Chest
Volume 141, Issue 4, April 2012, Pages 974-982
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Original Research
Chest Infections
Direct Comparison of Three Natriuretic Peptides for Prediction of Short- and Long-term Mortality in Patients With Community-Acquired Pneumonia

https://doi.org/10.1378/chest.11-0824Get rights and content

Background

Early and accurate risk stratification for patients with community-acquired pneumonia (CAP) is an unmet clinical need.

Methods

We enrolled 341 unselected patients presenting to the ED with CAP in whom blinded measurements of N-terminal pro-B-type natriuretic peptide (NT-proBNP), midregional pro-atrial natriuretic peptide (MR-proANP), and B-type natriuretic peptide (BNP) were performed. The potential of these natriuretic peptides to predict short- (30-day) and long-term mortality was compared with the pneumonia severity index (PSI) and CURB-65 (confusion, urea plasma level, respiratory rate, BP, age over 65 years). The median follow-up was 942 days.

Results

NT-proBNP, MR-proANP, and BNP levels at presentation were higher in short-term (median 4,882 pg/mL vs 1,133 pg/mL; 426 pmol/L vs 178 pmol/L; 436 pg/mL vs 155 pg/mL, all P < .001) and long-term nonsurvivors (3,515 pg/mL vs 548 pg/mL; 283 pmol/L vs 136 pmol/L; 318 pg/mL vs 103 pg/mL, all P < .001) as compared with survivors. Receiver operating characteristics analysis to quantify the prognostic accuracy showed comparable areas under the curve for the three natriuretic peptides to PSI for short-term (PSI 0.76, 95% CI, 0.71-0.81; NT-proBNP 0.73, 95% CI, 0.67-0.77; MR-proANP 0.72, 95% CI, 0.67-0.77; BNP 0.68, 95% CI, 0.63-0.73) and long-term (PSI 0.72, 95% CI, 0.66-0.77; NT-proBNP 0.75, 95% CI, 0.70-0.80; MR-proANP 0.73, 95% CI, 0.67-0.77, BNP 0.70, 95% CI, 0.65-0.75) mortality. In multivariable Cox-regression analysis, NT-proBNP remained an independent mortality predictor (hazard ratio 1.004, 95% CI, 1.00-1.01, P = .02 for short-term; hazard ratio 1.004, 95% CI, 1.00-1.01, P = .001 for long-term, increase of 300 pg/mL). A categorical approach combining PSI point values and NT-pro-BNP levels adequately identified patients at low, medium, and high short- and long-term mortality risk.

Conclusions

Natriuretic peptides are simple and powerful predictors of short- and long-term mortality for patients with CAP. Their prognostic accuracy is comparable to PSI.

Section snippets

Setting and Study Population

We screened 421 unselected consecutive patients with suspected CAP presenting to the University Hospital of Basel from November 2003 to March 2007.11, 12 Due to logistic reasons, the recruitment was interrupted from February 2005 to April 2006. Patients' data were included into the analysis if values from all three NPs were obtained at presentation.

Patients were evaluated in the ED by at least two physicians, a resident in internal medicine and an internal medicine specialist. The decision for

Baseline Characteristics

A total of 421 patients were evaluated in this study. Baseline values from all three natriuretic peptides were available for 341 of the 421 (81%) consecutive patients. These 341 patients constituted the study population included into analysis. PSI was calculated in 320 patients of the study population. There was no difference in age, sex, and mortality between the cohort of the patients evaluated and patients included into analysis (Table 1).

The median follow-up time was 942 days (366-1626).

Discussion

In this prospective study of 341 patients presenting with CAP to the ED, we compared the potential of admission plasma NT-proBNP, MR-proANP, and BNP levels to predict unfavorable outcome for patients with CAP. We report six major findings. First, NP levels at presentation are significantly elevated in short- and long-term decedents. Second, NP levels predict short- and long-term mortality with comparable accuracy to PSI point values and exceed the predictive potential of CURB-65 and common

Conclusion

NPs are simple and powerful predictors of short- and long-term mortality. Their prognostic accuracy is comparable to PSI. Importantly, a combined assessment using PSI point values and NT-pro-BNP levels appears to provide additional risk stratification over a single marker approach.

Acknowledgments

Author contributions: All authors are fully responsible for the presented analysis and conclusions drawn in the manuscript.

Dr Nowak: conceived the idea, designed and initiated the study, performed statistical analyses, drafted the manuscript, amended and commented on the manuscript, and approved the final version.

Dr Breidthardt: conceived the idea, designed and initiated the study, performed statistical analyses, drafted the manuscript, amended and commented on the manuscript, and approved the

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    Drs Nowak and Breidthardt are coauthors of this article.

    Funding/Support: Dr Meune was supported by a grant from the FAQ (Freie Akademische Gesellschaft), Basel, Switzerland.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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