Heart failure
Usefulness of B-Type Natriuretic Peptide and Cardiac Troponin Levels to Predict In-Hospital Mortality from ADHERE

https://doi.org/10.1016/j.amjcard.2007.07.066Get rights and content

B-type natriuretic peptide (BNP) and cardiac troponin (Tn) I or T have been demonstrated to provide prognostic information in patients with acute coronary syndromes. Whether admission BNP and Tn levels provide additive prognostic value in acutely decompensated heart failure (HF) has not been well studied. Hospitalizations for HF from April 2003 to December 2004 entered into ADHERE were analyzed. BNP assessment on admission was performed in 48,629 (63%) of 77,467 hospitalization episodes. Tn assessment was performed in 42,636 (88%) of these episodes. In-hospital mortality was assessed using logistic regression models adjusted for age, gender, blood urea nitrogen, systolic blood pressure, creatinine, sodium, pulse, and dyspnea at rest. Median BNP was 840 pg/ml (interquartile range 430 to 1,730). Tn was increased in 2,370 (5.6%) of 42,636 HF episodes. BNP above the median and increased Tn were associated with significantly increased risk of in-hospital mortality (odds ratios [OR] 2.09 and 2.41 respectively, each p value <0.0001). Mortality was 10.2% in patients with BNP ≥840/Tn increased compared with 2.2% with BNP <840/Tn not increased (OR 5.10, p <0.0001). After covariate adjustment, mortality risk remained significantly increased with BNP ≥840/Tn not increased (adjusted OR 1.56, 95% confidence interval 1.40 to 1.79, p <0.0001), BNP <840/Tn increased (adjusted OR 1.69, 95% confidence interval 1.17 to 2.45, p = 0.006), and BNP ≥840/Tn increased (adjusted OR 3.00, 95% confidence interval 2.47 to 3.66, p <0.0001). Admission BNP and cardiac Tn levels are significant, independent predictors of in-hospital mortality in acutely decompensated HF. Patients with BNP levels ≥840 pg/ml and increased Tn levels are at particularly high risk for mortality. In conclusion, a multimarker strategy for the assessment of patients hospitalized with HF adds incremental prognostic information.

Section snippets

Methods

ADHERE data were used to determine the risk associated with BNP levels and cardiac TnI or TnT assessed as part of routine clinical practice. The design, methods, and patient characteristics in ADHERE have been described previously.16 This registry collects detailed hospitalization data from initial presentation in the hospital or emergency department until discharge, transfer, or in-hospital death.16, 17 Medical records are reviewed at participating study sites and data from consecutive

Results

From April 2003 through December 2004, there were 48,629 of 77,467 patient episodes (63%) in 191 hospitals that had BNP assessment within 24 hours of presentation. BNP testing rate increased over time from 51.2% in the second quarter of 2003 to 75.4% in the fourth quarter of 2004 (p <0.0001). TnI or TnT assessment was performed in 42,636 (88%) of these episodes. BNP and Tn results were thus available in 42,636 of 77,467 patient episodes (55%).

Median BNP was 840 pg/ml (interquartile range 430 to

Discussion

This analysis of >42,000 acute decompensated HF hospitalizations in a broad population of patients from all regions of the country demonstrates that Tn and BNP on admission were predictive of in-hospital mortality. Overall, in-hospital mortality was 3.6%, but this mortality risk varied approximately fivefold based on a patient’s initial Tn and BNP levels. BNP and Tn levels provide risk prediction independently of numerous other clinical and laboratory variables previously demonstrated to be

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    ADHERE and this study were funded by Scios, Inc., Mountain View, California. ADHERE is registered at www.clinicaltrials.gov (NCT00366639).

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