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NT-proBNP in Risk Stratification of ED Patients With Syncope
Quick Takes
- The Canadian Syncope Risk Score (CSRS) is a validated clinical score for the risk stratification of patients presenting with syncope that can be easily calculated using routinely obtained clinical information.
- The addition of NT-proBNP to the CSRS did not improve risk discrimination for 30-day serious adverse events in patients presenting to the ED with syncope.
Study Questions:
Does measuring N-terminal pro–B-type natriuretic peptide (NT-proBNP) in the evaluation of patients presenting with syncope improve prediction of 30-day serious adverse events (SAE) over the Canadian Syncope Risk Score (CSRS)?
Methods:
The investigators measured NT-proBNP levels in 1,452 adult patients (ages ≥16 years) presenting within 4 hours of syncope to emergency departments (EDs) across six Canadian centers. The study excluded patients with prolonged loss of consciousness (>5 minutes); those with evident causes of syncope such as trauma, seizures, or intoxication; and those with mental status changes from baseline. The primary endpoint was 30-day SAEs (including index hospitalization), classified as death, cardiac and noncardiac SAEs with the requirement that the event be deemed related to the index syncope (for example, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage). Multivariable logistic regression modeling was used to determine whether adding NT-proBNP to the CSRS predictors improved model performance. CSRS is a validated risk score from the parent study that incorporates symptomatology, heart disease history, blood pressure, troponin testing, and electrocardiographic abnormalities.
Results:
A total of 152 patients (10.5%) had an SAE within 30 days including 14 deaths; 95 patients (6.5%) had an SAE identified during the index ED evaluation and 57 (3.9%) after the index ED visit disposition. Cardiac SAEs occurred in 109 patients (7.4%), of which 84 were arrhythmias. The median NT-proBNP values among study patients with SAEs, including arrhythmic or cardiac SAEs, were substantially higher than for those with no SAEs. While NT-proBNP was independently associated with SAEs, adding values to the CSRS predictors did not improve the prediction of SAEs or SAE subtypes by multiple measures, either overall or on the basis of whether they were identified during or after the index ED evaluation.
Conclusions:
The addition of NT-proBNP to CSRS does not improve the ability to predict risk of SAEs in patients presenting to the ED with syncope.
Perspective:
While its focus appears to be on NT-proBNP, what this well-designed and thorough analysis really highlights is that the CSRS is a remarkable predictor of 30-day SAEs in patients presenting with syncope. The area under the curve for the CSRS alone was 0.892—impressive for a risk score, making it difficult for NT-proBNP or any other biomarker to improve on. The CSRS is a validated risk score that can be calculated easily using routinely available information and standard testing in the evaluation of syncope. Addition of NT-proBNP to standard testing is likely to incur significant costs without clinically significant added benefit in short-term risk stratification of patients with syncope in the ED.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Hypertension
Keywords: Arrhythmias, Cardiac, Biomarkers, Blood Pressure, Electrocardiography, Emergency Service, Hospital, Hypertension, Pulmonary, Natriuretic Peptide, Brain, Peptide Fragments, Pulmonary Embolism, Primary Prevention, Risk Assessment, Subarachnoid Hemorrhage, Syncope, Troponin
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