Multimarker strategy for risk prediction in patients presenting with acute dyspnea to the emergency department

Multimarker approaches improve risk prediction in patients presenting with acute coronary syndrome. We hypothesized that simultaneous assessment of B-type natriuretic peptide (BNP), cardiac troponin I (cTNI) and C-reactive protein (CRP) enables clinicians to better predict risk among patients with acute dyspnea presenting to the emergency department.

In this post-hoc analysis of the B-Type natriuretic peptide for Acute Shortness of Breath Evaluation (BASEL) study, above biomarkers were available in 305 patients. Death occurred in 123 (40%) patients within 24 months of follow-up. Using prospectively defined cut-off points (BNP>100 pg/mL; cTNI>0.8 microg/L; CRP>5 mg/L) and categorizing patients by the number of elevated cardiac biomarkers, the 24 months risk of death increased in proportion to the number of cardiac biomarkers elevated (p<0.001 for trend). Elevated biomarkers significantly predicted increased risk of death at 24 months of follow-up in univariate Cox models (BNP: RR 4.78, 95%CI: 2.51-9.14; p<0.001; cTNI: RR: 2.29, 95%CI: 1.61-3.26, p<0.001; CRP: RR 1.98, 95%CI: 1.28-3.08; p=0.002). Multivariable Cox regression analysis revealed that elevated levels of BNP (p<0.001) and TNI levels (p<0.002) indicated increased risk of death during long-term follow-up, while only a statistical trend was seen for elevated CRP (p=0.09). Comparably, risk of death or rehospitalization significantly increased with the number of elevated biomarkers.

Our findings suggest that a simple multimarker approach with simultaneous assessment of BNP, and cTNI demonstrates potential to assist clinicians in predicting risk of death and/or rehospitalization in patients presenting with acute dyspnea in the emergency department.