Jesamyn Fuscardo DO Emergency Medicine PGY4 OVMC Wheeling, WV

1. The Utility of B-natriuretic peptide in the Emergency Department Diagnosis of CHFDrs. Jesamyn Fuscardo, Jared Halterman, and Richard Houck, DODr. Kevin Klauer, MD, supervising author and coordinatorDr. Joseph Dougherty, DO, supervising residency faculty Jesamyn Fuscardo DO Emergency Medicine PGY4 OVMC Wheeling, WV

2. Introduction CHF is one of the more common disease presentations in the emergency department today, with over a million affected patients in the US alone and more than 500,000 new cases yearly. With a lifetime risk for heart failure of greater than 20% beyond middle age, the crisis is only expected to worsen with an aging population. Many ED physicians would agree that there is no gold standard for diagnosis of CHF in the ED, rather it is generally based on a combination history and physical presentation. Neither a BNP nor NT-pro BNP test alone has been shown to definitively diagnose CHF in the acute ED setting; however, these test values are often followed over time to evaluate severity of chronic CHF in the inpatient setting. This brings us to our question, “Is a BNP level necessary for the diagnosis of CHF and subsequent admission of a patient in the ED setting?” Our objective is to elucidate the role of exam findings in providing the clinical evidence necessary to support the diagnosis of acute CHF in the ED setting, regardless of obtaining a BNP level.

3. Materials & Methods The charts of 313 ED patients who were admitted for CHF were reviewed regarding utility of BNP in the diagnosis of CHF. The following inclusion criteria were used: BNP level obtained in the ED and admission with diagnosis of CHF. Exclusion criteria were those that were diagnosed but not admitted for CHF (discharged home) and those without a BNP level ordered as part of ED workup. Charts were evaluated based on physician and nursing documentation, studies conducted, history obtained, and physical findings present on exam. The following characteristics were evaluated during ED workup after ordering a BNP level: pulmonary edema on CXR, peripheral edema, rales on auscultation, JVD and/or HJR. Results from the above were analyzed to determine whether a diagnosis of CHF was evident on physical exam, whether the patient had a previous history of CHF noted, and/or whether the BNP value resulted in a change in the ED management.

4. Results A Spearman’s Rank Correlation statistic was used to examine the link between CHF diagnosis and BNP Change of Management. It was determined that there is a significant negative correlation between the two (Spearman’s r = - 0.26, p < 0.01). Because our data was non-normal, the Spearman’s Rank Correlation test was used in place of the traditional Pearson correlation statistic. This showed that statistically, a BNP level is not necessary to diagnose CHF in the Emergency Department setting following appropriate clinical workup. This negative correlation between CHF diagnosis and BNP level necessitating change in management was the expected data result. A BNP level was ordered in 100% of cases reviewed. BNP itself only changed management in 15% of ED patients seen with CHF symptomatology. 64% of patients had a previously noted history of CHF. 77% were deemed to have a CHF diagnosis evident on exam. Only 30% exhibited JVD or HJR. 73% had rales on auscultation. 67% had peripheral edema on exam. 86% had pulmonary edema evident on CXR.

5. Discussion The significance of the above data shows overwhelming support for the diagnosis of CHF in the Emergency Department based on clinical exam findings and chest x-ray alone. Rarely is the addition of a BNP helpful or necessary in the ED setting. Particular biases would include; failure to evaluate all CHF patients, including those that were discharged after obtaining a BNP level within the same time frame. Other data which may have improved the validity of this study include: 1) Reason for ordering BNP, 2) Variance in physical exam skills between various careproviders, 3) Other symptoms/clinical findings that may contribute to diagnosis of CHF in the ED setting,4) Specific factors constituting a“change inmanagement,” 5) Acute, new onset CHF vs. chronic CHFexacerbation.

6. References • References: • Januzzi, JL, Troughton, Richard. Are Serial BNP Measurements Useful in Heart Failure Management? Serial Natriuretic Peptide Measurements Are Useful in Heart Failure Management. Controversies in Cardiovascular Medicine 2013; 127:500-508. • Desai, Akshay. Are Serial BNP Measurements Useful in Heart Failure Management? Serial Natriuretic Peptide Measurements Are Not Useful in Heart Failure Management: The Art of Medicine Remains Long. Controversies in Cardiovascular Medicine 2013; 127: 509-516. • DeBeradinis, Benedetta, Januzzi, James. Use of Biomarkers to Guide Outpatient Therapy of Heart Failure. Current Opinion, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts 2012; 27:661-668. • Tintinalli, Judith. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition. • www.uptodate.com