Lee KK et al.BMJ. 2022 Jun 13;377:e068424. 

本文主要评估NT-proBNP阈值。开发并验证了一种决策支持工具(心衰诊断与评估协作(CoDE-HF))，该工具结合NT-proBNP和临床变量来报告单个患者急性心衰的概率。

研究纳入10369例患者，43.9%(4549/10 369)的患者被确诊为急性心力衰竭(分别为73.3%(2286/3119)和29.0%(1802/6208))。无心衰病史的患者中，所有亚组诊断结果一致，40.3%(2502/6208)诊断为急性心衰的低概率(阴性预测值为98.6%，97.8%到99.1%)和28.0%(阳性预测值为75.0%，65.7%到82.5%)。

在一项关于NT-proBNP诊断性能的国际合作评估中，指南推荐的诊断急性心力衰竭的阈值在重要的患者亚组中存在显著差异。CoDE-HF决策支持工具结合NT-proBNP作为连续测量和其他临床变量，提供更一致、更准确和个性化的方法。

Abstract

Objectives: To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics.

Design: Individual patient level data meta-analysis and modelling study.

Setting: Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies.

Participants: Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated.

Main outcome measure: Adjudicated diagnosis of acute heart failure.

Results: Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure.

Conclusions: In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach.

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