Pro-BNP levels in the evaluation of patients presenting with chest pain

Patients with chest pain who “rule out” with negative ECGs and troponin levels present a difficult problem because although they lack objective signs of ischemia their symptoms may still have represented cardiac pain, placing them at risk for future events. Pro-BNP was shown to provide incremental prognostic information in such patients in a previous study.

A new study by the same authors compared the conventional strategy of stress testing such patients against a new strategy of combining a clinical risk score with Pro-BNP testing and found equivalent outcomes:

Results
A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%,P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04).

Conclusions
A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed.
A caveat not mentioned by the authors is that Pro-BNP levels may be falsely low in patients with obesity. A Pro-BNP cut off of 110 was used.

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