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Sandy M. Green, MD; Abelardo Martinez-Rumayor, MD; Shawn A. Gregory, MD; Aaron L. Baggish, MD; Michelle L. O’Donoghue, MD; Jamie A. Green, MD; Kent B. Lewandrowski, MD; James L. Januzzi Jr, MD

Arch Intern Med. 2008;168(7):741-748.

Background  Dyspnea is a common complaint in the emergency department (ED)and may be a diagnostic challenge. We hypothesized that diagnostic uncertainty in this setting is associated with adverse outcomes, and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) testing would improve diagnostic accuracy and reduce diagnostic uncertainty.

Methods  A total of 592 dyspneic patients were evaluated from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Managing physicians were asked to provide estimates from 0% to 100%of the likelihood of acutely destabilized heart failure (ADHF). A certainty estimate of either 20% or lower or 80% or higher was classified as clinical certainty, while estimates between 21% and 79% were defined as clinical uncertainty. Associations between clinical uncertainty,hospital length of stay, morbidity, and mortality were examined. The diagnostic value of clinical judgment vs NT-proBNP measurement was compared across categories of clinical certainty.

Results  Clinical uncertainty was present in 185 patients (31%), 103(56%) of whom had ADHF. Patients judged with clinical uncertainty had longer hospital length of stay and increased morbidity and mortality,especially those with ADHF. Receiver operating characteristic analysis of clinical judgment yielded an area under the curve (AUC) of 0.88in the clinical certainty group and 0.76 in the uncertainty group (P < .001); NT-proBNP testing alone in these same groups had AUCs of 0.96 and 0.91, respectively. The combination of clinical judgment with NT-proBNP testing yielded improvements in AUC.

Conclusions  Among dyspneic patients in the ED, clinical uncertainty is associated with increased morbidity and mortality, especially in those with ADHF.The addition of NT-proBNP testing to clinical judgment may reduce diagnostic uncertainty in this setting.

Author Affiliations: Department of Medicine (Drs S. M. Green, Martinez-Rumayor, and J. A. Green), Cardiology Division (Drs Gregory, Baggish, O’Donoghue, and Januzzi), and Department of Pathology and Laboratory Medicine (Dr Lewandrowski),Massachusetts General Hospital and Harvard Medical School, Boston.

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