Key result
Adding serum NT-proBNP to the Canadian Syncope Risk Score did not significantly improve the prediction of 30-day serious adverse events (c-statistic 0.90 vs 0.89; P=0.12).
Why the study?
Studies have reported that natriuretic peptides provide prognostic information for emergency department syncope, but whether adding NT-proBNP to the Canadian Syncope Risk Score improves prediction of 30-day serious adverse events was unknown.
Does adding NT-proBNP to the Canadian Syncope Risk Score improve the prediction of 30-day serious adverse events in adult emergency department patients with syncope?
Cohort (n=1,452)
Yes
Does adding NT-proBNP to the Canadian Syncope Risk Score improve the prediction of 30-day serious adverse events in adult emergency department patients with syncope?
Routine measurement of NT-proBNP does not significantly improve the already robust 30-day prognostic accuracy of the Canadian Syncope Risk Score in emergency department patients with syncope.
Answers are grounded in this paper and cite their sources.
NT-proBNP addition does not improve CSRS-based SAE prediction in ED syncope; leaves open any role in refined models or subgroups.
Background: Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. Objective: To evaluate whether adding N-terminal pro–B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). Design: Prospective cohort study. Setting: 6 EDs in 2 Canadian provinces. Participants: 1452 adult ED patients with syncope. Intervention: Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. Measurements: An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. Results: Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. Limitations: Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. Conclusion: Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. Primary Funding Source: Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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Thiruganasambandamoorthy et al. (2020) conducted a cohort in Syncope (n=1,452). Adding NT-proBNP to the Canadian Syncope Risk Score vs. Canadian Syncope Risk Score alone was evaluated on Adjudicated composite outcome of 30-day serious adverse events (SAEs), including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events (c-statistic 0.90 vs 0.89, p=0.12). Adding serum NT-proBNP to the Canadian Syncope Risk Score did not significantly improve the prediction of 30-day serious adverse events (c-statistic 0.90 vs 0.89; P=0.12).
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