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Utility of NT-proBNP as a rule-out test for left ventricular dysfunction in very old people with limiting dyspnoea:
Joanna Collerton1, Andrew Kingston, Fahad Yousaf
1Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK. joanna.collerton@ncl.ac.uk.
Insights
N-terminal pro-B-type natriuretic peptide (NT-proBNP) has limited utility for ruling out left ventricular dysfunction in very old adults with dyspnoea. Its effectiveness is poor for mild systolic dysfunction and diastolic dysfunction, with high rates of echocardiography use.
Area of Science:
- Cardiology
- Geriatric Medicine
- Diagnostic Biomarkers
Background:
- Guidelines recommend B-type natriuretic peptides for heart failure (HF) diagnosis, primarily to reduce echocardiography rates.
- Optimal cut-points for NT-proBNP in individuals aged 85 and older are not well-established.
- The utility of NT-proBNP in very elderly populations requires further investigation.
Purpose of the Study:
- To evaluate the diagnostic utility of NT-proBNP, alone and with myocardial infarction (MI) history, for ruling out left ventricular (LV) dysfunction in very old adults presenting with dyspnoea.
Main Methods:
- Cross-sectional analysis of a population-based sample in North-East England.
- Included 155 participants aged 87-89 with limiting dyspnoea.
- Assessed dyspnoea via questionnaire, performed domiciliary echocardiography for LV function grading, and measured NT-proBNP levels.
Main Results:
- NT-proBNP showed poor accuracy for detecting LV ejection fraction (LVEF) ≤50% (AUC 0.58) but good accuracy for LVEF ≤40% (AUC 0.80).
- Using the European Society of Cardiology (ESC) cut-point (125 ng/l) resulted in high echocardiography rates (88%) and false positives.
- Using the National Institute for Health and Care Excellence (NICE) cut-point (400 ng/l) reduced echocardiography rates but had poor exclusionary performance for LVEF ≤50% (NPV 68%).
Conclusions:
- High rates of echocardiography and poor exclusionary performance for mild systolic and diastolic dysfunction limit NT-proBNP's role in ruling out LV dysfunction in the very old.
- Adding a history of MI did not provide significant overall benefit in reducing missed cases or improving efficiency.
Background:
Guidelines advocate using B-type natriuretic peptides in the diagnostic work-up of suspected heart failure (HF). Their main role is to limit echocardiography rates by ruling out HF/LV dysfunction where peptide level is low. Recommended rule-out cut points vary between guidelines. The utility of B-type natriuretic peptides in the very old (85+) requires further investigation, with optimal cut points yet to be established. We examined NT-proBNP's utility, alone and in combination with history of myocardial infarction (MI), as a rule-out test for LV dysfunction in very old people with limiting dyspnoea.
Design:
Cross-sectional analysis.
Setting:
Population-based sample; North-East England.
Participants:
155 people (aged 87-89) with limiting dyspnoea.
Measures:
Dyspnoea assessed by questionnaire. Domiciliary echocardiography performed; LV systolic/diastolic function graded. NT-proBNP measured (Roche Diagnostics). Receiver operating characteristic analyses examined NT-proBNP's diagnostic accuracy for LV dysfunction.
Results:
AUC for LVEF less than or equal to 50% was poor (0.58, 95% CI 0.49-0.65), but good for LVEF less than or equal to 40% (0.80, 95% CI 0.73-0.86). At ESC cut point (125 ng/l), few cases of systolic dysfunction were missed (NPV 94-100%, depending on severity), but echocardiography (88%) and false positive rates (56-81 per 100 screened) were high. At NICE cut point (400 ng/l), echocardiography (51%) and false positive rates (33-45) were lower; exclusionary performance was good for LVEF less than or equal to 40% (1 case missed per 100 screened, 15% of cases; NPV 97%), but poor for LVEF less than or equal to 50% (16 cases missed per 100 screened, 45% of cases; NPV 68%). Incorporating isolated moderate/severe diastolic dysfunction into target condition increased the proportion of cases missed (lower NPV), whilst improving case detection. Incorporating MI history as an additional referral prompt slightly reduced the number of cases missed at expense of higher echocardiography and false positive rates.
Conclusions:
High echocardiography rates and poor exclusionary performance for mild degrees of systolic dysfunction and for diastolic dysfunction limit NT-proBNP's utility as a rule-out test for LV dysfunction in very old people with limiting dyspnoea. Incorporating MI history as an additional echocardiography prompt yields no overall benefit compared to using NT-proBNP level alone.
