N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure

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.