Mid-Regional Pro-Atrial Natriuretic Peptide and Pro-Adrenomedullin Testing for the Diagnostic and Prognostic Evaluation of Patients With Acute Dyspnoea

Study Questions:

Does mid-regional pro-atrial natriuretic peptide (MR-proANP) or adrenomedulin (MR-proADM) add diagnostic or prognostic value over amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients presenting to the emergency room with dyspnea?


This was a secondary analysis from the PRIDE study. NT-proBNP, MR-proANP and MR-proADM levels were measured in 560 patients presenting to an emergency room with dyspnea, and values were compared in those with (n = 180) and those without (n = 380) a diagnosis of acute decompensated heart failure (ADHF). The area under the receiver operating characteristic curves (AUCs) for the biomarkers’ ability to identify ADHF were calculated and then compared.


Compared with controls, patients with ADHF were older, were on more cardiac medications, displayed more signs of congestion, and had worse renal function. Patients with ADHF had significantly higher values (median [interquartile range]) of NT-proBNP (8136 [1689-9970] vs. 630 [47-830] pg/ml, respectively), MR-proANP (420 [205-558] vs. 97 [33-111] pmol/L, respectively) and MR-proADM (1.20 [0.60-1.6] vs. 0.50 [0.20-0.70] nmol/L, respectively) (all p < 0.001). The AUC for NT-proBNP, MR-proANP, and MR-proADM for identifying ADHF was 0.94, 0.90, and 0.80 (p < 0.001 for all AUC comparisons). There were 189 deaths over 4 years of follow-up. An age- and NT-proBNP-adjusted MR-proANP >194 pmol/L and MR-proADM >0.77 nmol/L was associated with 3.1 [1.9-5.3] and 1.5 [1.03-2.2] higher risk of death.


The authors concluded that MR-proANP and MR-proADM may be useful in assessing patients with ADHF.


Differentiating cardiac from noncardiac causes of dyspnea in the emergency room can be challenging, and BNPs have proven useful in this circumstance. B-type peptides are also prognostic of outcome in congestive heart failure. The authors presented data suggesting improved diagnostic discrimination and prognostication with the use of MR-proANP and (to a lesser extent) MR-proADM. The clinical utility of these markers will depend on their ease of use, affordability, and reproducibility of results. As with natriuretic peptides, the pitfalls of testing (impact of age, renal function, etc.) will also need to be determined.

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

Keywords: Prognosis, Natriuretic Peptides, Area Under Curve, Biological Markers, Heart Failure, Adrenomedullin

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