Authors
Moe G, Howlett J, Januzzi, et al.
Title
N-Terminal Pro-B-Type Natriuretic Peptide Testing Improves the Management of Patients With Suspected Acute Heart Failure
References
Circulation. 2007;115:3103-3110
Background
Previous trials from countries with high healthcare resource use demonstrate the usefulness and cost-effectiveness of NT-proBNP for diagnosing and managing acute HF.
Purpose
To evaluate the clinical and economic impact of NT-proBNP testing vs. usual care for acute heart failure management in a universal health coverage system such as Canada.
Design
Randomized, prospective, double-blind trial 500 patients enrolled, >18 years of age, presented to emergency department (ED) with dyspnea thought to be of cardiac origin received standard diagnostic tests and usual clinical evaluation in ED, ED physician also asked to identify the likelihood (0-100%) of dyspnea caused by acute HF (without NT-proBNP results) patients then randomized to usual care or NT-proBNP guided management; NT-proBNP results provided to ED/physicians with information on how to interpret NT-proBNP initially by manufacturer data and then by results from PRIDE study. confirmation of diagnosis through hospital records (without NT-proBNP values) adjudicated by two cardiologists and classified into three groups: acute HF, not HF in a patient who had previous HF and/or LV dysfunction, or no incident or prevalence of HF
Exclusion Criteria
serum creatinine >250 µmol/L, acute MI, malignant disorders, dyspnea from clinically overt origins (pneumothorax and chest wall trauma)
Follow-Up
60 days
Treatment Regimen
conventional treatment (usual care group) vs. conventional treatment with NT-proBNP results (NT-proBNP group) NT-proBNP levels taken after enrollment and at 72 hours if hospitalized/admitted to guide management
Results
With NT-proBNP results: Median duration of initial ED visit reduced by 21%; 5.6 hours (NT-proBNP) vs. 6.3 hours (usual care), p=0.0309 Rehospitalization by 60 days reduced by 35%; 13% (NT-proBNP) vs. 20% (usual care), p=0.0463 Total direct medical costs (all ED visits, hospitalizations, and subsequent outpatient services) reduced by 15%; US$5180 (NT-proBNP) vs. US$6129 (usual care), p=0.0232 No statistically significant difference seen with initial hospitalization, hospital length of stay, initial ICU admission and length of stay, and initial and 60-day mortality Median NT-proBNP level 3697 pg/mL in confirmed diagnosis of HF vs. NT-proBNP level 212 pg/mL in dyspnea not due to HF (p≤0.00001) Adding NT-proBNP results to clinical judgement alone significantly improved performance of diagnosing HF; area under the receiver-operating characteristic curve increased from 0.83 to 0.90, p<0.0001
Summary
The addition of NT-proBNP guided management to conventional care for patients with acute HF is superior from a diagnostic and cost perspective as compared to conventional care alone in a universal health coverage system such as Canada.