Congestive Heart Failure N-terminal pro–brain natriuretic peptide testing in the emergency department: Beneficial effects on hospitalization, costs, and outcome Joost H.W. Rutten, MD, a Ewout W. Steyerberg, PhD, b Frans Boomsma, PhD, a Jan L.C.M. van Saase, MD, PhD, a Jaap W. Deckers, MD, PhD, c Henk C. Hoogsteden, MD, PhD, d Jan Lindemans, PhD, e and Anton H. van den Meiracker, MD, PhD a Rotterdam, The Netherlands Background N-terminal pro–brain natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. Assessment of this biomarker in patients with acute dyspnea presenting to the emergency department (ED) may aid diagnostic decision-making, resulting in improved patient care and reduced costs. Methods In a prospective clinical trial, patients presenting with acute dyspnea to the ED of the Erasmus Medical College, Rotterdam, the Netherlands, were randomized for either rapid measurement or no measurement of NT-proBNP. For ruling out heart failure, cutoff values of 93 pg/mL in male and 144 pg/mL in female patients were used, and for ruling in heart failure, a cutoff value of 1,017 pg/mL was used. Time to discharge from the hospital and costs related to hospital admission were primary end points. Bootstrap analysis was used for comparison of costs and 30-day mortality between the NT-proBNP and control group. Results A total of 477 patients (54% male) was enrolled. The mean age was 59 years, with 44% of patients having a history of cardiac disease. Median time to discharge from the hospital was 1.9 days (interquartile range [IQR], 0.12- 8.4 days) in the NT-proBNP group (n = 241) compared with 3.9 days (IQR, 0.16-11.0 days) in the control group (n = 236) (P = .04). Introduction of NT-proBNP testing resulted in a trend toward reduction in costs related to hospital admission and diagnostic investigations of $1,364 per patient (95% CI $-246 to $3,215), whereas 30-day mortality was similar (15 patients in the NT-proBNP and 18 patients in the control group). Conclusions Introduction of NT-proBNP testing for heart failure in the ED setting reduces the time to discharge and is associated with a trend toward cost reduction. (Am Heart J 2008;156:71-7.) In patients with acute dyspnea presenting to the emergency department (ED), fast and accurate diagnosis is essential for the delivery of proper medical care. Diagnostic decision making can be difficult, especially because heart failure often coincides with other condi- tions, such as chronic obstructive pulmonary disease. 1-3 B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) testing has been evaluated for the diagnosis of heart failure in patients with complaints of acute dyspnea. 4-16 Based on these findings, BNP or NT-proBNP testing has been recommended for diagnostic evaluation of patients suspected for heart failure. 17,18 A crucial question is whether natriuretic peptide testing improves the management of care and saves costs of patients presenting with acute dyspnea to the ED. So far, a few studies have addressed this question. 19-22 These studies indicate that introduction of rapid point-of-care BNP or NT-proBNP testing in the ED is associated with cost savings without adversely affecting short-term outcome. Obviously, the effect of introduction of natriuretic peptide testing on clinical outcome and cost savings strongly depends on the way medical care is organized and delivered. Hence, findings may vary from region to region and, therefore, are not necessarily interchange- able. The objective of our study was to investigate whether introduction of rapid NT-proBNP testing in the ED of our hospital associates with improved diagnostic decision making as reflected in cost savings without compromising clinical outcome. From the a Department of Internal Medicine, Erasmus Medical College-University Medical Center Rotterdam, Rotterdam, The Netherlands, b Department of Public Health, Erasmus Medical College-University Medical Center Rotterdam, Rotterdam, The Netherlands, c Department of Cardiology, Thoraxcenter, Erasmus Medical College-University Medical Center Rotterdam, Rotterdam, The Netherlands, d Department of Pulmonary Medicine, Erasmus Medical College-University Medical Center Rotterdam, Rotterdam, The Nether- lands, and e Department of Clinical Chemistry, Erasmus Medical College-University Medical Center Rotterdam, Rotterdam, The Netherlands. This research project was funded by a grant of the Erasmus MC Medical Research Advisory Committee (Mrace). Submitted October 7, 2007; accepted February 12, 2008. Reprint requests: Anton H. van den Meiracker, MD, PhD, Erasmus MC, Department of Internal Medicine, Room D 432, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands. E-mails: jrutten@erasmusmc.nl, a.vandenmeiracker@erasmusmc.nl 0002-8703/$ - see front matter © 2008, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2008.02.021