 pg/ml [95% confidence interval (CI): 410–898] in the CPE group (n=141) versus 75 pg/ml (95% CI: 59–98) in the no CPE group (n=167) (p<0.001). The best threshold value of BNP was 250 pg/ml, with a sensitivity and specificity for CPE of 0.78 (95% CI: 0.71–0.84) and 0.90 (95% CI: 0.84–0.93), respectively. The area under the ROC curve was 0.874±0.081 (p<0.001). The accuracy of BNP-assisted diagnosis was higher than that of the emergency physician (0.84 versus 0.77, p<0.05).Conclusion Analysis of BNP is useful in elderly patients with acute dyspnea, but the threshold value is higher than that previously determined.Presented, in part, at the 30^th annual congress of the Société de Réanimation de Langue Française, Paris, January 2002 (abstract no. SP 94).     

Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.     

心钠素对急性呼吸困难的诊断和鉴别诊断意义

目的：探讨心钠素在急性呼吸困难中的诊断和鉴别诊断意义。方法：急性呼吸困难患者110例,测定血浆心钠素水平,以ANP=0．29pg／I,为阳性界定值对其诊断心衰的价值进行评价。结果：心衰患者ANP明显高于非心衰患者,以ANP=0．29pg／L为阳性界定值,ANP诊断心源性呼吸困难的敏感性为95．00％,特异性为88．64％,阳性预测值为86．36％,阴性预测值为95．12％。结论：ANP对于诊断和鉴别诊断急性呼吸困难,具有重要意义。     

检测B型利钠肽对急诊呼吸困难的鉴别诊断意义

目的:探讨B型利钠肽(B-type natriuretic peptide,BNP)用于甄别急诊呼吸困难中的充血性心力衰竭(congestive heart failure,CHF)的早期诊断意义.方法:130例急诊呼吸困难患者,根据临床资料及左心室射血分数(left ventricul ejection fraction,LVEF)分为CHF组(78例)和非CHF组(52例).采用干式快速免疫荧光法定量分析检测血液中的BNP浓度.结果:CHF组BNP浓度为(732±53)ng/L,显著高于非CHF组的(71±34)ng/L(P＜0.01);以BNP 100ng/L作为阈值区分呼吸困难是否为CHF所致,其敏感度、特异度、准确性分别为92%、96%、93%;在CHF组中,BNP浓度在不同心功能级别之间差异有统计学意义(P＜0.01),随心功能不全加重而升高.猝死者的BNP值高于存活者.结论:BNP水平对于CHF的诊断具有较高的灵敏度、特异度和准确性.对于鉴别呼吸困难是否为心源性具有重要意义.     

急性胸痛评分及血清B型脑钠肽对急诊胸痛患者心血管不良事件的预测价值

目的 探讨全球急性冠状动脉事件注册(Global Registry of Acute Coronary Events,GRACE)评分、心肌梗死溶栓疗法(the Thrombolysis in Myocardial Infarction,TIMI)危险评分及血清B型脑钠肽(B-type natriuretic peptide,BNP)对急诊胸痛患者心血管不良事件的预测价值.方法 回顾性分析536例急性胸痛患者的临床资料,计算患者基线水平GRACE、TIMI评分,检测血清BNP并进行30 d随访.应用单因素分析和logistic回归确定急性胸痛患者急诊入院、30 d死亡、急诊经皮冠状动脉介入术及其他心血管不良预后的独立预测因素;计算GRACE评分、TIMI评分及血清BNP预测相关不良心血管事件ROC曲线下面积.结果 536例患者年龄(55.7±12.7)岁,急诊入院31 9例(59.5％),30 d死亡45例(8.4％);与TIMI评分和血清BNP比较,GRACE评分可独立预测患者急诊入院(OR:1.02,95％CI:1.010～1.030,P=0.010)、30 d死亡(OR:1.05,95％CI:1.040～1.070,P=0.001)和急诊经皮冠状动脉介入术(OR:1.02,95％CI:1.010～1.030,P=0.000)的风险;GRACE评分的急诊入院(AUC:0.873,95％CI:0.843～0.903)、30 d死亡(AUC:0.654,95％CI:0.573-0.736)、急诊经皮冠状动脉介入术(AUC:0.746,95％CI:0.705 ～0.787)及其他心血管不良预后(AUC:0.651,95％CI:0.577～0.725)的ROC预测曲线均有统计学意义(P＜0.01).结论 与TIMI评分和血清BNP相比,GRACE评分可更有效判断急性胸痛患者急诊入院、30 d死亡、急诊经皮冠状动脉介入术及其他心血管不良预后的风险.     

B型钠尿肽对急性呼吸困难病因诊断的临床意义

目的 探讨B型钠尿肽(BNP)对鉴别急性呼吸困难病因的临床意义.方法 213例急性呼吸困难患者行BNP检测,将患者分为心源性急性呼吸困难组(112例)和肺源性急性呼吸困难组(101例),分别比较心源性和肺源性呼吸困难组不同心功能分级(NYHA)之间BNP水平、左室射血分数(LVEF)、左室舒张末期内径(LVEDD)及超敏C反应蛋白(hs-CRP)水平,计算BNP诊断心源性呼吸困难的受试者工作特征(ROC)曲线下面积及最佳界值.结果 心源性呼吸困难组BNP较肺源性组明显升高(P＜0.001),LVEDD也明显高于肺源性组＜0.001),但LVEF明显低于肺源性组(P＜0.001);不同心功能分级亚组之间BNP比较差异有统计学意义(P＜0.01);BNP及hs-CRP与LVEDD呈正相关;心源性呼吸困难患者BNP与LVEF呈高度负相关(r=-0.838,P＜0.001);BNP诊断心源性呼吸困难的ROC曲线下面积为0.926,95%可信区间为0.892～0.960(P＜0.01).BNP鉴别诊断的最佳界值为250 pg/mL,准确性为86%.结论 急性呼吸困难患者BNP的测定有助于心源性或肺源性病因的判定.     

B型脑钠肽在初发急性心肌梗死患者危险分层和短期临床预后中的作用

目的 分析初发急性心肌梗死(AMI)患者血浆B型脑钠肽(BNP)水平与梗死面积及住院期间和随访3个月的主要不良心脏事件(MACE)之间的关系,评价BNP在AMI患者的危险分层和短期预后中的意义.方法 选取非心力衰竭初发AMI患者82例,按照心电图分为ST段抬高型心肌梗死(STEMI)组和非ST段抬高型心肌梗死(NSTEMI)组,比较各组BNP水平;并按照BNP水平分为BNP＜100 ng/L组,BNP≥100～200 ng/L组和BNP≥200ng/L组,比较各组MACE的发生率.结果 STEMI组血浆BNP水平显著高于NSTEMI组,(208.4±180.2)ng/L vs(93.6±76.8)ng/L (P＜0.01).BNP≥200 ng/L组MACE发生率高于BNP≥100～200 ng/L组和BNP＜100ng/L组(分别为46.2％,8.33％,3.12％;P＜0.01).BNP与住院期间和短期MACE发生相关(HR＝0.985,95％可信区间CI=0.973～0.996;P＜0.01).结论 AMI患者的BNP水平越高,梗死面积越大,近期MACE发生率越高,高BNP水平是与住院期间和短期MACE发生率相关的危险因素.BNP测定有助于AMI患者的危险分层及预后判断.     

Midregional pro-atrial natriuretic peptide: a novel marker of myocardial fibrosis in patients with hypertrophic cardiomyopathy

We aimed to determine the diagnostic performance of biomarkers in predicting myocardial fibrosis assessed by late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR) in patients with hypertrophic cardiomyopathy (HCM). LGE CMR was performed in 40 consecutive patients with HCM. Left and right ventricular parameters, as well as the extent of LGE were determined and correlated to the plasma levels of midregional pro-atrial natriuretic peptide (MR-proANP), midregional pro-adrenomedullin (MR-proADM), carboxy-terminal pro-endothelin-1 (CT-proET-1), carboxy-terminal pro-vasopressin (CT-proAVP), matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase-1 (TIMP-1) and interleukin-8 (IL-8). Myocardial fibrosis was assumed positive, if CMR indicated LGE. LGE was present in 26 of 40 patients with HCM (65%) with variable extent (mean: 14%, range: 1.3–42%). The extent of LGE was positively associated with MR-proANP (r = 0.4; P = 0.01). No correlations were found between LGE and MR-proADM (r = 0.1; P = 0.5), CT-proET-1 (r = 0.07; P = 0.66), CT-proAVP (r = 0.16; P = 0.3), MMP-9 (r = 0.01; P = 0.9), TIMP-1 (r = 0.02; P = 0.85), and IL-8 (r = 0.02; P = 0.89). After adjustment for confounding factors, MR-proANP was the only independent predictor associated with the presence of LGE (P = 0.007) in multivariate analysis. The area under the ROC curve (AUC) indicated good predictive performance (AUC = 0.882) of MR-proANP with respect to LGE. The odds ratio was 1.268 (95% confidence interval 1.066–1.508). The sensitivity of MR-proANP at a cut-off value of 207 pmol/L was 69%, the specificity 94%, the positive predictive value 90% and the negative predictive value 80%. The results imply that MR-proANP serves as a novel marker of myocardial fibrosis assessed by LGE CMR in patients with HCM.     

严重呼吸困难患者血浆脑钠肽水平及意义

目的探讨严重呼吸困难患者血浆脑钠肽（BNP）水平及其与心功能的关系，为BNP在呼吸困难鉴别诊断中提供理论依据。方法使用BIOSITE公司的Triage^9BNP干氏快速诊断方法对65例心源性呼吸困难、40例肺源性呼吸困难患者的BNP进行测量，比较其浓度间的差异，并比较心源性呼吸困难患者BNP与心功能的关系。结果心力衰竭组与正常对照组及肺源性呼吸困难组的BNP水平差异有统计学意义（P〈0．001）。在严重心源性呼吸困难组未观察到呼吸困难时BNP与LVEDD及EF的相关性。结论血浆BNP水平测定是严重呼吸困难患者一敏感而特异的鉴别诊断标志物。     

心房纤颤病人B型利钠肽变化与护理要点

目的测定心房纤颤(房颤)病人血B型利钠肽(BNP)水平并探讨其护理要点。方法抽静脉血化验45例住院房颤病人的血B型利钠肽,并与35例非房颤病例对照;2组病人采取不同级别的护理措施。结果房颤组病人血BNP水平较对照组明显升高[(161±119)pg/ml和(89±64)pg/ml,t=4.87,P<0.01];2组病人对护理工作满意者分别有(43/45)例和(30/35)例,2组对比无显著性差异,(P>0.05)。结论房颤病人血BNP水平会增高,护理工作者应了解这些变化,并应用于护理实践中。     

Medical and economic long-term effects of B-type natriuretic peptide testing in patients with acute dyspnea

BACKGROUND: The objective of this prospective study was to assess the medical and economic long-term effects of using B-type natriuretic peptide (BNP) concentrations in the management of patients with acute dyspnea. METHODS: We performed follow-up analysis of the B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation, a randomized study including 452 patients who presented to the emergency department with acute dyspnea. Participants were randomly assigned to a diagnostic strategy involving the rapid measurement of BNP concentrations (n = 225) or standard assessment (n = 227). Mortality was assessed at 720 days, morbidity and economic data at 360 days. RESULTS: BNP testing induced several important changes in initial patient management, including a reduction in the initial hospital admission rate, the use of intensive care, and initial time to discharge. At 720 days, 172 deaths had occurred. Cumulative all-cause 720-day mortality was not different between the BNP group (37%) and the control group (36%, P = 0.6). Morbidity as reflected by days spent in-hospital at 360 days was significantly lower in the BNP group [median 12 days ([interquartile range 2-28 days)] compared with the control group [median 16 (7-32)] days, P = 0.025]. Functional status was similar in both groups. Economic outcome as quantified by total treatment cost at 360 days was significantly improved in the BNP group (mean 10,144 dollars vs 12,748 dollars in the control group, P = 0.008). CONCLUSIONS: Rapid BNP testing in patients with acute dyspnea has no effect on long-term mortality. However, morbidity as quantified by days spent in-hospital and economic outcome are still improved at 360 days.     

Midregional pro-A-type natriuretic peptide measurements for diagnosis of acute destabilized heart failure in short-of-breath patients: comparison with B-type natriuretic peptide (BNP) and amino-terminal proBNP

BACKGROUND: The aim of the present study was to assess the utility of amino-terminal pro-A-type natriuretic peptide (NT-proANP) measurements for the emergency diagnosis of acute destabilized heart failure (HF), using a novel sandwich immunoassay covering midregional epitopes (MR-proANP). METHODS: The retrospective analysis comprised 251 consecutive patients presenting to the emergency department of a tertiary care hospital with dyspnea as a chief complaint. The diagnosis of acute destabilized HF was based on the Framingham score for HF plus echocardiographic evidence of systolic or diastolic dysfunction. A commercially available immunoluminometric assay was used for measurement of MR-proANP plasma concentrations. RESULTS: Median MR-proANP plasma concentrations were significantly higher in patients with dyspnea attributable to acute destabilized HF (338 pmol/L; n = 137) than in patients with dyspnea attributable to other reasons (98 pmol/L; n = 114; P <0.001). The area under the curve for MR-proANP was 0.876 (SE = 0.022; 95% confidence interval, 0.829-0.914), and the cutoff concentration with the highest diagnostic accuracy was 169 pmol/L (sensitivity, 89%; specificity, 76%; diagnostic accuracy, 83%). In the setting evaluated, diagnostic information obtained by MR-proANP measurements was similar to that obtained with B-type natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) measurements. CONCLUSIONS: MR-proANP measurements may be useful as an aid in the diagnosis of acute destabilized HF in short-of-breath patients presenting to an emergency department. The diagnostic value of MR-proANP appears to be comparable to that of BNP and NT-proBNP.     

心房纤颤病人B型利钠肽变化与护理要点

目的测定心房纤颤(房颤)病人血B型利钠肽(BNP)水平并探讨其护理要点.方法抽静脉血化验45例住院房颤病人的血B型利钠肽,并与35例非房颤病例对照;2组病人采取不同级别的护理措施.结果房颤组病人血BNP水平较对照组明显升高[(161±119)pg/ml和(89±64)pg/ml,t=4.87,P＜0.01];2组病人对护理工作满意者分别有(43/45)例和(30/35)例,2组对比无显著性差异,(P＞0.05).结论房颤病人血BNP水平会增高,护理工作者应了解这些变化,并应用于护理实践中.     

Identifying risk factors for imminent death in cancer patients with acute dyspnea

A substantial proportion of cancer patients presenting to an emergency center (EC) or clinic with acute dyspnea survives fewer than 2 weeks. If these patients could be identified at the time of admission, physicians and patients would have additional information on which to base decisions to continue therapy to extend life or to refocus treatment efforts on palliation and/or hospice care alone. The purpose of this study was to identify risk factors for imminent death (survival 相似文献   

The effect of diabetes on B-type natriuretic peptide concentrations in patients with acute dyspnea: an analysis from the Breathing Not Properly Multinational Study

OBJECTIVE: Diabetes has been implicated in reduced myocardial compliance and changes in the intercellular matrix of the myocardium. We determined the effect of diabetes on B-type natriuretic peptide (BNP) concentrations in patients presenting to the emergency department with dyspnea. RESEARCH DESIGN AND METHODS: The Breathing Not Properly Multinational Study was a prospective evaluation of 1,586 patients. A subset of 922 patients was obtained and subdivided into the following groups: group 1 (n = 324), neither diabetes nor heart failure; group 2 (n = 107), diabetes and no heart failure; group 3 (n = 247), no diabetes and heart failure; group 4 (n = 183), both diabetes and heart failure; group 5 (n = 41), heart failure history with no diabetes; and group 6 (n = 20), heart failure history with diabetes. Patients from groups 1, 3, and 5 were matched to groups 2, 4, and 6, respectively, to have the same mean age, sex distribution, BMI, renal function, and New York Heart Association (NYHA) classification (for heart failure). RESULTS: There was no significant difference in median BNP levels between diabetes and no diabetes among no heart failure patients (32.4 vs.32.9 pg/ml), heart failure patients (587 vs. 494 pg/ml), and those with a heart failure history (180 vs. 120 pg/ml). Receiver-operating characteristic curve analysis of the area under the curve for BNP was not different in diabetic versus nondiabetic patients (0.888 vs. 0.878, respectively). However, in a multivariate model, diabetes was an independent predictor of a final diagnosis of heart failure (odds ratio 1.51, 95% CI 1.03-2.02; P < 0.05). CONCLUSIONS: History of diabetes does not impact BNP levels measured in patients with acute dyspnea in the emergency department. Despite the impact of diabetes on the cardiovascular system, diabetes does not appear to confound BNP levels in the emergency department diagnosis of heart failure.     

Characteristics and outcome of patients with DNACPR orders in an acute hospital; an observational study

Aims

To establish the characteristics and outcomes of patients with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders; to assess whether particular patient characteristics are associated with discussing resuscitation orders with patients.

Methods

Retrospective case note analysis from an acute hospital in 2009 was performed on: all in-hospital deaths; all patients who had carbon-copies of their DNACPR forms returned to the resuscitation department and a sample of age-matched discharged patients without known DNACPR order forms. Univariate and multivariate logistic regression analysis was used to test the significance of the associations and calculate odds ratios.

Results

Of 541 sampled patients, 51% of patients with DNACPR orders were discharged. Baseline characteristics of those who had in-hospital deaths or were discharged with DNACPR orders were similar. The overall one-year mortality for patients with a DNACPR order was 83%. 50% of patients had documentation of having DNACPR orders discussed: this was consistent across patient characteristics including those who were discharged and those who had in-hospital deaths. Cases of “inappropriate” resuscitation attempts were identified.

Conclusions

About half of patients with DNACPR orders were discharged home, and 17% were alive at one year. Characteristics of patients and frequency of discussions were similar in those who died or were discharged. Current focus of use of DNACPR orders only on those identified as most likely to die makes inappropriate resuscitation attempt a likely occurrence, and care is required to ensure conflation with “end of life” pathways does not distort the treatments given to this vulnerable group.