Rapid Emergency Department Heart Failure Outpatient Trial - REDHOT

Description:

The goal of the study was to evaluate levels of B-type natriuretic peptide (BNP), perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes in patients presenting to the emergency department with shortness of breath.

Study Design

Patients Enrolled: 464
NYHA Class: Class II 29%; class III 45.0%; class IV 22.6%
Mean Follow Up: 90 days after discharge
Mean Patient Age: Median age 64 years
Female: 46

Patient Populations:

Patients age ≥18 years presenting to the emergency department with CHF and who received treatment or hospital admission for CHF, and BNP level >100 pg/ml

Exclusions:

Myocardial infarction or acute coronary syndrome with ST-segment deviation of ≥1 mm, renal failure requiring dialysis, or patients with a baseline BNP concentration of ≤100 pg/ml

Drug/Procedures Used:

Informed consent was obtained and a blood sample was then collected to measure the BNP level. Physicians were not told the numeric BNP level, but only whether or not the patient met the enrollment criteria of BNP >100 pg/ml. Patients then assessed New York Heart Association (NYHA) class and whether or not the patient would be admitted to the hospital.

Principal Findings:

History of CHF was reported in 76.5% of patients, with 37.5% of patients having a CHF-related hospital admission within the prior three months. Symptoms suggestive of CHF on presentation included pulmonary rales (74.8%), orthopnea (78.4%), paroxysmal nocturnal dyspnea (59.0%), and peripheral edema (75.0%).

Physician assessed NYHA class III or IV was observed in 67.8% of patients. Ninety percent of patients in the study were hospitalized, although initial emergency room physician intent to hospitalize was only 68.3%.

There was no difference in BNP levels between patients who were discharged home versus hospitalized (976 vs. 766 ng/ml, p=0.6). BNP levels were not significantly different by perceived NYHA class (median class I 634 pg/ml; class II 677 pg/ml; class III 822 pg/ml; class IV 1,050 pg/ml; p=0.124). The composite of all-cause mortality or re-admission or emergency room visit for CHF by 90 days was more frequent in patients discharged home versus hospitalized (42.4% vs. 25.9%, p=0.02).

BNP level >200 pg/ml was associated with composite event at 90 days (29% for BNP>200 pg/ml vs. 9% for BNP <200 pg/ml,="" p="0.006)." the="" median="" baseline="" bnp="" level="" was="" lower="" in="" patients="" who="" were="" alive="" at="" 90="" days="" compared="" with="" those="" who="" died="" (727="" vs.="" 1224="" pg/ml,=""><0.001). likewise,="" mortality="" trended="" higher="" in="" patients="" with="" bnp="">200 pg/ml (9% vs. 2%, p=0.142).

In a multivariate model that included NYHA class, intent to admit, actual admission, and BNP, only BNP remained significantly associated with 90-day death (p=0.001) or the composite endpoint (p=0.005). Emergency room physician intention to admit or discharge a patient was not associated with the composite event at 90 days in the multivariate model.

Interpretation:

Among patients presenting to the emergency department with shortness of breath, BNP levels were associated with 90-day death or CHF visit or admission. This association remained even in a multivariate model that adjusted for NYHA class, intent to admit, and actual admission. Emergency room physician intention to admit or discharge a patient was not associated with the composite event at 90 days in the multivariate model.

These data, along with the recent BASEL and Breathing Not Properly trials, suggest that BNP levels can aid in decision making and patient management that may effect clinical outcomes. Additionally, in the BASEL study, use of BNP in diagnosis was associated with reduced costs, due in large part to fewer admissions overall and to the intensive care unit.

References:

Maisel A, Hollander JE, Guss D, et al. Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT): a multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath. J Am Coll Cardiol 2004;44:1328-33.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Intention, Intensive Care Units, Decision Making, Heart Failure, Edema, Emergency Service, Hospital, Respiratory Sounds, Dyspnea, Informed Consent, Atrial Natriuretic Factor, Natriuretic Peptide, Brain


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