Prehospital Triage of Patients With Severe Shortness of Breath Using Biomarkers (PreBNP)

Prehospital Triage of Patients With Severe Dyspnea Using Point-of-Care N-terminal Pro-Brain Natriuretic Peptide. PreBNP Trial.

Breathlessness is a dangerous symptom. Preliminary data from national and regional Danish databases show, that patients with shortness of breath in the ambulance have a very high mortality. Breathlessness can be caused by many different conditions - but heart diseases and lung diseases are dominant. The mortality is especially high in patients with breathlessness caused by heart disease. Distinguishing these different causes of breathlessness is a classical, often difficult, discipline in medicine. Visitation and guidance of treatment in patients with breathlessness in the prehospital setting relies on medical history and physical examination and as a consequence prehospital treatment for breathlessness is often non-specific. The use of heart-failure specific biomarkers may improve prehospital visitation and treatment of patients with breathlessness. We hypothesize, that Supplementing the routine examination by prehospital anesthesiologist with measurement of a biomarker for heart failure increases the proportion of patients with severe shortness of breath caused by heart disease triaged directly to department of cardiology This strategy does not increase the proportion of patients with severe shortness of breath caused by non-heart disease triaged directly to department of cardiology

Measurement of the biomarker for heart failure N-terminal pro-Brain Natriuretic Peptide (NT-proBNP): In patients randomized to the strategy with supplementary measurement of NT-proBNP, a blood sample will be drawn from the peripheral venous catheter that is routinely inserted. This will be analyzed point-of-care in the ambulance. Interpretation of NT-proBNP: Cut-off values based on bootstrap-validated optimal cut-points for heart failure on will be used. Confirmatory ('rule in') cut point < 50 years: 450 pg/mL 50-75 years: 900 pg/mL > 75 years: 1800 pg/mL Exclusionary ('rule out') cut point All patients: 300 pg/mL The emergency physicians will be thoroughly informed about these cut-points, but told not to triage to department of cardiology or other department strictly according to NT-proBNP, but according to clinical assessment AND NT-proBNP.

In patients randomized to the strategy with supplementary measurement of NT-proBNP, a blood sample will be drawn from the peripheral venous catheter that is routinely inserted and analyzed immediately using a COBAS H232 and Roche Diagnostics NT-proBNP assay.

Proportion of patients with dyspnea caused by heart disease initially triaged to department of cardiology

An endpoint committee determines final diagnoses as "dyspnea caused by heart disease", "dyspnea caused by lung disease" and "dyspnea caused by other diseases" based on clinical and paraclinical data excluding prehospital NT-pro-BNP value

Proportion of patients with dyspnea of other etiologies initially triaged to department of cardiology

An endpoint committee determines final diagnoses as "dyspnea of cardiac origin" and "dyspnea of non-cardiac origin" based on clinical and paraclinical data excluding prehospital NT-pro-BNP value

beta2-agonist inhalations, combined ipratropium/b2-agonist inhalations, intravenous b2-agonists, intravenous corticosteroids

Within the time from hospital admission related to the inclusion event to discharge from hospital related to inclusion event

Proportion of patients with dyspnea caused by lung disease, that receives traditional heart failure medication

An endpoint committee determines final diagnoses based on clinical and paraclinical data excluding prehospital NT-pro-BNP value

Proportion of patients where congestive heart failure is correctly disproved in the prehospital setting

An endpoint committee determines final diagnoses based on clinical and paraclinical data excluding prehospital NT-pro-BNP value

Inclusion Criteria: All patients requiring dispatch of emergency physician because of severe dyspnea. Severe dyspnea is defined by dyspnea plus at least ONE of the following Respiration frequency > 20 or < 8 Saturation < 96 without supplementary oxygen Heart rate > 100 or < 50 Systolic blood pressure < 100 or > 200 Difficulty talking Central or peripheral cyanosis Use of accessory muscles of respiration Glasgow coma scale score < 15 AND because of the physical condition, the patient is not able to give informed consent Exclusion Criteria Age < 18

Botker MT, Jorgensen MT, Stengaard C, Seidenfaden SC, Tarpgaard M, Granfeldt A, Mortensen TO, Grofte T, Friesgaard KD, Maerkedahl R, Pedersen AB, Lundorff S, Hansen TM, Kirkegaard H, Christensen EF, Terkelsen CJ. Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial. Eur Heart J Acute Cardiovasc Care. 2018 Jun;7(4):302-310. doi: 10.1177/2048872617709985. Epub 2017 May 11.