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Role of N-Terminal Pro-B-Type Natriuretic Peptide in Risk Stratification in Patients Presenting in the Emergency Room

¹ Department of Cardiology and ² Institute for Clinical Chemistry, Charité–University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany.
³ James Cook University, School of Public Health/Tropical Medicine, Townsville, Australia.
⁴ Klinikum Oldenburg, Institute for Laboratory Medicine and Microbiology, Oldenburg, Germany.
⁵ University Hospital Mainz, Institute for Clinical Chemistry and Laboratory Medicine and⁶ Medical Clinic II, Mainz, Germany.

^aAddress correspondence to this author at: Department of Cardiology, Charité–University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany. Fax 49-30-450-553927; e-mail martin.moeckel{at}charite.de.

Background: Natriuretic peptides are promising markers in diagnosing acute and chronic heart failure and assessing prognosis in these patients. Increasing routine use to unselected patients is challenged by false-positive results. The aims of this study were to assess (a) the distributions of N-terminal B-type natriuretic peptide (NT-proBNP) values in various diagnostic groups, (b) factors that influence NT-proBNP, and (c) the value of NT-proBNP in risk stratification in unselected emergency room (ER) patients.

Methods: NT-proBNP was measured in 876 unselected consecutive patients [mean (SD) age, 58 (18) years; 53% male] attending the ERs of 2 university hospitals and 1 community hospital. Diagnoses, age, sex, hemoglobin, creatinine (CREA), C-reactive protein (CRP), troponin T, and intensity of care were documented. In a subset consisting of all 417 patients at 1 center, in-hospital follow-up was completed with respect to a complicated clinical course, including intensive care treatment and death.

Results: NT-proBNP was significantly increased in patients with cardiac diagnoses or histories compared with patients with only pulmonary or other diagnoses. In patients with other diagnoses, NT-proBNP values increased significantly with the number of atherosclerotic risk factors (P = 0.044). Age, renal function, CRP, and to a much lesser extent, hemoglobin significantly influenced NT-proBNP values. The amount of care was positively correlated with NT-proBNP (P <0.001). Classification and regression tree analysis showed a superior impact of NT-proBNP for identification of high-risk patients.

Conclusions: NT-proBNP is a promising marker for identification of patients with structural heart disease in the ER and a suitable tool for risk stratification. Its use in the ER should be limited to clearly clinically defined patient groups at present to avoid a potential excess of additional diagnostic procedures in positive but asymptomatic patients.

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