Usefulness of the N-terminal pro brain natriuretic peptide as short-term prognostic factor for mortality in elderly patients with infection seen in emergency departments

García-Tercero, Elisa; Iqbal-Mirza, Sadaf Zafar; Julián-Jiménez, Agustín

doi:10.1016/j.medcle.2018.05.011

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In it, the authors conclude that said biomarker (BM) obtained in the first 72h of admission in patients with low mortality risk (according to the score Sepsis-related Organ Failure Assessment [SOFA]) is “the best predictor of in-hospital mortality”. Statement, in our opinion, too categorical without solid scientific evidence, at least for the time being.In addition to congratulating the authors for their results and for highlighting the relevance of adding new tools to classify the severity of the patient with sepsis and improve their vital prognosis,<a class="elsevierStyleCrossRef" href="#bib0035">2</a> as is the case of biomarkers (BM),<a class="elsevierStyleCrossRefs" href="#bib0040">3,4</a> we agree with them that NT-proBNP should be considered as a BM with a great capacity for predicting mortality, but we would like to make some considerations.As a contribution to what was said by García Villalba et al., we would like to compare our results with theirs, from a pilot study that we have carried out with patients treated for infection in the emergency department (ED). The samples of both studies are similar: (García Villalba et al.: 174 patients with mean age 73 [SD: 16] years with 9.8% mortality during hospitalization, a SOFA of 2 [IQR 1–3] and with 25% of patients with a history of heart failure [HF]) and our study (136 patients of whom 13 died [9.6%] at 30 days, age 85 [SD: 8] years, a SOFA of 2 [IQR 1–3] and 28% with IC). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows various patient data. In 51.47% the site of infection was respiratory, in 33.8% urinary and 6% abdominal.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>On the other hand, the authors find that the best receiver operating characteristic (ROC) under the curve (AUC) area obtained corresponds to NT-proBNP with 0.793 (95% HF: 0.686–0.9; p<0.001) and its best cut-off point (CP)=1.330pg/ml; whereas lactate measurement achieves the worst results (lower performance than C-reactive protein [CRP] and procalcitonin [PCT]) with 0.514 (95% HF: 0.377–0.650; p=0.863). These results contrast with those obtained in our study, in the first ED assessment, since lactate, as occurs in most studies<a class="elsevierStyleCrossRef" href="#bib0045">4</a> is shown as the best predictor of in-hospital and short-term mortality (30 days). In our case, it obtained an ROC-AUC of 0.823 (95% HF: 0.710–0.936; p<0.001) and with a CP: 3.13mmol/l a sensitivity (Se) of 98% and a specificity (Sp) of 88%, while NT-proBNP an AUC-ROC of 0.777 (95% HF: 0.651–0.903; p=0.001) with an optimal CP of 1253pg/ml with Se: 76% and Sp: 70%. In our case, CRP does not obtain any prognostic performance with AUC of 0.571 (95% HF: 0.426–0.716; p=0.403), which also corresponds to the latest published reviews.<a class="elsevierStyleCrossRef" href="#bib0045">4</a>We believe that the difference in results is due to the difference in clinical scenarios. The measurement of lactate and NT-proBNP during the 72h after admission determines their levels. If we assume that they have been adequately treated with electrolyte replenishment and support treatments. So, logically, the prediction of mortality should be different upon arrival. For lactate, the levels decrease along with the prediction of mortality when a good intravascular volume balance is achieved. And, on the other hand, the maintenance or elevation of NT-proBNP levels as a consequence of diverse factors (existence of acute heart failure or water overload, age, patients with reduced systolic function compared to maintained systolic function, hypertension or renal failure, among others).<a class="elsevierStyleCrossRef" href="#bib0050">5</a> In other words, in addition to the already mentioned factors, the time for obtaining the sample must be taken into account when interpreting the results.In summary, although NT-proBNP may be a good BM to predict short-term mortality, it cannot be stated that it is the best predictor, or that it exceeds lactate, which should be measured and monitored, as recommended by all sepsis patient care guidelines. And, also, that we must always bear in mind the patient's kinetics, characteristics, clinical situation and when and how the sample is obtained (especially if an antimicrobial and electrolyte replacement therapy has been previously administered)." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García-Tercero E, Iqbal-Mirza SZ, Julián-Jiménez A. Rendimiento pronóstico de mortalidad a corto plazo del fragmento N-terminal del propéptido natriurético cerebral en ancianos con infección en el servicio de urgencias. Med Clin (Barc). 2018;151:e3–e4." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation; GCS: Glasgow coma score; NT-proBNP: N-terminal pro-brain natriuretic peptide; SBP: systolic blood pressure; qSOFA: quick Sepsis-related Organ Failure Assessment; SIRS: systemic inflammatory response syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Survivors at 30 days N=123 (90.5%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Short-term mortality (30 days) N=13 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age in years, (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (45%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (77%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index≥3, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (53%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (61%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBP≤90mmHg, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Altered consciousness (GCS≤14), n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (31%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (84%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SIRS criteria≥2, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (21%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">qSOFA≥2, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (24%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (77%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum lactate in mmol/l (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.63 (0.79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.86 (1.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NT-proBNP in pg/ml (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.091 (6377) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,602 (18,498) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1805613.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Some clinical, epidemiological, exploratory and laboratory characteristics according to 30-day mortality since their assessment in the emergency department." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El fragmento N-terminal del propéptido natriurético cerebral es el mejor predictor de mortalidad intrahospitalaria en pacientes con sepsis y bajo riesgo de lesión orgánica" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. 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ISSN: 2387-0206

Launched in 1943, Medicina Clínica is a fortnightly journal aimed at the promotion of clinical research and practice among internal medicine and other specialists. The key characteristics of Medicina Clínica are the scientific and methodological rigor of its manuscripts, the topicality of its contents, and, especially, its practical focus with highly useful information for clinical practice. Medicina Clínica is predominantly interested in publishing original research manuscripts, which are rigorously selected according to their quality, originality, and interest, and also in continued medical education-oriented manuscripts, which are commissioned by the journal to relevant authors (Editorials, Reviews, and Diagnosis and Treatment). These manuscripts contain updated topics with a major clinical or conceptual relevance in modern medicine. The journal adheres to the standards of academic research publications in all aspects including peer-review and ethical principles. Medicina Clínica is included in the General and Internal Medicine category of Thomson Reuters.

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

2.6

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

3.1

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.371

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.511

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Vol. 151. Issue 1.