Effect of oral beta-blocker on short and long-term mortality in patients with acute respiratory failure: results from the BASEL-II-ICU study

Acute respiratory failure (ARF) is responsible for about one-third of intensive care unit (ICU) admissions and is associated with adverse outcomes. Predictors of short- and long-term outcomes in unselected ICU-patients with ARF are ill-defined. The purpose of this analysis was to determine predictors of in-hospital and one-year mortality and assess the effects of oral beta-blockers in unselected ICU patients with ARF included in the BASEL-II-ICU study. The BASEL II-ICU study was a prospective, multicenter, randomized, single-blinded, controlled trial of 314 (mean age 70 (62 to 79) years) ICU patients with ARF evaluating impact of a B-type natriuretic peptide- (BNP) guided management strategy on short-term outcomes. In-hospital mortality was 16% (51 patients) and one-year mortality 41% (128 patients). Multivariate analysis assessed that oral beta-blockers at admission were associated with a lower risk of both in-hospital (HR 0.33 (0.14 to 0.74) P = 0.007) and one-year mortality (HR 0.29 (0.16 to 0.51) P = 0.0003). Kaplan-Meier analysis confirmed the lower mortality in ARF patients when admitted with oral beta-blocker and further shows that the beneficial effect of oral beta-blockers at admission holds true in the two subgroups of patients with ARF related to cardiac or non-cardiac causes. Kaplan-Meier analysis also shows that administration of oral beta-blockers before hospital discharge gives striking additional beneficial effects on one-year mortality. Established beta-blocker therapy appears to be associated with a reduced mortality in ICU patients with acute respiratory failure. Cessation of established therapy appears to be hazardous. Initiation of therapy prior to discharge appears to confer benefit. This finding was seen regardless of the cardiac or non-cardiac etiology of respiratory failure. ClinicalTrials.gov Identifier: NCT00130559

Value of arterial blood gas analysis in patients with acute dyspnea: an observational study

ABSTRACT: INTRODUCTION: The diagnostic and prognostic value of arterial blood gas analysis (ABGA) parameters in unselected patients presenting with acute dyspnea to the Emergency Department (ED) is largely unknown. METHODS: We performed a post-hoc analysis of two different prospective studies to investigate the diagnostic and prognostic value of ABGA parameters in patients presenting to the ED with acute dyspnea. RESULTS: We enrolled 530 patients (median age 74 years). ABGA parameters were neither useful to distinguish between patients with pulmonary disorders and other causes of dyspnea nor to identify specific disorders responsible for dyspnea. Only in patients with hyperventilation from anxiety disorder, the diagnostic accuracy of pH and hypoxemia rendered valuable with an area under the receiver operating characteristics curve (AUC) of 0.86. Patients in the lowest pH tertile more often required admission to Intensive Care Unit (28% vs 12% in the first tertile, P >0.001) and had higher in-hospital (14% vs 5%, P =0.003) and 30-day mortality (17% vs 7%, P =0.002). Cumulative mortality rate was higher in the first (37%), than in the second (28%), and the third tertile (23%, P =0.005) during 12 months follow-up. pH at presentation was an independent predictor of 12-month mortality in multivariable Cox proportional hazard analysis both for patients with pulmonary (P =0.043) and non-pulmonary disorders (P =0.038). CONCLUSIONS: ABGA parameters provide limited diagnostic value in patients with acute dyspnea, but pH is an independent predictor of 12 months mortality

Midregional pro-Adrenomedullin in addition to b-type natriuretic peptides in the risk stratification of patients with acute dyspnea: an observational study

The identification of patients at highest risk for adverse outcome who are presenting with acute dyspnea to the emergency department remains a challenge. This study investigates the prognostic value of the newly described midregional fragment of the pro-Adrenomedullin molecule (MR-proADM) alone and combined to B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) in patients with acute dyspnea.; We conducted a prospective, observational cohort study in the emergency department of a University Hospital and enrolled 287 unselected, consecutive patients (48% women, median age 77 (range 68 to 83) years) with acute dyspnea.; MR-proADM levels were elevated in non-survivors (n = 77) compared to survivors (median 1.9 (1.2 to 3.2) nmol/L vs. 1.1 (0.8 to 1.6) nmol/L; P > 0.001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.81 (95% CI 0.73 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for MR-proADM, NT-proBNP and BNP, respectively (MRproADM vs. NTproBNP P = 0.38; MRproADM vs. BNP P = 0.009). For one-year mortality the AUC were 0.75 (95% CI 0.69 to 0.81), 0.75 (95% CI 0.68 to 0.81), 0.69 (95% CI 0.62 to 0.76) for MR-proADM, NT-proBNP and BNP, respectively without any significant difference. Using multivariate linear regression analysis, MR-proADM strongly predicted one-year all-cause mortality independently of NT-proBNP and BNP levels (OR = 10.46 (1.36 to 80.50), P = 0.02 and OR = 24.86 (3.87 to 159.80) P = 0.001, respectively). Using quartile approaches, Kaplan-Meier curve analyses demonstrated a stepwise increase in one-year all-cause mortality with increasing plasma levels (P > 0.0001). Combined levels of MR-proADM and NT-proBNP did risk stratify acute dyspneic patients into a low (90% one-year survival rate), intermediate (72 to 82% one-year survival rate) or high risk group (52% one-year survival rate).; MR-proADM alone or combined to NT-proBNP has a potential to assist clinicians in risk stratifying patients presenting with acute dyspnea regardless of the underlying disease

Use of procalcitonin for the diagnosis of pneumonia in patients presenting with a chief complaint of dyspnoea: results from the BACH (Biomarkers in Acute Heart Failure) trial

Biomarkers have proven their ability in the evaluation of cardiopulmonary diseases.We investigated the utility of concentrations of the biomarker procalcitonin (PCT) alone and with clinical variables for the diagnosis of pneumonia in patients presenting to emergency departments (EDs) with a chief complaint of shortness of breath. The BACH trial was a prospective, international, study of 1641 patients presenting to EDs with dyspnoea. Blood samples were analysed for PCT and other biomarkers. Relevant clinical data were also captured. Patient outcomes were assessed at 90 days. The diagnosis of pneumonia was made using strictly validated guidelines. A model using PCT was more accurate [area under the curve (AUC) 72.3%] than any other individual clinical variable for the diagnosis of pneumonia in all patients, in those with obstructive lung disease, and in those with acute heart failure (AHF). Combining physician estimates of the probability of pneumonia with PCT values increased the accuracy to .86% for the diagnosis of pneumonia in all patients. Patients with a diagnosis of AHF and an elevated PCT concentration (.0.21 ng/mL) had a worse outcome if not treated with antibiotics (P ¼ 0.046), while patients with low PCT values (,0.05 ng/mL) had a better outcome if they did not receive antibiotic therapy (P ¼ 0.049). Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty. Importantly, PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection

Natriuretic peptides and their evolving clinical applications

Natriuretic peptides (NP) are quantitative plasma biomarkers of heart failure, which are widely used in clinical practice in many countries. NP levels are accurate in the diagnosis of heart failure in patients presenting with dyspnea. The use of NP improves patient management and reduces total treatment costs in patients with dyspnea. As NP levels quantify disease severity in patients with established heart failure, NP levels are powerful predictors of outcome in predicting death and rehospitalization. NP-guided therapy may improve morbidity in patients with chronic heart failure. Although NP levels also risk-stratify patients with many other conditions such as stable or unstable coronary artery disease, pulmonary embolism and community-acquired pneumonia, there is insufficient evidence on how patient outcome could be altered in patients identified as high risk

Risk stratification for 1-year mortality in acute heart failure

BACKGROUND: Simple tools for risk stratification of patients with acute heart failure (AHF) are an unmet clinical need, particularly regarding long-term mortality. METHODS: We prospectively enrolled 610 consecutive patients presenting to the emergency department with AHF. The diagnosis of AHF was adjudicated by two independent cardiologists. The classification and regression tree (CART) analysis was used to develop a simple risk algorithm. This was internally validated by cross-validation. RESULTS: One-year follow-up was complete in all patients (100%). A total of 201 patients (33%) died within 360 days. The CART analysis identified blood urea nitrogen (BUN) and age as the best single predictors of 1-year mortality and patients were categorised to three risk groups: high risk group (BUN /= 86 years) and low risk group (BUN >/= 27.5 mg/dl). The Kaplan-Meier curves showed a significant increase in mortality in the high risk group compared with the lower risk groups (log-rank test p >0.001). The hazard ratio regarding 1-year mortality between patients identified as low and high risk was 2.0 (95% confidence interval, 1.7-2.4), with statistically significant differences between all risk groups (p >0.001). The likelihood-based 95%-confidence set for the age- and the urea-threshold is contained in the rectangular set defined by 25 mg/dl >/= urea threshold >/=30.6 mg/dl and 76 years >/= age threshold >/=96 years. CONCLUSION: These results suggest that AHF patients at low, intermediate and high risk for death within 360 days can be easily identified using patient's demographics and laboratory data obtained at presentation. Application of this simple risk stratification algorithm may help to improve the management of these patients

B-type natriuretic peptide-guided management and outcome in patients with obesity and dyspnea - results from the BASEL study

BACKGROUND: Obesity may reduce diagnostic accuracy of B-type natriuretic peptide (BNP) and affect long-term outcome. METHODS: This study evaluated patients included in the BASEL study (N = 452). We compared BNP levels in patients with (n = 86) and without (n = 366) obesity (body mass index >30 and .05) without impacting other end points. CONCLUSIONS: Adjustment of BNP values in the assessment of obese patients presenting with acute dyspnea seems necessary to improve diagnostic accuracy and patient management. Obese patients had half the short- and long-term mortality of nonobese patients, independent of their final discharge diagnosis

The use of B-type natriuretic peptide in the management of patients with atrial fibrillation and dyspnea

The utility of B-type natriuretic peptide (BNP) testing in patients with atrial fibrillation (AF) is poorly defined. We analyzed patients (n=452) included in the BNP for Acute Shortness of Breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with or without the use of BNP. Ninety-nine patients presented with AF (n=48 BNP group; n=51 control group). Although comparable with respect to gender and cardiopulmonary comorbidity, patients with AF were older and more often had heart failure as the cause of dyspnea. In addition, patients with AF had higher in-hospital mortality (13% versus 6%, P=0.012). The use of BNP significantly reduced time to discharge (BNP group median 8 days [1-16] versus 12 days [IQR 4-21] control group; P=0.046) in patients with AF. Initial total treatment costs (median) were $4239 [769-7422] in the BNP group and$5940 [4024-10848] in the control group (P=0.041). These benefits were maintained after 90 days: patients in the BNP group had spent fewer days in hospital (10 days [2-21] versus 15 days [IQR 9-27]; P=0.022) and induced lower total treatment costs ($4790 [1260-9387] versus$7179 [4311-13173]; P=0.016). In conclusion, the use of BNP seems to improve the management of patients with AF presenting with dyspnea

Natriuretic peptides for the prediction of severely impaired peak VO2 in patients with lung disease

B-type natriuretic peptide (BNP) is a predictor of death in patients with lung disease. We hypothesised that in patients with lung disease, BNP and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) could predict a peak VO(2)>15 ml/kg/min, which is the proposed cut-off indicating an increased risk of perioperative complications during lung resection surgery.; BNP and NT-proBNP were measured in 85 patients with a variety of pulmonary pathologies undergoing cardiopulmonary exercise testing and fulfilling criteria for appropriate effort.; BNP [69 (42-270) vs. 33 (15-65)pg/ml; p=0.001] and NT-proBNP [290 (129-1075) vs. 65 (21-129)pg/ml; p>0.001] were higher in patients with peak VO(2)>15 ml/kg/min (n=27) as compared to those with peak VO(2)15 ml/kg/min. The areas under the receiver-operator-characteristics curve (AUC) for BNP and NT-proBNP to predict a peak VO(2)>15 ml/kg/min were 0.73 and 0.80 respectively. A five-item (BNP) or four-item (NT-proBNP) score including BMI, FEV(1), diabetes, D(A-a)O(2), and BNP/NT-proBNP had an AUC of 0.87 and 0.88 respectively for the prediction of peak VO(2)>15ml/kg/min.; In patients with lung disease, BNP or NT-proBNP is independently associated with low peak VO(2). A simple score based on spirometry, blood gases and BNP or NT-proBNP has a high accuracy for the prediction of a peak VO(2)>15 ml/kg/min