Brain natriuretic peptide for Acute Shortness of breath Evaluation: a randomized comparison - BASEL
The goal of the BASEL trial was to evaluate whether rapid brain natriuretic peptide (BNP) testing results in shorter stays and reduced costs compared with clinical assessment of heart failure (HF) in patients presenting with dyspnea in the emergency department (ED).
Use of rapid BNP testing will reduce length of stay and costs compared with clinical assessment of HF in patients presenting to the ED with dyspnea.
Patients Screened: 665
Patients Enrolled: 452
Mean Follow Up: 30 days
Mean Patient Age: Mean age 70 years
Patient's age ≥18 years, and presenting with acute dyspnea not due to a traumatic cause
1) Time to discharge; and 2) total treatment costs
Time to treatment initiation; and ICU and hospital admissions
Patients with acute dyspnea presenting to the ED were randomized to clinical assessment (n=227) or rapid BNP testing (n=225). Using rapid BNP testing, which took 15 minutes, diagnosis of HF was defined as BNP >500 pg/ml, and no HF as BNP <100 pg/ml.
For patients with BNP 100-500 pg/ml, clinical judgment was used to determine the final assessment of HF. Patients were followed for 30 days for clinical outcomes.
Patients diagnosed with HF were treated with diuretic and angiotensin-converting enzyme (ACE) inhibitor as appropriate.
Patients enrolled in the trial were generally older (mean age 70 years), with many comorbidities (50% coronary artery disease; >50% hypertension). The primary endpoint of median time to discharge was shorter in the BNP arm (8.0 days vs. 11.0 days, p=0.001), as was median time to appropriate treatment (63 vs. 90 minutes, p=0.03).
The coprimary endpoint of total treatment costs was also significantly lower in the BNP arm ($5,410 vs. $7,264, p=0.006). Both intensive care unit (ICU) admissions (15% vs. 24%, p=0.014) and hospital admissions (75% vs. 85%, p=0.008) occurred less frequently in the BNP arm.
There was no difference in in-hospital mortality (6% vs. 9%, p=0.212) or 30-day death or HF hospitalizations. Final diagnosis in the BNP arm was CHF in 45% of patients and chronic obstructive pulmonary disease in 23% of patients; in the clinical assessment arm, it was 51% and 11%, respectively.
Among patients presenting to the ED with acute dyspnea, diagnosis of HF using the rapid BNP test was associated with reduced hospital length of stay and total treatment costs compared with clinical assessment. Appropriate and early diagnosis in patients presenting with dyspnea is important to ensure appropriate therapy.
While the BNP test was clearly an effective diagnosis tool in the present trial, there were several limitations, including the lack of blinding, which is inherent in the trial design, and the gray area of diagnosis with BNP results in the 100-500 pg/ml range. Additionally, timing of dyspnea onset may also influence BNP levels, and may deserve further exploration.
Mueller C, et al. Use of B-Type Natriuretic Peptide in the Evaluation and Management of Acute Dyspnea. N Engl J Med 2004;350:647-54.
Presented by Christian Mueller at the European Society of Cardiology Congress, Vienna, Austria, September 2003.
Keywords: Intensive Care Units, Hospital Mortality, Early Diagnosis, Comorbidity, Health Care Costs, Emergency Service, Hospital, Dyspnea, Length of Stay, Judgment, Pulmonary Disease, Chronic Obstructive, Heart Failure, Hypertension, Natriuretic Peptide, Brain
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