Heart failure & cardiomyopathies
Evidence-Based Application of Natriuretic Peptides in the Evaluation of Chronic Heart Failure With Preserved Ejection Fraction in the Ambulatory Outpatient Setting
Authors' conclusion
In patients with chronic unexplained dyspnea, current rule-in and rule-out NT-proBNP diagnostic thresholds lead to unacceptably high error rates, with important interactions by obesity and AF status.
Study context
- Population
- Patients with chronic dyspnea; Heart failure with preserved ejection fraction (HFpEF) or noncardiac dyspnea determined by exercise catheterization (derivation and validation cohorts 1–3), resting catheterization, previous HF hospitalization or exercise echocardiography (cohorts 4–6)derivation cohort n=414 + 6 validation cohorts
- Comparison
- NT-proBNP rule-out and rule-in thresholds, stratified by body mass index (BMI) and AF, for HFpEF diagnosis
- Outcome
- Diagnostic performance (sensitivity for rule-out, specificity for rule-in) of NT-proBNP thresholds for HFpEF
Methodological detailsmulticentre validation cohorts
- Multicentre validation cohorts
Performance
As reported in the abstract
Diagnostic performance in the derivation cohort
| Strategy | Sensitivity, BMI <35 kg/m² | Sensitivity, BMI ≥35 kg/m² | Specificity | Specificity, BMI <35 kg/m² | Specificity, BMI ≥35 kg/m² |
|---|---|---|---|---|---|
| Rule-out <125 pg/mL | 82% (95% CI, 77%-88%) | 67% (95% CI, 58%-77%) | Not reported in the abstract | Not reported in the abstract | Not reported in the abstract |
| Rule-out <50 pg/mL | 97% [95% CI, 95%-99%] | 86% [95% CI, 79%-93%] | Not reported in the abstract | Not reported in the abstract | Not reported in the abstract |
| Consensus rule-in | Not reported in the abstract | Not reported in the abstract | 65% (95% CI, 57%-72%) | Not reported in the abstract | Not reported in the abstract |
| Rule-in ≥500 pg/mL | Not reported in the abstract | Not reported in the abstract | Not reported in the abstract | 85% (95% CI, 78%-91%) | 100% |
| Rule-in ≥220 pg/mL | Not reported in the abstract | Not reported in the abstract | Not reported in the abstract | Not reported in the abstract | 88% [95% CI, 73%-100%] |
Sensitivity, BMI <35 kg/m²
Rule-out <125 pg/mL82% (95% CI, 77%-88%)
Rule-out <50 pg/mL97% [95% CI, 95%-99%]
Consensus rule-inNot reported in the abstract
Rule-in ≥500 pg/mLNot reported in the abstract
Rule-in ≥220 pg/mLNot reported in the abstract
Sensitivity, BMI ≥35 kg/m²
Rule-out <125 pg/mL67% (95% CI, 58%-77%)
Rule-out <50 pg/mL86% [95% CI, 79%-93%]
Consensus rule-inNot reported in the abstract
Rule-in ≥500 pg/mLNot reported in the abstract
Rule-in ≥220 pg/mLNot reported in the abstract
Specificity
Rule-out <125 pg/mLNot reported in the abstract
Rule-out <50 pg/mLNot reported in the abstract
Consensus rule-in65% (95% CI, 57%-72%)
Rule-in ≥500 pg/mLNot reported in the abstract
Rule-in ≥220 pg/mLNot reported in the abstract
Specificity, BMI <35 kg/m²
Rule-out <125 pg/mLNot reported in the abstract
Rule-out <50 pg/mLNot reported in the abstract
Consensus rule-inNot reported in the abstract
Rule-in ≥500 pg/mL85% (95% CI, 78%-91%)
Rule-in ≥220 pg/mLNot reported in the abstract
Specificity, BMI ≥35 kg/m²
Rule-out <125 pg/mLNot reported in the abstract
Rule-out <50 pg/mLNot reported in the abstract
Consensus rule-inNot reported in the abstract
Rule-in ≥500 pg/mL100%
Rule-in ≥220 pg/mL88% [95% CI, 73%-100%]
Further findings
| Outcome | <50 pg/mL | ≥500 pg/mL | ≥220 pg/mL | |
|---|---|---|---|---|
| Rule-out and rule-in thresholds in validation cohorts 1 and 2 | ||||
| Sensitivity, BMI <35 (cohort 1) | 91% (95% CI, 88%-95%) | Not reported in the abstract | Not reported in the abstract | ≥500 pg/mL, ≥220 pg/mL: not reported in the abstract |
| Sensitivity, BMI <35 (cohort 2) | 86% (95% CI, 80%-93%) | Not reported in the abstract | Not reported in the abstract | ≥500 pg/mL, ≥220 pg/mL: not reported in the abstract |
| Sensitivity, BMI ≥35 (cohort 1) | 80% (95% CI, 74%-87%) | Not reported in the abstract | Not reported in the abstract | ≥500 pg/mL, ≥220 pg/mL: not reported in the abstract |
| Sensitivity, BMI ≥35 (cohort 2) | 84% (95% CI, 74%-93%) | Not reported in the abstract | Not reported in the abstract | ≥500 pg/mL, ≥220 pg/mL: not reported in the abstract |
| Specificity, BMI <35 (validation cohorts) | Not reported in the abstract | 87% [95% CI, 80%-94%] and 90% [95% CI, 81%-99%] | Not reported in the abstract | <50 pg/mL, ≥220 pg/mL: not reported in the abstract |
| Specificity, BMI ≥35 (validation cohorts) | Not reported in the abstract | 93% [95% CI, 81%-100%] and 100% | 93% [95% CI, 81%-100%] and 100% | <50 pg/mL: not reported in the abstract |
Thresholds in validation cohorts 3 through 6
- Sensitivity of <50 pg/mL
- 93%-98%
- Specificity of ≥500 pg/mL
- 82%-89%
- Findings consistent with derivation
Patients with AF
- Patients with AF and dyspnea found to have HFpEF
- ≥98%
- NT-proBNP provided no incremental discrimination with history of AF
Original publication
Evidence-Based Application of Natriuretic Peptides in the Evaluation of Chronic Heart Failure With Preserved Ejection Fraction in the Ambulatory Outpatient Setting. Circulation. Published 22 January 2025. doi:10.
Summarised from the published abstract; every number is checked against it