B-Type Natriuretic Peptide in the Evaluation of Acute Dyspnea
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《新英格兰医药杂志》
To the Editor: Mueller et al. (Feb. 12 issue)1 conclude that rapid measurement of B-type natriuretic peptide in the emergency department improved the evaluation and treatment of patients with acute dyspnea. The authors state that echocardiography was "strongly recommended." However, they provide no data regarding left ventricular ejection fraction. About half of all patients with heart failure have preserved left ventricular systolic function,2 and there are important limitations in the use of B-type natriuretic peptide to diagnose heart failure with preserved systolic function, with considerable overlap in B-type natriuretic peptide levels in patients who have heart failure with preserved systolic function and in those without heart failure.3 Because hand-carried echocardiographic devices are being increasingly used,4 it would be of interest to know whether measurement of B-type natriuretic peptide also improves the evaluation of patients with preserved systolic function.
Manuel Martinez-Selles, M.D., Ph.D.
Hospital Gregorio Maranon
28007 Madrid, Spain
mmselles@navegalia.com
References
Mueller C, Scholer A, Laule-Kilian K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647-654.
Hogg K, Swedberg K, McMurray J. Heart failure with preserved left ventricular systolic function: epidemiology, clinical characteristics, and prognosis. J Am Coll Cardiol 2004;43:317-327.
Massie BM. Natriuretic peptide measurements for the diagnosis of "nonsystolic" heart failure: good news and bad. J Am Coll Cardiol 2003;41:2018-2021.
Roelandt JR. A personal ultrasound imager (ultrasound stethoscope): a revolution in the physical cardiac diagnosis! Eur Heart J 2002;23:523-527.
The authors reply: We fully agree with Dr. Martinez-Selles that the diagnosis of heart failure with preserved left ventricular systolic function is a clinical challenge. Because Doppler echocardiography was not performed at presentation in the majority of patients included in the B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study, we cannot definitely answer the question raised. However, there is indirect evidence from our study and others that the measurement of B-type natriuretic peptide improves the evaluation of patients who have heart failure with preserved left ventricular systolic function. First, heart failure with preserved left ventricular systolic function is particularly common in women and the elderly.1,2,3 Used in conjunction with other clinical information, the rapid measurement of B-type natriuretic peptide improved the treatment of the two groups of patients in the BASEL study. The median time to discharge was reduced from 10.0 days to 6.0 days (P=0.02) in women and from 11.0 days to 9.0 days in the elderly (P=0.03). Second, B-type natriuretic peptide levels were recently shown to be significantly higher in patients with dyspnea that was due to an adjudicated final diagnosis of heart failure with preserved left ventricular systolic function than in patients with noncardiac dyspnea (median value, 413 vs. 34 pg per milliliter).1
Christian Mueller, M.D.
André P. Perruchoud, M.D.
University Hospital Basel
CH-4031 Basel, Switzerland
chmueller@uhbs.ch
References
Maisel AS, McCord J, Nowak RM, et al. Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction: results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2003;41:2010-2017.
Logeart D, Saudubray C, Beyne P, et al. Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea. J Am Coll Cardiol 2002;40:1794-1800.
Lubien E, DeMaria A, Krishnaswamy P, et al. Utility of B-type natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002;105:595-601.
Manuel Martinez-Selles, M.D., Ph.D.
Hospital Gregorio Maranon
28007 Madrid, Spain
mmselles@navegalia.com
References
Mueller C, Scholer A, Laule-Kilian K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647-654.
Hogg K, Swedberg K, McMurray J. Heart failure with preserved left ventricular systolic function: epidemiology, clinical characteristics, and prognosis. J Am Coll Cardiol 2004;43:317-327.
Massie BM. Natriuretic peptide measurements for the diagnosis of "nonsystolic" heart failure: good news and bad. J Am Coll Cardiol 2003;41:2018-2021.
Roelandt JR. A personal ultrasound imager (ultrasound stethoscope): a revolution in the physical cardiac diagnosis! Eur Heart J 2002;23:523-527.
The authors reply: We fully agree with Dr. Martinez-Selles that the diagnosis of heart failure with preserved left ventricular systolic function is a clinical challenge. Because Doppler echocardiography was not performed at presentation in the majority of patients included in the B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study, we cannot definitely answer the question raised. However, there is indirect evidence from our study and others that the measurement of B-type natriuretic peptide improves the evaluation of patients who have heart failure with preserved left ventricular systolic function. First, heart failure with preserved left ventricular systolic function is particularly common in women and the elderly.1,2,3 Used in conjunction with other clinical information, the rapid measurement of B-type natriuretic peptide improved the treatment of the two groups of patients in the BASEL study. The median time to discharge was reduced from 10.0 days to 6.0 days (P=0.02) in women and from 11.0 days to 9.0 days in the elderly (P=0.03). Second, B-type natriuretic peptide levels were recently shown to be significantly higher in patients with dyspnea that was due to an adjudicated final diagnosis of heart failure with preserved left ventricular systolic function than in patients with noncardiac dyspnea (median value, 413 vs. 34 pg per milliliter).1
Christian Mueller, M.D.
André P. Perruchoud, M.D.
University Hospital Basel
CH-4031 Basel, Switzerland
chmueller@uhbs.ch
References
Maisel AS, McCord J, Nowak RM, et al. Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction: results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2003;41:2010-2017.
Logeart D, Saudubray C, Beyne P, et al. Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea. J Am Coll Cardiol 2002;40:1794-1800.
Lubien E, DeMaria A, Krishnaswamy P, et al. Utility of B-type natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002;105:595-601.