Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide,the PreBNP trial: a randomised controlled clinical trial

Abstract

Purpose:

The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea.

Methods:

Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology.

Results:

A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed.

Conclusion:

Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease.

ClinicalTrials.gov identifier NCT02050282.

Keywords

Dyspnoea heart failure brain natriuretic peptide decision-making emergency medical services randomised controlled trial

Get full access to this article

View all access options for this article.

References

Botker

Stengaard

Andersen

et al . Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scand J Trauma Resusc Emerg Med 2016; 24: 15–24.

Botker

Terkelsen

Sørensen

et al . Long-term mortality of emergency medical services patients. Ann Emerg Med. Epub ahead of print 25 March 2017. DOI: 10.1016/j.annemergmed.2016.12.017.

Prekker

Feemster

Hough

et al . The epidemiology and outcome of prehospital respiratory distress. Acad Emerg Med 2014; 21: 543–550.

Green

Martinez-Rumayor

Gregory

et al . Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea. Arch Intern Med 2008; 168: 741–748.

Wuerz

Meador

. Effects of prehospital medications on mortality and length of stay in congestive heart failure. Ann Emerg Med 1992; 21: 669–674.

Ponikowski

Voors

Anker

et al . 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC). Eur Heart J 2016; 20: 129–2200.

Hawkins

Virani

Ceconi

. Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services. Eur Heart J 2013; 34: 2795–2803.

Rutten

Cramer

Lammers

et al . Heart failure and chronic obstructive pulmonary disease: an ignored combination? Eur J Heart Fail 2006; 8: 706–711.

Prosen

Klemen

Strnad

et al . Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care 2011; 15: 114–123.

10.

Teboul

Gaffinel

Meune

et al . Management of acute dyspnoea: use and feasibility of brain natriuretic peptide (BNP) assay in the prehospital setting. Resuscitation 2004; 61: 91–96.

11.

Thygesen

Mair

Mueller

et al . Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2012; 33: 2001–2006.

12.

Mebazaa

Yilmaz

Levy

et al . Recommendations on pre-hospital and early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine – short version. Eur Heart J 2015; 36: 1958–1966.

13.

Januzzi

van Kimmenade

Lainchbury

et al . NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006; 27: 330–337.

14.

Schmidt

Sandegaard

et al . The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol 2015; 7: 449–490.

15.

Schmidt

Pedersen

Sorensen

. The Danish Civil Registration System as a tool in epidemiology. Eur J Epidemiol 2014; 29: 541–549.

16.

Moe

Howlett

Januzzi

et al . N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Circulation 2007; 115: 3103–3110.

17.

Mueller

Scholer

Laule-Kilian

et al . Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004; 350: 647–654.

18.

Rutten

Steyerberg

Boomsma

et al . N-terminal pro-brain natriuretic peptide testing in the emergency department: beneficial effects on hospitalization, costs, and outcome. Am Heart J 2008; 156: 71–77.

19.

Schneider

Lam

Lokuge

et al . B-type natriuretic peptide testing, clinical outcomes, and health services use in emergency department patients with dyspnea: a randomized trial. Ann Intern Med 2009; 150: 365–371.

20.

Lam

Cameron

Schneider

et al . Meta-analysis: effect of B-type natriuretic peptide testing on clinical outcomes in patients with acute dyspnea in the emergency setting. Ann Intern Med 2010; 153: 728–735.

21.

Trinquart

Ray

Riou

et al . Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis. Am J Emerg Med 2011; 29: 757–767.

22.

Januzzi

Jr. Camargo

Anwaruddin

et al . The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005; 95: 948–954.

23.

Maisel

Krishnaswamy

Nowak

et al . Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347: 161–167.

24.

Gorissen

Baumgarten

de Groot

et al . Analytical and clinical performance of three natriuretic peptide tests in the emergency room. Clin Chem Lab Med 2007; 45: 678–684.

25.

McCullough

Duc

Omland

et al . B-type natriuretic peptide and renal function in the diagnosis of heart failure: an analysis from the Breathing Not Properly Multinational Study. Am J Kidney Dis 2003; 41: 571–579.

26.

Eckstein

Potocki

Murray

et al . Direct comparison of mid-regional pro-atrial natriuretic peptide with N-terminal pro B-type natriuretic peptide in the diagnosis of patients with atrial fibrillation and dyspnoea. Heart 2012; 98: 1518–1522.

27.

Knudsen

Omland

Clopton

et al . Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide concentration in dyspneic patients: an analysis from the breathing not properly multinational study. J Am Coll Cardiol 2005; 46: 838–844.

28.

Morello

Lloyd-Jones

Chae

et al . Association of atrial fibrillation and amino-terminal pro-brain natriuretic peptide concentrations in dyspneic subjects with and without acute heart failure: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Am Heart J 2007; 153: 90–97.

29.

Chung

Sindone

Foo

et al . Influence of history of heart failure on diagnostic performance and utility of B-type natriuretic peptide testing for acute dyspnea in the emergency department. Am Heart J 2006; 152: 949–955.

30.

Rudiger

Gasser

Fischler

et al . Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock, and acute heart failure. Crit Care Med 2006; 34: 2140–2144.

31.

Maisel

Neath

Landsberg

et al . Use of procalcitonin for the diagnosis of pneumonia in patients presenting with a chief complaint of dyspnoea: results from the BACH (Biomarkers in Acute Heart Failure) trial. Eur J Heart Fail 2012; 14: 278–286.

32.

Klemen

Golub

Grmec

. Combination of quantitative capnometry, N-terminal pro-brain natriuretic peptide, and clinical assessment in differentiating acute heart failure from pulmonary disease as cause of acute dyspnea in pre-hospital emergency setting: study of diagnostic accuracy. Croat Med J 2009; 50: 133–142.

33.

Laursen

Sloth

Lambrechtsen

et al . Focused sonography of the heart, lungs, and deep veins identifies missed life-threatening conditions in admitted patients with acute respiratory symptoms. Chest 2013; 144: 1868–1875.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.68 MB

0.00 MB