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Clinical Investigations: CARDIOLOGY |

B-Type Natriuretic Peptide and Echocardiographic Determination of Ejection Fraction in the Diagnosis of Congestive Heart Failure in Patients With Acute Dyspnea*

Philippe Gabriel Steg, MD; Laurence Joubin; James McCord, MD; William T. Abraham, MD; Judd E. Hollander, MD; Torbjorn Omland, MD; France Mentré; Peter A. McCullough, MD; Alan S. Maisel, MD; for the Breathing Not Properly Multinational Study Investigators
Author and Funding Information

Affiliations: *From the Department of Cardiology (Dr. Steg), Centre d’Investigation Clinique, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France; Department of Epidemiology, Biostatistics and Clinical Research (Drs. Joubin and Mentré), Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France; Heart and Vascular Institute (Dr. McCord), Detroit, MI; Division of Cardiovascular Medicine (Dr. Abraham), Davis Heart & Lung Research Institute, The Ohio State University, Columbus, OH; Department of Emergency Medicine (Dr. Hollander), University of Pennsylvania, Department of Emergency Medicine, Philadelphia, PA; Department of Medicine (Dr. Omland), Akershus University Hospital, University of Oslo, Oslo, Norway; Department of Medicine (Dr. Maisel), University of California, San Diego School of Medicine, Veterans Affairs Medical Center, San Diego, CA; and Division of Nutrition and Preventive Medicine (Dr. McCullough), William Beaumont Hospital, Royal Oak, MI.,  Additional investigators are listed in the Appendix.

Correspondence to: Philippe Gabriel Steg, MD, Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique–Hôpitaux de Paris, 46 rue Henri Huchard, 75877 Paris Cedex 18, France; e-mail: gabriel.steg@bch.ap-hop-paris.fr



Chest. 2005;128(1):21-29. doi:10.1378/chest.128.1.21
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Background: Echocardiography and B-type natriuretic peptide (BNP) are diagnostic tests for congestive heart failure (CHF), but an emergency diagnosis can be difficult.

Objective: To assess the diagnostic performance of BNP testing and echocardiographic assessment of left ventricular systolic function, separately and combined, for the identification of CHF in patients with acute dyspnea.

Design: Prospective, multinational, multicenter study.

Setting: Patients presenting to emergency departments in seven hospitals between June 1999 and December 2000.

Patients: A total of 1,586 patients with acute dyspnea.

Main outcome measures: Echocardiographic determination of ejection fraction (EF) and point-of care BNP measurement for the diagnosis of CHF.

Results: Seven hundred nine of the 1,586 patients underwent echocardiography; 492 patients (69.4%) had a final diagnosis of CHF. Patients with CHF were older (68.5 years vs 61.6 years, p < 0.0001), had a lower EF (39.5% vs 56.1%, p < 0.0001), and a higher BNP (683 pg/mL vs 129 pg/mL, p < 0.0001) than patients without CHF. Area under the receiver operating characteristic (ROC) curve for the diagnosis of CHF was significantly higher for BNP (0.89) than for EF (0.78; area under the ROC curve difference, 0.12; p < 0.0001). The sensitivity of BNP ≥ 100 pg/mL for the diagnosis of CHF was 89%, and specificity was 73%. Values for EF ≤ 50% had a sensitivity of 70% and a specificity of 77%. Multivariate logistic regression analysis showed that, in combination with clinical, ECG, and chest radiograph data, BNP ≥ 100 pg/mL and EF ≤ 50% remained independent predictors of CHF (odds ratios, 32.1 and 6.2, respectively). The proportions of patients who were correctly classified were 67% for BNP alone, 55% for EF alone, 82% for the two variables together, and 97.3% when clinical, ECG, and chest radiograph data were added.

Conclusion: BNP measurement was superior to two-dimensional echocardiographic determination of EF in identifying CHF, regardless of the threshold value. The two methods combined have marked additive diagnostic value.

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