Prognostic utility of ST2 in patients with acute dyspnea and preserved left ventricular ejection fraction.

BACKGROUND: Soluble ST2 (sST2), an interleukin-1 receptor family member, is an emerging risk indicator for patients with cardiovascular disease. We evaluated the prognostic role of sST2 for patients presenting to the emergency department with acute dyspnea, with a focus on those with preserved left ventricular ejection fraction (LVEF ≥50%), as risk stratification is often most complex in this subgroup. METHODS: We conducted a post hoc analysis of 387 patients [39% female, mean (SD) age 57.6 (14.5) years] presenting to the emergency department with dyspnea and followed for 1 year (97% complete follow-up). We examined clinical data, concentrations of serum biomarkers [sST2, amino-terminal pro-B-type natriuretic peptide (NT-proBNP)], and transthoracic echocardiography. RESULTS: Patients had a median sST2 concentration of 38.4 U/mL [interquartile range (IQR) 25.5-64 U/mL]. Forty-six patients (12%) died during follow-up. Log sST2 [hazard ratio (HR) (95% CI) 2.85 (2.04-3.99), P < 0.001rsqb] and log NT-proBNP [1.28 (1.13-1.45), P < 0.001] concentrations were significant predictors of mortality at 1 year. After multivariate adjustment, only sST2 remained predictive of mortality [per log: 2.14 (1.37-3.38), P = 0.001]. In the subpopulation of individuals with normal systolic function (n = 200), only sST2 continued to predict mortality after multivariate adjustment [per log: 2.57 (1.12-5.91), P = 0.03]. Only NT-proBNP, but not sST2, concentrations correlated with multiple echocardiographic indices of left ventricular diastolic function. CONCLUSIONS: sST2 is a strong predictor of mortality in patients presenting with acute dyspnea, particularly those with preserved LVEF, and may be useful for triage and risk stratification of this challenging group.

Post-discharge changes in NT-proBNP and quality of life after acute dyspnea hospitalization as predictors of one-year outcomes.

AIMS: The association of serial NT-proBNP changes and poor quality of life (QOL) with progressive heart failure (HF) and clinical outcomes in emergency department dyspnea patients is poorly understood. METHODS AND RESULTS: The predictive value of changes in NT-proBNP and QOL (Minnesota Living with Heart Failure scale) from baseline to 30-day follow-up was examined for all-cause 1-year mortality and HF hospitalization. Patients with an initially elevated NT-proBNP (≥300 ng/L) which persisted at 30-days (no ≥25% decrease) were at high risk of death or HF hospitalization (HR=6.36, 95%CI=3.04-13.28). Combined with sustained poor QOL, these subjects with persistently elevated NT-proBNP were at highest mortality risk or HF hospitalization (HR=8.75, 95%CI=3.62-21.16). CONCLUSIONS: Dyspnea patients with elevated NT-proBNP concentrations and no improvement in either NT-proBNP or QOL at 30-days are at high risk of mortality and HF hospitalization. These data highlight the value of serial biomarker measurements combined with serial evaluations for QOL.

Registered nurses as members of interprofessional primary health care teams in remote or isolated areas of Queensland: Collaboration, communication and partnerships in practice.

Nurses represent the largest occupational group of health care professionals in Australia. The ratio of nurses to population is relatively consistent, unlike other health care professional groups (including medical doctors and allied health staff) whose numbers decline as population density and distance from metropolitan areas increases. Nurses working in areas where other health care professionals are limited or absent have expanded scopes of practice with their work being more generalist than specialist. The role of nurses in remote and isolated areas of Queensland, Australia was the focus of a commissioned multi-case research project. Findings reported in this paper relate to the position of registered nurses as part of an interprofessional team. These findings indicated that, in some instances, local health care teams were limited to a single nurse and Indigenous health care worker/s, while in others the teams were more diverse. In all cases collegial support was available either locally or via telecommunication technology. Understanding the role of each team member, having useful strategies to enhance communication and work collaboratively were identified as essential criteria for "good practice".

Natriuretic peptides and echocardiography in acute dyspnoea: implication of elevated levels with normal systolic function.

AIMS: Previous evaluations of natriuretic peptide (NP) levels in patients with acute dyspnoea presenting to the emergency department (ED) have selected only a minority of patients for echocardiography. We aimed to evaluate the association between NPs and more subtle echocardiographic findings and to assess the potential for NPs to provide additional prognostic information beyond that provided by echocardiography in 'all-comers' with acute dyspnoea. METHODS AND RESULTS: Prospective echocardiograms were performed on 338/412 patients presenting to the ED with acute dyspnoea. B-type natriuretic peptide and NT-proBNP were measured on presentation. Patients were followed-up for 1 year. Decompensated heart failure was diagnosed in 37% of patients and 13% died. The diagnostic accuracy (c-statistic) of BNP and NT-proBNP for identifying LVEF or= 50%. Natriuretic peptides, but not LV mass or diastolic parameters, independently predicted mortality at 1 year in all patients and in those with an LVEF >or= 50%. CONCLUSION: In an acute dyspnoea population with 'all-comers' undergoing echocardiography, NPs correlate strongly with structural abnormalities and identify those with preserved LVEF at highest risk for death. Careful interpretation of elevated NP values is needed in the presence of preserved systolic function.

Lack of diagnostic and prognostic utility of circulating plasma myeloperoxidase concentrations in patients presenting with dyspnea.

BACKGROUND: Plasma myeloperoxidase (MPO), an inflammatory biomarker, is associated with increased mortality in patients with acute coronary syndrome or chronic left ventricular systolic dysfunction. We sought to assess the diagnostic accuracy of MPO for acute decompensated heart failure (ADHF) and its prognostic value for patients with acute dyspnea. METHODS: In a prospective, observational study conducted in 5 US centers, 412 patients [mean (SD) age, 58 (14) years; 39% women] presenting with dyspnea to the emergency department were enrolled and followed for 1 year. Clinical, serum/plasma biomarker [MPO, B-type natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP)], and transthoracic echocardiographic data were obtained. RESULTS: We observed no differences in MPO concentration (P = 0.07) between patients with ADHF [n = 147; median, 553 pmol/L; interquartile range (IQR), 415-738 pmol/L] and those without ADHF (n = 265; median, 576 pmol/L; IQR, 413-884 pmol/L). The diagnostic accuracy for ADHF was excellent for BNP [area under the ROC curve (AUC), 0.90; P < 0.001] and NT-proBNP (AUC, 0.90; P < 0.001) but poor for MPO (AUC, 0.46; P = 0.18). MPO appeared uncorrelated with echocardiographic measures of cardiac structure or function. The observed 1-year mortality rate was 12%. MPO concentration also appeared unrelated to mortality [hazard ratio, 1.25 (above vs below the median); 95% CI, 0.71-2.18], whereas BNP (P = 0.001) and NT-proBNP (P < 0.001) were significant predictors of mortality. MPO concentration provided no prognostic information in addition to that of BNP or NT-proBNP concentration. CONCLUSIONS: Unlike natriuretic peptides, MPO concentration was not predictive of ADHF diagnosis or 1-year mortality in a heterogeneous sample of emergency department patients with acute dyspnea.