Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide.
Abstract
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.
Type
Journal articleSubject
acute coronary syndromebiomarkers
coronary artery disease
echocardiography
emergency medicine
myocardial ischaemia and infarction (IHD)
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https://hdl.handle.net/10161/17878Published Version (Please cite this version)
10.1136/openhrt-2018-000847Publication Info
Limkakeng, Alexander T; Leahy, J Clancy; Griffin, S Michelle; Lokhnygina, Yuliya;
Jaffa, Elias; Christenson, Robert H; & Newby, L Kristin (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.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Elias Joseph Jaffa
Assistant Professor of Surgery
Alexander Tan Limkakeng Jr.
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. I also have an interest in sepsis and empirical bioethics. 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
Yuliya Vladimirovna Lokhnygina
Associate Professor of Biostatistics & Bioinformatics
Statistical methods in clinical trials, survival analysis, adaptive designs, adaptive
treatment strategies, causal inference in observational studies, semiparametric inference
Laura Kristin Newby
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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