Prof. Dr. Christian MuellerUniversity Hospital Basel

Lisboa, June 13th, 2005

BNP in Acute DyspneaBNP in Acute Dyspnea

BNP in Acute DyspneaBNP in Acute Dyspnea

Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?

BNP in Acute DyspneaBNP in Acute Dyspnea

Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?

Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic uncertainty

Initial diagnosis correct in only 25-50% of pts.(Eur Heart J 1991;12:315, Lancet 1997;350:1349)

CHF false positive, CHF false negative

Heart or Lung?Heart or Lung?

0

50

100

150

200

250

300

350

400Pa

tient

(n)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

CHF Probability

uncertainuncertain

McCullough et al., Circulation 2002 106:416-422

Acute Dyspnea: Diagnostic uncertaintyAcute Dyspnea: Diagnostic uncertainty

BNP in Acute DyspneaBNP in Acute Dyspnea

Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?

Physiology

ANPBNP

CNPVolume ↑Pressure ↑

Maisel A, et al. N Engl J Med 2002;347:161-7.

Acute Dyspnea: BNP

McCullough et al., Circulation 2002 106:416-422

Acute Dyspnea: BNP ROC Curve

BNP in Acute DyspneaBNP in Acute Dyspnea

Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?

Supported by:Swiss National Science Foundation

Swiss Heart FoundationKrokus Foundation

University BaselBiosite

B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation

(BASEL) Study:

BASEL StudyBASEL Study

BNP group

Pts with acute dyspnea

Start of specific treatment

Control group

Further evaluation recommended: Echo & spirometry

randomized

History, physical exam, ECG, chest X-ray, blood tests, SaO2

Rapid BNP Test

Hospital Discharge

Tim

e to

dis

char

ge

30 day outcome

Study Algorithm

Base-Line Characteristics

Medical History – no. (%)

Smoking status – no. (%)

Sex – no. %

Age – yrCharacteristic

22 (10)19 (8)Deep-vein thrombosis56 (25)56 (25)Chronic kidney disease49 (22)40 (18)Stroke or PVD21 (9)15 (7)Depressive disorder

107 (47)119 (53)Any pulmonary disorder26 (11)20 (9)Other pulmonary disease13 (6)18 (8)Pulmonary embolism28 (12)30 (13)Pneumonia12 (5)17 (8)Asthma65 (29)75 (33)COPD56 (25)47 (21)Diabetes mellitus

124 (55)113 (50)Arterial hypertension112 (49)113 (50)Coronary artery disease68 (30)60 (27)Previous smoker45 (20)64 (28)Current smoker

114 (50)101 (45)Never smoked97 (43)93 (41)Female

130 (57)132 (59)Male21 - 9619 – 97Range

68.9 – 72.768.2 – 72.495% Confidence interval70.870.3Mean

Control Group (N=227)

BNP Group (N=225)

Results

BNP groupClinical group

Tim

e to

ade

quat

e th

erap

y (m

in)

100

90

80

70

60

50

40

30

20

10

0

63

90p=0.029

Time to adequate therapy

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

Time to Discharge

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

BNP groupClinical group

Hos

pita

l adm

issi

on (%

)

100

90

80

70

60

50

40

30

20

10

0

75

85

p=0.008

Hospital Admissions

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

BNP groupClinical group

Tota

l tre

atm

ent c

ost (

$)

8000

7000

6000

5000

4000

3000

2000

1000

0

5410

7264 p=0.006

-26%

Total Treatment Costs

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

BNP groupClinical group

In-H

ospi

tal M

orta

lity

(%)

10

9

8

7

6

5

4

3

2

1

0

6

9 p=0.212

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

In-Hospital Mortality

BASEL: Conclusion

Used in conjunction with other clinical information, rapid measurement of BNP in the ED improved the evaluation and treatment of pts with acute dyspnea and thereby reduced the time to discharge and the total cost of treatment.

Mueller Ch. et al. N Engl J Med 2004;350:647-54.

<100pg/ml* >400pg/ml100-400pg/ml

Clinical evaluationNo CHF CHF

Always in conjunction with other clinical information

No CHF CHF DiureticsNitratesACE-I*if Creatinine Clearance > 60ml/min

Interpretation of BNP Values in Patientspresenting with Acute Dyspnea

BNP in Acute DyspneaBNP in Acute Dyspnea

Do we really need it?How good is it?Can I do a better job in the ED with BNP?Does it also work in the elderly?

BASEL: Elderly

Mueller Ch et al. J Intern Med 2005; in press.

BASEL: Elderly

Mueller Ch et al. J Intern Med 2005; in press.

BASEL: Elderly

Mueller Ch et al. J Intern Med 2005; in press.

BASEL: Elderly

BNP in Acute DyspneaBNP in Acute Dyspnea

We really need it!It is good!We can do a better job in the ED with BNP!It also works in the elderly!