 |
|
A Systematic Review of the Diagnostic Accuracy of Natriuretic Peptides for Heart Failure
Jenny A. Doust, BMBS, FRACGP;
Paul P. Glasziou, FRACGP, PhD;
Eva Pietrzak, PhD;
Annette J. Dobson, PhD
Arch Intern Med. 2004;164:1978-1984.
ABSTRACT
| |
Background The diagnosis of heart failure is difficult, with both overdiagnosis and underdiagnosis occurring commonly in practice. Natriuretic peptides have been proposed as a possible test for assisting diagnosis. We assessed the diagnostic accuracy of brain natriuretic peptide (BNP), including a comparison with atrial natriuretic peptide (ANP).
Methods Electronic searches were conducted of MEDLINE and EMBASE from January 1994 to December 2002 and handsearches of reference lists of included studies. We included studies that assessed the diagnostic accuracy of BNP against echocardiographic or clinical criteria or that compared the diagnostic accuracy of BNP with ANP. Two reviewers assessed studies for inclusion and quality and extracted the relevant data. A meta-analysis was performed by pooling the diagnostic odds ratios for studies that used a common reference standard.
Results Twenty studies were included. For the 8 studies (n = 4086) that measured BNP against the criterion of left ventricular ejection fraction of 40% or less (or equivalent), the pooled diagnostic odds ratio was 11.6 (95% confidence interval, 8.4-16.1). The pooled diagnostic odds ratio was greater, 30.9 (95% confidence interval, 27.0-35.4), in the 7 studies (n = 2374) that measured BNP against clinical criteria (generally a consensus view using all other clinical information). The diagnostic odds ratio was similar in studies conducted in general practice and in hospital settings. Three studies compared BNP with N-terminal–ANP, a precursor form of ANP, and pooling of the results of these studies showed BNP to be a more accurate marker of heart failure than NT-ANP.
Conclusions Brain natriuretic peptide is an accurate marker of heart failure. Use of a cutoff value of 15 pmol/L achieves high sensitivity, and BNP values below this exclude heart failure in patients in whom disease is suspected. As the diagnostic odds ratio for BNP is greater when assessed against clinical criteria than against left ejection fraction alone, BNP may also be detecting patients with "diastolic" heart failure.
INTRODUCTION
The rising prevalence1 and cost2 of heart failure and increasing treatment options3 have made the accurate diagnosis of heart failure increasingly important. Heart failure is difficult to diagnose correctly, with both overdiagnosis and underdiagnosis occurring commonly in practice. Studies that have investigated the prevalence of echocardiographic abnormalities in populations have found that at least half of patients with significant left ventricular dysfunction on echocardiogram are asymptomatic or have not previously been diagnosed as having heart failure.4-5 In the Rotterdam Study, a population-based cohort study of chronic disease in persons aged 55 years or older, 60% of people with a left ventricular ejection fraction of 25% or less were asymptomatic.6 Conversely, patients with signs and symptoms suggestive of heart failure are frequently found not to have the disease when measured against more objective criteria. One study investigated all suspected new cases of heart failure referred by general practitioners during a 15-month period against a consensus decision of 3 cardiologists, including the results of further investigations such as echocardiogram. Against this definition, only 30% of the referred patients had heart failure.7
The diagnosis of heart failure is hindered if access to further investigations is limited. It is especially difficult for general practitioners, who are faced with many patients at high risk of the disease and who must make decisions regarding appropriate further investigation, treatment, and referral. General practitioners in the United Kingdom identified a lack of confidence in establishing an accurate diagnosis as a major barrier to treating patients with heart failure.8 Both in general practice and in emergency departments, many patients presenting with symptoms of heart failure have comorbidities that may also account for their symptoms.
The myocardium releases neuropeptides that serve to maintain circulatory homeostasis. A-type (atrial) natriuretic peptide (ANP) is secreted primarily by the atrial myocardium in response to dilation, and B-type (brain) natriuretic peptide (BNP) is secreted by the ventricles in response to end-diastolic pressure and volume.9 Both ANP and BNP and various precursor forms, such as N-terminal (NT)–ANP, have been evaluated as potential diagnostic tests for heart failure. We performed a systematic review of the literature and meta-analysis to quantify the diagnostic accuracy of BNP for the diagnosis of heart failure and to compare it with the diagnostic accuracy of ANP.
METHODS
We searched MEDLINE and EMBASE from January 1994 to December 2002 for all studies of the diagnostic accuracy of natriuretic peptides for heart failure. The search strategy for MEDLINE is available fom the authors. The reference lists of primary studies and review articles identified by the search were checked for further relevant studies. We included all studies that compared the diagnostic accuracy of natriuretic peptides against a reference standard and where the results were reported so that a 2 x 2 table of results could be constructed. Several studies that examined the association between natriuretic peptide levels and heart failure were excluded, as were case-control studies. Six studies involving overlapping or duplicate cohorts of patients were also excluded.
Two reviewers (J.A.D. and E.P.) assessed independently the quality of each study and extracted data. Disagreements were resolved by consensus or by consulting a third reviewer (P.P.G.). Each reviewer extracted the data to construct a 2 x 2 table for every cutoff point that was published in each study. To allow for changes in the cutoff points used both within and between studies, the diagnostic odds ratio (DOR) = {[Sensitivity/(1 – Sensitivity)]/[(1 – Specificity)/Specificity]} was chosen as the measure of diagnostic accuracy. If there was more than one cutoff point within a study, we took the average of the DORs for each cutoff point. This was done by taking the average of the natural logarithm of the odds ratio and the average of the variance of the natural logarithm of the odds ratio for cutoff points within a study (unweighted, because the study size was the same in each case), and back-transforming to calculate the average DOR and confidence interval (CI). The studies were grouped so that a DOR was calculated against each reference standard, using a DerSimonian and Laird random-effects model10 on a logarithmic scale with a corresponding test of heterogeneity. Where possible, the positive and negative likelihood ratios were calculated where studies had used similar cutoff levels and the same reference standard, again using a DerSimonian and Laird random-effects model.
An unweighted least-squares regression model using the method of Moses et al11 was used to assess whether the odds ratio was independent of the cutoff point. The model is D = a + bS, where the difference D is defined as the logit true-positive rate minus the logit false-positive rate, which is equivalent to the log of the DOR, and the sum S is defined as the logit true-positive rate plus the logit false-positive rate, which is a measure in the variation of the threshold. For each study, the values D and S were calculated, then the regression line was fitted. An unpaired, 2-tailed t test was used to see whether the slope of the line was significantly different from zero, which would imply that the overall diagnostic accuracy of the test varied with the cutoff point used.
In studies that compared the diagnostic accuracy of BNP with ANP, the estimated area under the curve (AUC) for each study was pooled by an inverse variance method. The diagnostic accuracy of the 2 natriuretic peptides was assessed by comparing the difference between the 2 pooled AUCs divided by the variance of the AUC,
with a standard normal distribution.12 This method will underestimate the true measure of difference, as the data are derived from paired study designs, but would require individual patient data to estimate the true difference.
RESULTS
We identified 20 studies with published data that met the inclusion criteria of the review13-31 (Table 1).
|
|
|
|
Table 1. Accuracy of Brain Natriuretic Peptides for Diagnosis of Heart Failure by Diagnostic Standard
|
|
|
The quality of the studies was generally high, with most satisfying the following criteria (with the number reporting each criterion in parentheses): (1) patients were a consecutive series or random sample (15/20); (2) the index and reference tests were assessed independently and blinded to the other test result (15/20); (3) all patients received both tests (16/20); (4) the methods for performing both tests were described (20/20); (5) the characteristics of the study population were described (20/20); and (6) there was no time delay between the measurement of the 2 tests (14/20). The details of the first 2 quality criteria are also shown in Table 1.
The DORs of BNP against each reference standard are shown in Figure 1. In the 8 studies that measured BNP against a left ventricular ejection fraction of 40% or less, the pooled DOR was 11.6 (95% CI, 8.4-16.1). The results of the studies were consistent, with no evidence of heterogeneity. With less restrictive echocardiographic criteria, the DOR was smaller and the degree of heterogeneity greater, as would be expected with studies with a more imperfect reference standard and varying levels for the reference threshold. Using a reference standard of left ventricular ejection fraction of 40% or less and pooling studies that used a cutoff between 14 and 19 pmol/L gave an estimated positive likelihood ratio of 4.1 (95% CI, 2.6-6.6) and a negative likelihood ratio of 0.35 (95% CI, 0.17-0.72).
|
|
|
Figure 1. Pooled diagnostic odds ratio (DOR) (95% confidence interval), with  2 test for homogeneity. BNP indicates brain natriuretic peptide; LVEF, left ventricular ejection fraction; and MI, myocardial infarction. The abscissa is on a log scale.
|
|
|
In the 7 studies that measured BNP against a consensus clinical opinion, generally using all other diagnostic information available, the DOR was greater (30.9; 95% CI, 27.0-35.4). The degree of heterogeneity between the studies was also low. This result suggests that BNP and clinical diagnosis are in greater agreement than BNP and left ventricular function, assuming no other differences between the 2 groups of studies. The results were heavily weighted by the results of one study, however, the Breathing Not Properly study reported by Maisel et al in 2002.29 This was a multicenter study with 1586 patients that assessed the diagnostic accuracy of BNP in patients presenting to 7 emergency departments against the diagnosis by 2 cardiologists who had access to all clinical data, including results of radiology and echocardiography. In this study, using a cutoff level of 14.4 pmol/L, the positive likelihood ratio was 2.6 (95% CI, 2.3-2.8) and the negative likelihood ratio was 0.05 (95% CI, 0.03-0.07).
In the 2 studies that measured BNP against echocardiographic criteria for both systolic and diastolic heart failure, the DOR (37.7; 95% CI, 5.9-237.2) was again greater than in studies that measured only systolic function, but the results of the 2 studies were different.
Of the studies that investigated BNP vs systolic or systolic plus diastolic function, 7 studies were conducted in general practice or community settings and 11 were conducted in hospital settings. The DOR from the studies in the 2 settings showed similar results (Figure 1). As these groups of studies pool results using different reference standards, they both showed highly statistically significant levels of heterogeneity.
The data for the individual studies and the curve derived from the pooled odds ratio for studies comparing BNP with a reference standard of left ventricular ejection fraction of 40% or less are shown in Figure 2. This figure illustrates the variation seen between studies in terms of the sensitivity and specificity for various cutoff points. The Moses et al11 regression model was estimated for studies that used a reference standard of left ventricular ejection fraction of 40% or less and clinical diagnosis. These both showed a significant negative relationship, implying that the diagnostic accuracy decreases with increases in the cutoff.32
|
|
|
|
Figure 2. Estimates of diagnostic accuracy from individual studies that measured brain natriuretic peptide vs left ventricular ejection fraction of 40% or less plotted in receiver operating characteristic curve space, ie, sensitivity vs 1 – specificity. Results from different cutoff points within the same study are joined, with the numbers next to the circles being the cutoff point (in picomoles per liter). The pooled diagnostic odds ratio (DOR) is used to estimate the plot of summary receiver operating characteristic curve and the area under the curve (AUC). The area of the circles is proportional to the size of the studies.
|
|
|
Six studies compared the diagnostic accuracy of BNP and ANP. The results of these studies are shown in Table 2.7, 13, 15, 17 The BNP was generally more accurate as a diagnostic marker of heart failure than ANP. The AUCs for the receiver operating characteristic curves were available for 3 studies that compared NT-ANP with BNP. The pooled AUC for the 3 studies that compared NT-ANP with echocardiogram was 0.78 (95% CI, 0.73-0.84). The pooled AUC for BNP in the same studies was 0.84 (95% CI, 0.80-0.89). The test statistic for the difference between the 2 measures shows a marginally statistically significant difference with a z score of 1.66 (P = .048). This calculation underestimates the true significance because the original data were from paired study designs.
|
|
|
|
Table 2. Studies That Compared BNP and ANP
|
|
|
COMMENT
The results of these 20 studies show that BNP is accurate in the diagnosis of heart failure. However, there is considerable variation in the estimates of diagnostic accuracy between studies, and this variation does not seem to be accounted for by differences in the clinical setting or the type of test used. It would be helpful to understand the sources of this variation before recommending the routine clinical use of the test.
Measurement of BNP is cheaper and is potentially more accessible than echocardiography. Results of BNP testing can be obtained within 20 minutes of blood collection.33-34 As echocardiography provides additional information that may be important in the clinical treatment of patients with heart failure, the most likely use of BNP will be in the ambulatory care setting to determine which patients require further testing with echocardiogram. The cutoff level will therefore need to be sufficiently low that patients who have heart failure are not excluded from further testing. In the Breathing Not Properly study, combining BNP with clinical judgment improved diagnostic accuracy across the entire range of diagnostic certainty. Even when the clinician had a high degree of certainty in his or her diagnosis, combining this judgment with the BNP result improved diagnostic accuracy.35
Measurement of BNP may play a role in the diagnosis of patients with diastolic heart failure. The diagnostic accuracy of BNP was greater when the definition of disease used as the reference standard included patients who were diagnosed as having heart failure but who had "preserved left ventricular systolic dysfunction." This raises the question of whether BNP could be a better marker of disease, prognosis, and response to treatment than left ventricular function and whether comparison with echocardiographic criteria of left ventricular function may, in fact, be a comparison with a "silver" standard. To date, almost all of the trials of treatment for heart failure have been conducted in patients with impaired left ventricular function.36-38 Although there is a group of patients who have heart failure with preserved left ventricular systolic function (diastolic heart failure), it is not clear how these patients could be identified or how patients chosen by alternative criteria would respond to treatment.39
Using a cutoff value of 15 pmol/L achieves high sensitivity, and BNP values below this are able to exclude heart failure in patients in whom disease is suspected. Early studies have also shown a potential role for BNP in monitoring the response to treatment.40-41 Future research will need to further define BNP's role in clinical management, and to determine whether it is better at predicting prognosis and response to treatment than echocardiography.
AUTHOR INFORMATION
Correspondence: Jenny A. Doust, BMBS, FRACGP, Centre for General Practice, School of Population Health, University of Queensland, Herston Road, Herston Qld 4006, Australia (j.doust{at}uq.edu.au).
Accepted for publication March 23, 2004.
We thank Jon Deeks, Senior Medical Statistician, Centre for Statistics in Medicine, Oxford, England, for comments on an earlier draft of this article.
From the Centre for General Practice (Drs Doust, Glasziou, and Pietrzak) and Division of Epidemiology and Social Medicine (Dr Dobson), School of Population Health, University of Queensland, Herston, Australia. The authors have no relevant financial interest in this article.
REFERENCES
1. Davies M, Hobbs F, Davis R, et al. Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet. 2001;358:439-444.
FULL TEXT
|
ISI
| PUBMED
2. Redfield M. Heart failure: an epidemic of uncertain proportions. N Engl J Med. 2002;347:1442-1444.
FREE FULL TEXT
3. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA. 2003;289:194-202.
FREE FULL TEXT
4. Morgan S, Smith H, Simpson I, et al. Prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in general practice setting: cross sectional survey. BMJ. 1999;318:368-372.
FREE FULL TEXT
5. McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet. 1997;350:829-833.
FULL TEXT
|
ISI
| PUBMED
6. Mosterd A, Hoes AW, de Bruyne MC, et al. Prevalence of heart failure and left ventricular dysfunction in the general population: the Rotterdam Study. Eur Heart J. 1999;20:447-455.
FREE FULL TEXT
7. Cowie MR, Struthers AD, Wood DA, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet. 1997;350:1349-1353.
FULL TEXT
|
ISI
| PUBMED
8. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ. 2003;326:196.
FREE FULL TEXT
9. Baughman KL. B-type natriuretic peptide: a window to the heart. N Engl J Med. 2002;347:158-159.
FREE FULL TEXT
10. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177-188.
FULL TEXT
|
ISI
| PUBMED
11. Moses LE, Shapiro D, Littenberg B. Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Stat Med. 1993;12:1293-1316.
ISI
| PUBMED
12. Pepe M. The Statistical Evaluation of Medical Tests for Classification and Prediction. Oxford, England: Oxford University Press; 2003:108.
13. McDonagh TA, Robb SD, Murdoch DR, et al. Biochemical detection of left-ventricular systolic dysfunction. Lancet. 1998;351:9-13.
FULL TEXT
|
ISI
| PUBMED
14. Bettencourt P, Ferreira A, Pardal-Oliveira N, et al. Clinical significance of brain natriuretic peptide in patients with postmyocardial infarction. Clin Cardiol. 2000;23:921-927.
15. Choy AM, Darbar D, Lang CC, et al. Detection of left ventricular dysfunction after acute myocardial infarction: comparison of clinical, echocardiographic, and neurohormonal methods. Br Heart J. 1994;72:16-22.
FREE FULL TEXT
16. Valli N, Georges A, Corcuff JB, Barat JL, Bordenave L. Assessment of brain natriuretic peptide in patients with suspected heart failure: comparison with radionuclide ventriculography data. Clin Chim Acta. 2001;306:19-26.
FULL TEXT
|
ISI
| PUBMED
17. Vasan RS, Benjamin EJ, Larson MG, et al. Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: the Framingham Heart Study. JAMA. 2002;288:1252-1259.
FREE FULL TEXT
18. Hutcheon SD, Gillespie ND, Struthers AD, McMurdo ME. B-type natriuretic peptide in the diagnosis of cardiac disease in elderly day hospital patients. Age Ageing. 2002;31:295-301.
FREE FULL TEXT
19. Landray MJ, Lehman R, Arnold I. Measuring brain natriuretic peptide in suspected left ventricular systolic dysfunction in general practice: cross-sectional study. BMJ. 2000;320:985-986.
FREE FULL TEXT
20. Smith H, Pickering RM, Struthers A, Simpson I, Mant D. Biochemical diagnosis of ventricular dysfunction in elderly patients in general practice: observational study. BMJ. 2000;320:906-908.
FREE FULL TEXT
21. McGeoch G, Lainchbury J, Town GI, Toop L, Espiner E, Richards AM. Plasma brain natriuretic peptide after long-term treatment for heart failure in general practice. Eur J Heart Fail. 2002;4:479-483.
FREE FULL TEXT
22. Yamamoto K, Burnett JC Jr, Bermudez EA, Jougasaki M, Bailey KR, Redfield MM. Clinical criteria and biochemical markers for the detection of systolic dysfunction. J Card Fail. 2000;6:194-200.
FULL TEXT
|
ISI
| PUBMED
23. Yamamoto K, Burnett JC Jr, Jougasaki M, et al. Superiority of brain natriuretic peptide as a hormonal marker of ventricular systolic and diastolic dysfunction and ventricular hypertrophy. Hypertension. 1996;28:988-994.
FREE FULL TEXT
24. Luchner A, Burnett JC Jr, Jougasaki M, et al. Evaluation of brain natriuretic peptide as marker of left ventricular dysfunction and hypertrophy in the population. J Hypertens. 2000;18:1121-1128.
FULL TEXT
|
ISI
| PUBMED
25. Krishnaswamy P, Lubien E, Clopton P, et al. Utility of B-natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med. 2001;111:274-279.
FULL TEXT
|
ISI
| PUBMED
26. Osca J, Quesada A, Arnau MA, et al. Brain natriuretic peptide: diagnostic value in heart failure [in Spanish]. Rev Esp Cardiol. 2002;55:7-15.
27. Davis M, Espiner E, Richards G, et al. Plasma brain natriuretic peptide in assessment of acute dyspnoea. Lancet. 1994;343:440-444.
FULL TEXT
|
ISI
| PUBMED
28. Hobbs F, Davis R, Roalfe A, Hare R, Davies M, Kenkre J. Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. BMJ. 2002;324:1498-1500.
FREE FULL TEXT
29. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161-167.
FREE FULL TEXT
30. Castro A, Dias P, Pereira M, et al. Type B natriuretic peptide in the diagnosis of heart failure with preserved systolic function [in Portuguese]. Rev Port Cardiol. 2001;20:1109-1113.
31. Lubien E, DeMaria A, Krishnaswamy P, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation. 2002;105:595-601.
FREE FULL TEXT
32. Boyko EJ. Re: "Meta-analysis of Pap test accuracy." Am J Epidemiol. 1996;143:406-407.
FREE FULL TEXT
33. Kalra PR, Struthers AD. More evidence for bedside BNP in heart failure assessment. Int J Cardiol. 2002;86:149-152.
34. Del Ry S, Giannessi D, Clerico A. Plasma brain natriuretic peptide measured by fully-automated immunoassay and by immunoradiometric assay compared. Clin Chem Lab Med. 2001;39:446-450.
FULL TEXT
|
ISI
| PUBMED
35. McCullough PA, Nowak RM, McCord J, et al. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study. Circulation. 2002;106:416-422.
FREE FULL TEXT
36. Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353:9-13.
FULL TEXT
|
ISI
| PUBMED
37. Pfeffer MA, Braunwald E, Moye LA, et al, SAVE Investigators. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the survival and ventricular enlargement trial. N Engl J Med. 1992;327:669-677.
ABSTRACT
38. Packer M, Coats AJ, Fowler MB, et al. Effect of carvedilol on survival in severe congestive heart failure. N Engl J Med. 2001;344:1651-1658.
FREE FULL TEXT
39. Cheitlin MD. Can clinical evaluation differentiate diastolic from systolic heart failure? if so, is it important? Am J Med. 2002;112:496-497.
40. Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000;355:1126-1130.
FULL TEXT
|
ISI
| PUBMED
41. Murdoch DR, McDonagh TA, Byrne J, et al. Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy. Am Heart J. 1999;138:1126-1132.
FULL TEXT
|
ISI
| PUBMED
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTER
Diagnostic Accuracy of Natriuretic Peptides for Heart Failure
Markus Battaglia, Lucas M. Bachmann, and Matthias Egger
Arch Intern Med. 2005;165(6):704.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
The accuracy of plasma natriuretic peptide levels for diagnosis of cardiac dysfunction and chronic heart failure in community-dwelling elderly: a systematic review
Vaes et al.
Age Ageing 2009;38:655-662.
ABSTRACT
| FULL TEXT
A randomized, double-blind, placebo-controlled study to determine the effects of valsartan on exercise time in patients with symptomatic heart failure with preserved ejection fraction
Parthasarathy et al.
Eur J Heart Fail 2009;11:980-989.
ABSTRACT
| FULL TEXT
Hypoxia induces B-type natriuretic peptide release in cell lines derived from human cardiomyocytes
Casals et al.
Am. J. Physiol. Heart Circ. Physiol. 2009;297:H550-H555.
ABSTRACT
| FULL TEXT
Genetic Polymorphisms of the Natriuretic Peptide System in the Pathogenesis of Cardiovascular Disease: What Lies on the Horizon?
Vassalle and Andreassi
Clin. Chem. 2009;55:878-887.
ABSTRACT
| FULL TEXT
B-type natriuretic peptide concentrations to guide treatment of patent ductus arteriosus
Attridge et al.
Arch. Dis. Child. Fetal Neonatal Ed. 2009;94:F178-F182.
ABSTRACT
| FULL TEXT
Old and new biomarkers of heart failure
Emdin et al.
Eur J Heart Fail 2009;11:331-335.
ABSTRACT
| FULL TEXT
Clinically relevant diagnostic research in primary care: the example of B-type natriuretic peptides in the detection of heart failure
Kelder et al.
Fam Pract 2009;26:69-74.
ABSTRACT
| FULL TEXT
Relation of N-terminal pro-brain natriuretic peptide levels and their prognostic power in chronic stable heart failure to obesity status
Frankenstein et al.
Eur Heart J 2008;29:2634-2640.
ABSTRACT
| FULL TEXT
B-type natriuretic peptide levels predict outcomes for children on extracorporeal life support after cardiac surgery.
Chikovani et al.
J. Thorac. Cardiovasc. Surg. 2007;134:1179-1187.
ABSTRACT
| FULL TEXT
Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope
Reed et al.
Emerg. Med. J. 2007;24:769-773.
ABSTRACT
| FULL TEXT
Lipoprotein-Associated Phospholipase A2 Predicts 5-Year Cardiac Mortality Independently of Established Risk Factors and Adds Prognostic Information in Patients with Low and Medium High-Sensitivity C-Reactive Protein (The Ludwigshafen Risk and Cardiovascular Health Study)
Winkler et al.
Clin. Chem. 2007;53:1440-1447.
ABSTRACT
| FULL TEXT
Brain Natriuretic Peptide: Clinical and Research Challenges
Carrillo-Jimenez et al.
J CARDIOVASC PHARMACOL THER 2007;12:85-88.
ABSTRACT
N-Terminal Pro-B-Type Natriuretic Peptide Predicts Total and Cardiovascular Mortality in Individuals with or without Stable Coronary Artery Disease: The Ludwigshafen Risk and Cardiovascular Health Study
Marz et al.
Clin. Chem. 2007;53:1075-1083.
ABSTRACT
| FULL TEXT
Comparison of the Diagnostic Accuracy of Brain Natriuretic Peptide (BNP) and the N-Terminal Part of the Propeptide of BNP Immunoassays in Chronic and Acute Heart Failure: A Systematic Review
Clerico et al.
Clin. Chem. 2007;53:813-822.
ABSTRACT
| FULL TEXT
Diastolic Dysfunction in Heart Failure With Preserved Systolic Function: Need for Objective Evidence: Results From the CHARM Echocardiographic Substudy-CHARMES
Persson et al.
J Am Coll Cardiol 2007;49:687-694.
ABSTRACT
| FULL TEXT
A Gray Zone Assigned to Inconclusive Results of Quantitative Diagnostic Tests: Application to the Use of Brain Natriuretic Peptide for Diagnosis of Heart Failure in Acute Dyspneic Patients
Coste et al.
Clin. Chem. 2006;52:2229-2235.
ABSTRACT
| FULL TEXT
Association of Left-Heart Dysfunction with Severe Exacerbation of Chronic Obstructive Pulmonary Disease: Diagnostic Performance of Cardiac Biomarkers
Abroug et al.
Am. J. Respir. Crit. Care Med. 2006;174:990-996.
ABSTRACT
| FULL TEXT
Natriuretic peptides in the diagnosis and management of heart failure.
Felker et al.
CMAJ 2006;175:611-617.
ABSTRACT
| FULL TEXT
Rapid Brain Natriuretic Peptide Test and Doppler Echocardiography for Early Diagnosis of Mild Heart Failure
Aspromonte et al.
Clin. Chem. 2006;52:1802-1808.
ABSTRACT
| FULL TEXT
Review: ECG, BNP, and N terminal-pro BNP are more sensitive than specific for chronic left ventricular systolic dysfunction
Doust
Evid. Based Med. 2006;11:117-117.
FULL TEXT
Collapse query cause: the management of adult syncope in the emergency department.
Reed and Gray
Emerg. Med. J. 2006;23:589-594.
ABSTRACT
| FULL TEXT
Accuracy of B-type natriuretic peptide levels in the diagnosis of left ventricular dysfunction and heart failure: A systematic review
Latour-Perez et al.
Eur J Heart Fail 2006;8:390-399.
ABSTRACT
| FULL TEXT
Assay for Measurement of Intact B-Type Natriuretic Peptide Prohormone in Blood
Giuliani et al.
Clin. Chem. 2006;52:1054-1061.
ABSTRACT
| FULL TEXT
Accuracy of B-type natriuretic Peptide tests to exclude congestive heart failure: systematic review of test accuracy studies.
Battaglia et al.
Arch Intern Med 2006;166:1073-1080.
ABSTRACT
| FULL TEXT
Serum N-Terminal Brain Natriuretic Peptide as a Prognostic Parameter in Patients With Pulmonary Hypertension
Fijalkowska et al.
Chest 2006;129:1313-1321.
ABSTRACT
| FULL TEXT
B-Type Natriuretic Peptide (BNP) and N-Terminal Pro-BNP in Obese Patients without Heart Failure: Relationship to Body Mass Index and Gastric Bypass Surgery
St. Peter et al.
Clin. Chem. 2006;52:680-685.
ABSTRACT
| FULL TEXT
Alterations in plasma B-type natriuretic peptide levels after repair of congenital heart defects: a potential perioperative marker.
J. Thorac. Cardiovasc. Surg. 2006;131:632-638.
Usefulness of anti-oxidized LDL antibody determination for assessment of clinical control in patients with heart failure
George et al.
Eur J Heart Fail 2006;8:58-62.
ABSTRACT
| FULL TEXT
Cardiac endocrine function is an essential component of the homeostatic regulation network: physiological and clinical implications
Clerico et al.
Am. J. Physiol. Heart Circ. Physiol. 2006;290:H17-H29.
ABSTRACT
| FULL TEXT
Role of N-Terminal Pro-B-Type Natriuretic Peptide in Risk Stratification in Patients Presenting in the Emergency Room
Mockel et al.
Clin. Chem. 2005;51:1624-1631.
ABSTRACT
| FULL TEXT
Comparison of a Fully Automated Immunoassay with a Point-of-Care Testing Method for B-Type Natriuretic Peptide
Prontera et al.
Clin. Chem. 2005;51:1274-1276.
FULL TEXT
Editorial Comment--Brain Natriuretic Peptide and Early Cardiac Dysfunction After Subarachnoid Hemorrhage
Schillinger
Stroke 2005;36:1570-1571.
FULL TEXT
Brain natriuretic peptide in heart failure: an improving prognosis?
Crook and Smith
Eur Heart J 2005;26:1052-1053.
FULL TEXT
Human N-Terminal proBNP Is a Monomer
Crimmins
Clin. Chem. 2005;51:1035-1038.
FULL TEXT
Diagnostic Accuracy of Natriuretic Peptides for Heart Failure--Reply
Doust et al.
Arch Intern Med 2005;165:1199-1199.
FULL TEXT
Cardiovascular Risk Stratification in Older Patients: Role of Brain Natriuretic Peptide, C-Reactive Protein, and Urinary Albumin Levels
Schillinger
JAMA 2005;293:1667-1669.
FULL TEXT
Diagnostic Accuracy of Natriuretic Peptides for Heart Failure
Battaglia et al.
Arch Intern Med 2005;165:704-704.
FULL TEXT
How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review
Doust et al.
BMJ 2005;330:625.
ABSTRACT
| FULL TEXT
BNP for Diagnosing Heart Failure
JWatch Emergency Med. 2004;2004:2-2.
FULL TEXT
|
