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Section 12: Evaluation and Management of Patients with Acute Journal of Cardiac Failure Vol. 16 No. 6 2010 Section 12: Evaluation and Management of Diagnosis Patients with Acute Decompensated Heart Failure Recommendation Overview 12.1 The diagnosis of acute decompensated HF should be based primarily on signs and symptoms. Acute decompensated heart failure (ADHF) has emerged (Strength of Evidence 5 C) as a major public health problem over the past 2 decades.1,2 Heart failure (HF) is the leading cause of hospitalization in When the diagnosis is uncertain, determination of patients older than 65 years of age. In-hospital mortality is plasma B-type natriuretic peptide (BNP) or N- excessive and readmission is disturbingly common, despite terminal pro-B-type natriuretic peptide (NT- advances in pharmacotherapy and device therapy for HF.3,4 proBNP) concentration is recommended in patients The large direct costs associated with caring for the 5 mil- being evaluated for dyspnea who have signs and lion Americans who have chronic HF are largely attribut- symptoms compatible with HF. (Strength of Evi- able to hospitalization.5 dence 5 A) Data from several studies have refined our understanding The natriuretic peptide concentration should not of the clinical characteristics of patients hospitalized with be interpreted in isolation, but in the context of 2,4e6 worsening HF. These studies demonstrate that the ma- all available clinical data bearing on the diagnosis jority of patients hospitalized with HF have evidence of of HF, and with the knowledge of cardiac and non- systemic hypertension on admission and commonly have cardiac factors that can raise or lower natriuretic preserved left ventricular ejection fraction (LVEF). Most peptide levels. hospitalized patients have significant volume overload, and congestive symptoms predominate. Patients with se- Background verely impaired systolic function, reduced blood pressure, Signs and Symptoms. The major symptoms of ADHF, and symptoms from poor end-organ perfusion are in the shortness of breath, congestion, and fatigue, are not specific distinct minority. Natural history studies have shown that for cardiac and circulatory failure.8 They may be caused by ADHF represents a period of high risk for patients, during other conditions which mimic HF, complicating the identi- which their likelihood of death and rehospitalization is sig- fication of patients with this syndrome. Various forms of nificantly greater than for a comparable period of chronic, pulmonary disease, including pneumonia, reactive airway but stable HF.6 disease and pulmonary embolus, may be especially difficult The clinical classification of patients with ADHF con- to differentiate clinically from HF.9 tinues to evolve and reflects ongoing changes in our under- 7 standing of the pathophysiology of this syndrome. Diagnostic Utility of Natriuretic Peptides. Two forms Worsening renal function, persistent neurohormonal activa- of natriuretic peptides, BNP and NT-proBNP,have been stud- tion, and progressive deterioration in myocardial function ied as aids to establish the diagnosis, estimate prognosis and all seem to play a role. Decompensation also commonly oc- monitor the response to therapy of patients with ADHF.10 curs without a fundamental worsening of underlying car- Measurement of these peptides has been proposed in cases diac structure or function. Failure to adhere to prescribed where the diagnosis of HF is uncertain. A large, multicenter medications related to inadequate financial resources, investigation, The Breathing Not Properly Study provides poor adherence, and lack of education or an inadequate important evidence supporting the clinical utility of plasma medical regimen may lead to hospitalization without a wors- BNP in the assessment of patients presenting with possible ening of underlying circulatory function. HF.11,12 This study evaluated 1586 patients seen in the emer- There is a paucity of controlled clinical trial data to de- gency department with the complaint of acute dyspnea who fine optimal treatment for patients with acute HF. The had prospective determination of BNP by bedside assay. Pa- few trials have focused primarily on symptom relief, not tients were assigned a probability of HF by physicians in the outcomes, and have mainly enrolled patients with reduced emergency department who were blinded to the results of the LVEF who were not hypertensive. Clinical studies to deter- BNP assay. The final determination of whether or not HF was mine the best care processes to achieve the multiple goals present was based on a review of the clinical data by 2 cardi- for patients admitted with ADHF are lacking. The recom- ologists also blinded to the BNP assay results. The sensitivity mendations in this section address the common therapeutic and specificity of BNP measurements for the diagnosis of HF dilemmas associated with the broad group of patients with were compared with the accuracy of an assessment based on ADHF using the best available evidence from clinical re- standard clinical examination. search and consensus expert opinion. The diagnostic accuracy of BNP, using a cutoff value of 100 pg/mL, was 83% relative to the assessment made by the independent cardiologists, whereas the negative predic- 1071-9164/$ - see front matter ! Ó 2010 Elsevier Inc. All rights reserved. tive value of BNP for HF when levels were 50 pg/mL doi:10.1016/j.cardfail.2010.05.021 was 96%. As expected, measurement of BNP appeared to e134 Heart Failure Practice Guideline HFSA e135 be most useful in patients with an intermediate probability !100 pg/mL, whereas levels of O500 pg/mL were consid- of HF. In these patients, a BNP cutoff value of 100 pg/mL ered diagnostic of ADHF. resulted in the correct classification 74% of the time. BNP Fewer patients were hospitalized or admitted to intensive was found to be predictive of HF when left ventricular (LV) care units in the BNP aided group compared with those function was depressed or preserved.13 Although BNP evaluated by standard clinical evaluation alone. The median levels were lower in patients with HF associated with pre- time to discharge was 8 days in the group with BNP mea- served LVEF, the cutoff value of 100 pg/mL still had a sen- sured versus 11 days in the control group (P 5 .001). Al- sitivity of 86% and a negative predictive value of 96%. though the data on outcomes from this study are not BNP levels increase with age, more so in older women, definitive and the hospital lengths of stay are not reflective so that cutoff of 100 pg/mL may not provide the same de- of practice patterns in the United States, making generaliz- gree of specificity for the diagnosis of HF, especially in el- ability problematic, they do not suggest that triage using derly women with dyspnea.14,15 BNP resulted in the under-treatment of patients truly at The clinical utility of NT-proBNP in the diagnosis of HF risk. The readmission rate for HF was similar in the 2 study was reported in the N-terminal Pro-BNP Investigation of groups and the mortality rate, while not reduced statisti- Dyspnea in the Emergency Department (PRIDE) study. cally, was lower in those patients with BNP determined. This study used NT-proBNP measurements in the emer- Larger randomized trials of this strategy are needed to as- gency department to rule out acute HF in 600 patients sess the impact of this approach on adverse outcomes asso- who presented with dyspnea.16 NT-proBNP results were ciated with admission for ADHF. correlated with a clinical diagnosis of acute HF as deter- mined by study physicians blinded to these measurements. Use of Natriuretic Peptides to Guide Therapy. A small The median NT-proBNP level among the 209 patients who number of studies have evaluated the use of BNP or NT- had acute HF (35%) was 4054 versus 131 pg/mL among proBNP to guide HF therapy. In the initial study, Troughton 390 patients who did not (65%, P !.001). NT-proBNP et al24 randomized 69 patients with symptomatic HF and levels increase with age so that the study investigators rec- LVEF !40% to a clinically guided treatment group and ommend NT-proBNP cut points of O450 pg/mL for pa- a group for whom therapy was increased to drive the ami- tients younger than 50 years of age and O900 pg/mL for noterminal portion of BNP (N-BNP) level to !200 pg/mL. patients age 50 years or older, both of which were highly In the N-BNP guided group there were fewer total cardio- sensitive and specific for HF in this study. For patients 75 vascular events (death, hospital admission, or HF decom- years or older, 1800 pg/mL is the recommended cutpoint pensation than in the clinical group (19 vs 54, p50$02). for NT-proBNP.17,18 At 6 months, 27% of patients in the N-BNP group and 53% in the clinical group had experienced a first cardiovas- Prognostic Role of Natriuretic Peptides. Although cular event (p50$034). Changes in LV function, quality of baseline BNP levels may correlate only modestly with pul- life, renal function, and adverse events were similar in both monary capillary wedge pressure (PCWP), changes in groups. In the Systolic Heart Failure Treatment Supported PCWP do correlate directly with changes in BNP concen- by BNP (STARS-BNP) study25 220 patients with New tration during hospitalization.19,20 The predischarge BNP York Heart Association (NYHA) Class II-III HF symptoms after treatment for acute HF appears to predict patients at on evidence-based medical therapy with angiotensin con- risk of early readmission or death following hospitalization verting enzyme (ACE) inhibitors and beta blockers were for HF.21,22 Although specific discharge cutoff values are randomized to a clinical care group and a group for still being defined, patients whose BNP increases during whom the goal was a BNP of !100 pg/mL.
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