Amino-terminal pro-brain–type natriuretic peptide: Heart or lung disease in pediatric respiratory distress?

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Cohen S, Springer C, Avital A, Perles Z, Rein AJ, Argaman Z, et al. Pediatrics 2005;115:1347-50

Context Brain natriuretic peptide (BNP) is secreted mainly by cardiac ventricular myocytes in response to stretching, and its plasma levels are related to left ventricular filling pressures. BNP has been found to be a good marker for cardiac dysfunction in adults. Its utility in children has not been as widely studied.

Objectives To determine whether plasma levels of amino-terminal pro-brain natriuretic peptide (N-BNP) could differentiate between heart failure and lung disease among infants with acute respiratory distress, and whether plasma levels of N-BNP could be used to monitor the effects of treatment in infants with heart failure.

Design Longitudinal cohort study.

Setting A university hospital in Jerusalem, Israel.

Participants Infants (age range, 1 to 36 months; median age, 10 months) who presented with respiratory distress underwent physical examination, plasma N-BNP measurement, and echocardiography within 24 hours after admission. Seventeen infants were finally diagnosed with acute heart failure, and 18 were diagnosed with acute lung disease. Thirteen healthy infants served as a control group.

Main Outcome Measure Plasma N-BNP levels.

Results Plasma N-BNP levels were significantly higher for the infants with heart failure (median, 18 452 pg/mL; range: 5375–99 700 pg/mL) than for the infants with lung disease (median, 311 pg/mL; range, 76 to 1341 pg/mL). Among the infants with heart failure, there was a significant difference in plasma N-BNP levels before and after treatment for congestive heart failure.

Conclusions In infants with respiratory distress, plasma N-BNP measurements can differentiate between acute heart failure and lung disease and can be used to monitor the effects of treatment in infants with heart failure.

Comment The objective of this study was to establish the utility of N-BNP in differentiating cardiac and pulmonary causes of respiratory distress in pediatric patients. In addition, the authors assessed the value of N-BNP levels in monitoring the response to treatment for congestive heart failure. The authors reported significantly higher N-BNP levels in infants with tachypnea due to underlying congestive heart failure compared with infants with acute respiratory disease and healthy controls. In this study the calculated N-BNP cutoff value differentiating cardiac from respiratory causes of tachypnea was 2940 pg/mL, with a test accuracy of 100%. This degree of accuracy demonstrates the advantage of using N-BNP instead of BNP as a marker of underlying cardiac disease in tachypneic infants. An earlier investigation of the utility of BNP in distinguishing cardiac from pulmonary causes of tachypnea in pediatric patients resulted in a cutoff value of 40 pg/mL with 87% accuracy.¹

Although this study represents the beginnings of a potentially clinically useful approach to the evaluation of tachypneic infants, there are still limitations to the use of N-BNP in the clinical setting. As noted by the authors, the presence of comorbid conditions can be misleading, necessitating continued, comprehensive clinical evaluation. N-BNP level is a sensitive indicator of underlying cardiac disease in infants with respiratory distress. A large-scale, prospective study is needed to more definitively establish the utility of this approach in evaluating tachypneic infants.

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Reference 

1. Koulouri S, Acherman RJ, Wong PC, Chan LS, Lewis AB. Utility of B-type natriuretic peptide in differentiating congestive heart failure from lung disease in pediatric patients with respiratory distress. Pediatr Cardiol. 2004;25:341–346
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