• B-type natriuretic peptide;
  • cost;
  • dyspnoea;
  • heart failure;
  • primary care

Abstract.  Burri E, Hochholzer K, Arenja N, Martin-Braschler H, Kaestner L, Gekeler H, Hatziisaak T, Büttiker M, Fräulin A, Potocki M, Breidthardt T, Reichlin T, Socrates T, Twerenbold R, Mueller C (University Hospital Basel, Basel; University Hospital, Basel, Switzerland). B-type natriuretic peptide in the evaluation and management of dyspnoea in primary care. J Intern Med 2012; 272: 504–513.

Objectives.  The rapid and accurate diagnosis of heart failure in primary care is a major unmet clinical need. We evaluated the additional use of B-type natriuretic peptide (BNP) levels.

Design.  A randomized controlled trial.

Setting.  Twenty-nine primary care physicians in Switzerland and Germany coordinated by the University Hospital Basel, Switzerland.

Subjects.  A total of 323 consecutive patients presenting with dyspnoea.

Interventions.  Assignment in a 1 : 1 ratio to a diagnostic strategy including point-of-care measurement of BNP (= 163) or standard assessment without BNP (= 160). The total medical cost at 3 months was the primary end-point. Secondary end-points were diagnostic certainty, time to appropriate therapy, functional capacity, hospitalization and mortality. The final diagnosis was adjudicated by a physician blinded to the BNP levels.

Results.  Heart failure was the final diagnosis in 34% of patients. The number of hospitalizations, functional status and total medical cost at 3 months [median $1655, interquartile range (IQR), 850–3331 vs. $1541, IQR 859–2827; = 0.68] were similar in both groups. BNP increased diagnostic certainty as defined by the need for further diagnostic work-up (33% vs. 45%; = 0.02) and accelerated the initiation of the appropriate treatment (13 days vs. 25 days; = 0.01). The area under the receiver-operating characteristics curve for BNP to identify heart failure was 0.87 (95% confidence interval, 0.81–0.93).

Conclusions.  The use of BNP levels in primary care did not reduce total medical cost, but improved some of the secondary end-points including diagnostic certainty and time to initiation of appropriate treatment.