Mr. Cowie et al., VALUE OF NATRIURETIC PEPTIDES IN ASSESSMENT OF PATIENTS WITH POSSIBLENEW HEART-FAILURE IN PRIMARY-CARE, Lancet, 350(9088), 1997, pp. 1349-1353
Background The reliability of a clinical diagnosis of heart failure in
primary care is poor. Concentrations of natriuretic peptides are high
in heart failure. This population-based study examined the predictive
value of natriuretic peptides in patients with a new primary-care dia
gnosis of heart failure. Methods Concentrations of plasma atrial (ANP
and N-terminal ANP) and B-type (BNP) natriuretic peptides were measure
d by radioimmunoassay in 122 consecutive patients referred to a rapid-
access heart-failure clinic with a new primary-care diagnosis of heart
failure. On the basis of clinical assessment, chest radiography, and
transthoracic echocardiography, a panel of three cardiologists decided
that 35 (29%) patients met the case definition for new heart failure.
ANP and NT-ANP results were available for 117 patients (34 with heart
failure) and BNP results for 106 (29 with heart failure). Findings Ge
ometric mean concentrations of natriuretic peptides were much higher i
n patients with heart failure than in those with other diagnoses (29.2
vs 12.4 pmol/L for ANP; 63.9 vs 13.9 pmol/L for BNP; 1187 vs 410.6 pm
ol/L for NT-ANP; all p<0.001). At cut-off values chosen to give negati
ve predictive values for heart failure of 98% (ANP greater than or equ
al to 18.1 pmol/L, NT-ANP greater than or equal to 537.6 pmol/L, BNP g
reater than or equal to 22.2 pmol/L), the sensitivity, specificity, an
d positive predictive value for ANP were 97%, 72%, and 55%; for NT-ANP
97%, 66%, and 54%; and for BNP 97%, 84%, and 70%. Addition of ANP or
NT-ANP concentration or both did not improve the predictive power of a
logistic regression model containing BNP concentration alone. Interpr
etation In patients with symptoms suspected by a general practitioner
to be due to heart failure, plasma BNP concentration seems to be a use
ful indicator of which patients are likely to have heart failure and r
equire further clinical assessment.