Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide.
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Objective:Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls. Methods:We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4 hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging. Results:Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2 hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4 hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009). Conclusion:Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.
Subjectacute coronary syndrome
coronary artery disease
myocardial ischaemia and infarction (IHD)
Published Version (Please cite this version)10.1136/openhrt-2018-000847
Publication InfoLokhnygina, Yuliya; Limkakeng, Alexander; Jaffa, Elias; Newby, Laura; Leahy, J Clancy; Griffin, S Michelle; & Christenson, Robert H (2018). Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide. Open Heart, 5(2). pp. e000847. 10.1136/openhrt-2018-000847. Retrieved from https://hdl.handle.net/10161/17878.
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Assistant Professor of Surgery
Associate Professor of Surgery
My personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, I am interested in novel biomarkers and precision medicine approaches to this problem. As Vice Chief of Research for the Duke Division of Emergency Medicine, I also work with researchers from many fields spanning global health, innovation, clinical trials, basic discovery and translational research. The common element is time-sensitive health conditions. I help
Assistant Professor of Biostatistics and Bioinformatics
Statistical methods in clinical trials, survival analysis, adaptive designs, adaptive treatment strategies, causal inference in observational studies, semiparametric inference
Professor of Medicine
Research Description General Focus: Clinical investigation the process and treatment of acute and chronic coronary artery disease and systems issues for delivery of care to patients with these illnesses. Particular interests include management of patients with chest pain and unstable angina, evaluation of the use of biochemical markers other than CK-MB for diagnosis and risk stratification in these patients, issues related to coronary artery disease in women, and systems issues
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