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Meta-analysis: Effect of B-Type Natriuretic Peptide Testing on Clinical Outcomes in Patients With Acute Dyspnea in the Emergency Setting

Louisa L. Lam, MPH; Peter A. Cameron, MBBS, MD; Hans G. Schneider, MBBS, MD; Michael J. Abramson, MBBS, PhD; Christian Müller, MD; and Henry Krum, MBBS, PhD
[+] Article and Author Information

From Monash University, Melbourne, and Alfred Health, Prahran, Victoria, Australia, and University Hospital, Basel, Switzerland.


Acknowledgment: The authors sincerely thank Professor Gordon Moe, Dr. Joost H.W. Rutten, Ms. Hanna Zowall, Professor Judd Hollander, Professor Adam Singer, and Dr. Henry Thode for answering queries and providing supplementary data from their studies for this meta-analysis.

Potential Conflicts of Interest: Dr. Abramson: Board membership (money to institution): GlaxoSmithKline. Grants received (money to institution): Reckitts-Benckiser. Payment for lectures including service on speakers bureaus: Boehringer Ingelheim. Dr. Müller: Grants received (money to institution): Alere, Brahms, Siemens, and Abbott. Payment for lectures including service on speakers bureaus: Roche, Alere, Brahms, Siemens, and Abbott. Dr. Schneider: Payment for lectures including service on speakers bureaus: Amgen. Travel/accommodations/meeting expenses unrelated to activities listed: Australasian Association of Clinical Biochemists. Brahms, Siemens, and Abbott. Dr. Schneider: Payment for lectures including service on speakers bureaus: Amgen. Travel/accommodations/meeting expenses unrelated to activities listed: Australasian Association of Clinical Biochemists. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1390.

Requests for Single Reprints: Louisa L. Lam, MPH, Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Level 6, The Alfred Centre, 99 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia; e-mail, louisa.lam@monash.edu.

Current Author Addresses: Ms. Lam: Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Level 6, The Alfred Centre, 99 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia.

Dr. Cameron: Department of Epidemiology and Preventive Medicine, Research Emergency and Trauma Centre, Alfred Hospital, Level 6, The Alfred Centre, 99 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia.

Dr. Schneider: Alfred Pathology Service, 55 Commercial Road, PO Box 315, Prahran, Victoria 3181, Australia.

Dr. Abramson: Department of Epidemiology and Preventive Medicine, Level 6, The Alfred Centre, 99 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia.

Dr. Müller: Department of Internal Medicine, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.

Dr. Krum: Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Level 6, The Alfred Centre, 99 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia.

Author Contributions: Conception and design: L.L. Lam, P.A. Cameron, H.G. Schneider, H. Krum.

Analysis and interpretation of the data: L.L. Lam, P.A. Cameron, H.G. Schneider, M.J. Abramson, C. Müeller, H. Krum.

Drafting of the article: L.L. Lam, P.A. Cameron, H.G. Schneider, M.J. Abramson, C. Müeller, H. Krum.

Critical revision of the article for important intellectual content: L.L. Lam, P.A. Cameron, H.G. Schneider, M.J. Abramson, C. Müeller, H. Krum.

Final approval of the article: L.L. Lam, P.A. Cameron, H.G. Schneider, M.J. Abramson, C. Müeller, H. Krum.

Provision of study materials or patients: L.L. Lam, C. Müeller.

Statistical expertise: L.L. Lam, M.J. Abramson, C. Müeller.

Obtaining of funding: L.L. Lam.

Administrative, technical, or logistic support: L.L. Lam, P.A. Cameron, C. Müeller.

Collection and assembly of data: L.L. Lam, H.G. Schneider, M.J. Abramson, C. Müeller.


Ann Intern Med. 2010;153(11):728-735. doi:10.7326/0003-4819-153-11-201012070-00006
Text Size: A A A

Background: Although the accuracy of B-type natriuretic peptide (BNP) testing for diagnosing acute decompensated heart failure has been extensively evaluated, the effect of this test on clinical outcomes remains unclear.

Purpose: To investigate whether BNP testing of patients presenting with acute dyspnea in the emergency department leads to fewer admissions, shorter length of stay, and improved short-term survival compared with usual care without BNP testing.

Data Sources: Two reviewers searched Ovid MEDLINE and EMBASE, without language restrictions, to identify pertinent studies published from January 1996 to July 2010.

Study Selection: Randomized, controlled trials that compared BNP testing to diagnose heart failure with routine care in patients presenting with acute dyspnea and information about 1 or more of the following outcomes: mortality, admission, or length of hospital stay.

Data Extraction: Two authors independently reviewed articles, extracted data, and assessed quality and risk for bias of studies.

Data Synthesis: Five trials conducted in 5 countries and involving 2513 patients met inclusion criteria. Study settings had differing emergency department staffing models and used various BNP testing protocols. The pooled estimate of effect of BNP testing on all-cause mortality had wide confidence bounds and was inconclusive (odds ratio, 0.96 [95% CI, 0.65 to 1.41]). Admission rates decreased in the tested group compared with the control group (odds ratio, 0.82 [CI, 0.67 to 1.01]), although this finding was not statistically significant. Length of hospital and critical care unit stay were both modestly reduced in the tested group compared with the control group, with a mean difference of −1.22 days (CI, −2.31 to −0.14 day) and −0.56 day (CI, −1.06 to −0.05 day), respectively.

Limitation: Few relevant trials were studied. Patients included in the trials and the settings in which trials were conducted were heterogeneous.

Conclusion: B-type natriuretic peptide testing in the emergency department for patients presenting with acute dyspnea decreased length hospital of stay by about 1 day and possibly reduced admission rates but did not conclusively affect hospital mortality rates.

Primary Funding Source: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Figures

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Figure 1.
Summary of evidence search and selection.

* Articles were substudies of reference (21). One article was a substudy of reference (26).

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Figure 2.
Risk for bias in included studies.

Risk for bias summary: review authors' judgments about each risk for bias item for each included study.

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Figure 3.
Hospital admission rate.

BNP = B-type natriuretic peptide; M-H = Mantel–Haenszel.

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Figure 4.
Length of hospital and critical care unit stay.

BNP = B-type natriuretic peptide; IV = inverse variance.

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The Underestimated Benefits of B-Type Natriuretic Peptide Testing at Emergency Department
Posted on December 7, 2010
Gen-Min Lin
Hualien-Armed Forces General Hospital, Hualien, Taiwan
Conflict of Interest: None Declared

To the Editor: We appreciate the meta-analysis by Lam et al. which reported that B-type natriuretic peptide testing in the emergency department for patients presenting with acute dyspnea decreased length of hospital stay by about 1 day and possibly reduced admission rates but did not conclusively affect hospital mortality rates.1 Actually, the benefits for the reductions of hospital stay and in-hospital mortality may be underestimated by the reduction of admission rates in the tested participants. In other words, the untested patients with unreconized normal B-type natriuretic peptide levels may be admitted and discahrged quickly. After adjusment by the reduced admission rate (0.82) in the tested group, the odds ratio of mortality rate (0.96) should be corrected to 0.79 and the length of hospital stay is further shortened. Accordingly, B-type natriuretic peptide testing in the emergency department may be important for the cost- effectiveness and the possible benefits of death reductions

Reference

1. Lam LL, Cameron PA, Schneider HG, et al. Meta-analysis: Effect of B- Type Natriuretic Peptide Testing on Clinical Outcomes in Patients With Acute Dyspnea in the Emergency Setting. Ann Inten Med 2010; 153: 728-735.

Conflict of Interest:

None declared

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