The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea ( J Intern Med 2005;258:77–85) - reply


Dr Christian Mueller, Medizinische Klinik A. Universitätsklinik, Petersgraben 4, CH-4031 Basel, Switzerland.
(fax: 0041 61 2655353; e-mail:

We fully agree with Dr Jolobe that radiographic stigmata of acute heart failure are important in the diagnosis of patients with acute dyspnoea. Obviously, chest X-ray had an integral part in the diagnosis and management of patients in both groups in the BASEL study [1]. However, it is important to point out three details. First, chest X-ray is only moderately accurate in the diagnosis of acute heart failure [2, 3]. Radiographic findings of acute heart failure are specific, but only moderately sensitive [2, 3]. Secondly, B-type natriuretic peptide (BNP) levels provide complementary diagnostic information to the clinical investigation and chest X-ray [2]. BNP levels >100 pg mL−1 contribute significantly to the prediction of heart failure over each of the radiographic indicators [2]. Thirdly, when used in conjunction with the clinical evaluation and chest X-ray, the use of BNP levels improves the management of patients with acute dyspnoea [1].

Although the clinical and radiographic response to diuretic and vasodilator therapy can at times be very helpful in the diagnosis, this ‘try and error’ strategy seems to be only a second-line approach to me.