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Reviews in Cardiovascular Medicine  2010, Vol. 11 Issue (S2): 51-65     DOI: 10.3909/ricm11S2S0002
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An Evidence-Based Algorithm for the Use of B-Type Natriuretic Testing in Acute Coronary Syndromes
Peter A. McCullough1, W. Frank Peacock2, Brian O'Neil3, James A. de Lemos4, Norman E. Lepor5, Robert Berkowitz6
1 Department of Medicine, Divisions of Cardiology, Nutrition, and Preventive Medicine, William Beaumont Hospital, Royal Oak, MI
2 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH
3 Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI
4 Donald W. Reynolds Cardiovascular Research Center, UT Southwestern Medical Center, Dallas, TX
5 Cedars Sinai Medical Center, Los Angeles, CA
6 Heart Failure Program, Hackensack University Medical Center, Hackensack, NJ
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Measurable B-type natriuretic peptides (BNPs), which are largely produced by the left ventricle, include BNP and N-terminal prohormone BNP (NT-proBNP). These proteins are released by cardiomyocytes in response to wall tension and neurohumoral signals, and are established tools in the diagnosis and prognosis of heart failure (HF). We identified 32 articles for entry into evidence tables that presented original data on BNP and/or NT-proBNP in more than 100 patients with acute coronary syndromes (ACS) presenting with chest discomfort with or without dyspnea. Natriuretic peptide (NP) elevation was associated with older age, female sex, hypertension, diabetes, prior HF, prior ischemic heart disease, and reduced renal function. Clinical correlates of elevated blood NP levels included left main or 3-vessel coronary disease, lipid-rich plaques with large necrotic cores in proximal locations, large zones of myocardial ischemia or infarction, no-reflow and impaired perfusion after percutaneous intervention, reduced left ventricular ejection fraction, higher Killip classification, and the development of cardiogenic shock. All studies indicated that after adjustment for baseline predictors and clinical risk scores, elevated NP concentrations were independently predictive of the development of HF and all-cause mortality. In contrast, studies did not consistently demonstrate that NPs were predictive of myocardial infarction and rehospitalization for ACS. In addition to baseline measurement, there is consensus that repeat testing at 4 to 12 weeks and 6 to 12 months in follow-up is helpful in the anticipation of late cardiac sequelae and may assist in assessing prognosis and guiding management.
Key words:  B-type natriuretic peptide      N-terminal pro-B-type natriuretic peptide      Acute coronary syndrome      Acute myocardial infarction      Diagnosis      Complications      Prognosis      Systematic review      Hospitalization      Mortality     
Published:  20 February 2010     

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Peter A. McCullough, W. Frank Peacock, Brian O'Neil, James A. de Lemos, Norman E. Lepor, Robert Berkowitz. An Evidence-Based Algorithm for the Use of B-Type Natriuretic Testing in Acute Coronary Syndromes. Reviews in Cardiovascular Medicine, 2010, 11(S2): 51-65.

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