Published online before print June 4, 2007, doi: 10.1161/CIRCULATIONAHA.106.666255
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(Circulation. 2007;115:3103-3110.)
© 2007 American Heart Association, Inc.
Heart Failure |
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
From the University of Toronto, St Michael’s Hospital, Toronto, Ontario, Canada (G.W.M.); McGill University, Montreal, Quebec, Canada (H.Z.); Harvard Medical School, Massachusetts General Hospital, Boston (J.L.J.); and Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada (J.H.).
Correspondence to Gordon W. Moe, MD, St. Michael’s Hospital, 30 Bond St, Toronto, Ontario, Canada, M5B1W8. E-mail moeg{at}smh.toronto.on.ca
Received October 25, 2006; accepted April 9, 2007.
Background— The diagnostic utility of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure has been documented. However, most of the data were derived from countries with high healthcare resource use, and randomized evidence for utility of NT-proBNP was lacking.
Methods and Results— We tested the hypothesis that NT-proBNP testing improves the management of patients presenting with dyspnea to emergency departments in Canada by prospectively comparing the clinical and economic impact of a randomized management strategy either guided by NT-proBNP results or without knowledge of NT-proBNP concentrations. Five hundred patients presenting with dyspnea to 7 emergency departments were studied. The median NT-proBNP level among the 230 subjects with a final diagnosis of heart failure was 3697 compared with 212 pg/mL in those without heart failure (P<0.00001). Knowledge of NT-proBNP results reduced the duration of ED visit by 21% (6.3 to 5.6 hours; P=0.031), the number of patients rehospitalized over 60 days by 35% (51 to 33; P=0.046), and direct medical costs of all ED visits, hospitalizations, and subsequent outpatient services (US $6129 to US $5180 per patient; P=0.023) over 60 days from enrollment. Adding NT-proBNP to clinical judgment enhanced the accuracy of a diagnosis; the area under the receiver-operating characteristic curve increased from 0.83 to 0.90 (P<0.00001).
Conclusions— In a universal health coverage system mandating judicious use of healthcare resources, inclusion of NT-proBNP testing improves the management of patients presenting to emergency departments with dyspnea through improved diagnosis, cost savings, and improvement in selected outcomes.
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