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Heart failure (HF) is a clinical syndrome that associates clinical signs in people over 80 years of age, an increase in natriuretic peptides and abnormal cardiac structures that result from cardiac aging in many cases. The most common symptoms are grouped according to the acronym "EPOF" (shortness of breath, weight gain, edema, fatigue). Over the age of 80, comorbidities must be taken into account. The incidence and prevalence of HF significantly increases with age and makes HF the most common reason for hospitalization for people over 80, and an important health expense. The management of HF, necessarily multidisciplinary with a geriatric evaluation, has improved over time due to effective targeted treatment, but mortality, hospitalization and readmission rates remain high. Therapeutic education and patient follow-up for treatment optimization are needed., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The management of heart failure requires reproducible and easily accessible biomarkers. For diagnosis, measurement of natriuretic peptides is highly recommended as first line. For the stratification of patients, natriuretic peptide testing is highly recommended and other biomarkers such as troponin or fibrosis markers can also be used. For any biomarkers, changes in blood levels over time is more relevant than a single assay. For monitoring as well as guiding heart failure treatment, serial testing of natriuretic peptides is useful in young patients with systolic dysfunction. For the screening of high-risk patients, natriuretic peptides testing is not fully validated yet., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Based on a case report, this article reviews the different forms of cardiac involvement in amyloidosis. This affection refers to the extracellular tissue deposition of protein fibrils (the amyloid substance), which gradually invades a variety of organs, disrupting their function. The clinical presentation depends on the type of the amyloidogenic protein and on its main distribution. The most severe cardiac impairment and with the worse prognosis is seen in its primary form (or AL), while it is less frequent, with a slower course and a better prognosis in its other forms: secondary (AA), familial (ATTR) or senile (SSA).

Aim: We report the first experience of Lyon's university hospital regarding renal denervation to treat patients with resistant essential hypertension., Patients and Methods: Over a one-year period, 17 patients were treated (12 men, 5 women) with renal denervation. Baseline characteristics were as follows: age 56.5±11.5 years, BMI 33±5kg/m(2) and ambulatory blood pressure 157±16/87±13mmHg with 4.2±1.5 anti-hypertensive treatment., Results: We did not observe intra-operative or early complications. After a median follow-up of 3 months and with the same anti-hypertensive treatment, office systolic blood pressure (SBP) and diastolic blood pressure (DBP) decrease respectively of 20±15 (P<0.001) and 10±13mmHg (P=0.014) (n=17). After six months of follow-up, ambulatory blood pressure (ABPM) decrease of 17.5±14.9mmHg (P=0.027) for SBP and of 10.5±9.6mmHg (P=0.029) for DBP (n=6). Among these patients, five of them were controlled (ABPM inferior to 130/80mmHg) and electrical left ventricular hypertrophy indexes decreased: R wave in aVL lead of 4±3mm (P=0.031), Sokolow index of 3±3mm (P=0.205), Cornell voltage criterion of 9±7mm (P=0.027) and Cornell product of 1310±1104 (P=0.027)., Conclusion: Our results are in accordance with data from other centers. On average blood pressure decreases significantly but important inter individual variations are observed. The procedure seems safe., (Copyright © 2014. Published by Elsevier SAS.)

The study of the influence of the anticoagulant used in blood collection tubes to obtain plasma was performed for fifteen biochemical parameters measured with automated Cobas 6000 (Roche Diagnostics). For each parameter tested the entire measurement domain was studied. The comparison of results obtained on plasma blood sample obtained by lithium heparin and EDTA include: correlation, the limits of acceptability in the standards of monitoring and interpretation standards regression defined by the SFBC and analysis of Bland-Altman. The parameters studied were classified into three categories. The parameters for which the assay is not influenced by the nature of the anticoagulant used: apolipoprotéin A1, apolipoprotein B, alanine amino-transferase, creatine kinase, creatinine, total cholesterol, HDL-cholesterol, lipase, NT-Pro BNP, troponine T and urea. The parameters for which the results are underestimated EDTA plasma, including those for which the impact is moderate and for which the interpretive standards are not changed: triglycerides, and those for which performance standards are changed on one or more levels: aspartate aminotransferase and lactate dehydrogenase; and finally the not practicable EDTA plasma parameters: alkaline phosphatase.

The study of the influence of hemolysis was determined experimentally for twenty two biochemical parameters on the analyzer Cobas 6000 ce (Roche Diagnostics). The addition method of hemolysate was used to create an increasing concentration of hemoglobin ranging from 0 to 2000 μmol/L. The limit of 10% variation was chosen to define the influence of hemolysis on the measurement. The parameters studied were classified into several categories: the parameters for which hemolysis does not influence the measurement: albumin, uric acid, calcium, C-reactive protein, myoglobin, NT -pro BNP, S100 protein, and urea; parameters impacted positively leading to an overestimation of the result: aspartate aminotransferase, total cholesterol, creatine kinase, creatinine, lactate dehydrogenase, magnesium, magnesium, total protein, triglycerides; and negatively impacted settings so causing an underestimation of the result: alanine amino- transferase, gamma glutamyl transferase, lipase, alkaline phosphatase, troponin T hypersensitive. Certain parameters influence of hemolysis varies depending on the magnitude of the measured parameter this interference being observed for normal values but disappearing for pathological values: creatinine, cholesterol, alkaline phosphatase, triglycerides, or the inverse interference is greater than for conventional pathological values: lipase, alanine amino-transferase. Knowledge of this variability interference allows the biologist to adapt its methods of reporting in the case of haemolysed samples.

Reducing readmissions after hospitalisation for acute heart failure is the new challenge of these diseases, approaching 30% within 60 to 90 days of discharge. Congestion related to high ventricular filling pressures, reflected by the high levels of natriuretic peptides, is the main reason for heart failure readmission. Natriuretic peptide levels are a patent prognostic marker of cardiovascular event in chronic heart failure. Treshold values of BNP and NT-proBNP being respectively 125 and 1000 pg/mL. Optimizing treatment of heart failure by monitoring natriuretic peptides, including management of diuretic doses, remains matter of controversies.

Mycoplasma pneumonia is responsible for multisystemic infection. Pulmonary symptoms are most common in children. We describe herein two unusual severe forms of M. pneumoniae infection without initial pulmonary symptoms. The first case is an 8-month-old boy who was hospitalized in the pediatric intensive care unit with severe sepsis. There were no initial pulmonary symptoms, nor obvious clinical infection. Initial blood tests and x-ray did not aid the diagnosis. The blood tests came back positive for M. pneumonia. Pulmonary symptoms eventually appeared 24h later, and there was a pneumonia outbreak on the chest radiograph. The boy was given josamycin and improved quickly. The second case concerns an 8-year-old child who was hospitalized in the pediatric intensive care unit with toxic shock. No clinical infectious origin was found. A broad-spectrum antibiotic therapy was started with ceftriaxone and josamycin. The M. pneumoniae blood test came back positive, which confirmed the diagnosis of septic shock in M. pneumoniae, requiring adjustment of the antibiotic therapy. Current guidelines for the choice of probabilistic antibiotic therapy in case of severe sepsis do not include the case of M. pneumoniae. The early initiation of antibiotic therapy plays a major role in the prognosis of these patients. It seems useful to search for M. pneumoniae in cases of severe atypical infections, particularly in the absence of pulmonary symptoms., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: It would be interesting to the emergency doctor to have at his disposal a helpful diagnostic tool like brain natriuretic peptide (BNP). Such assay is simple, available and reliable., Aims: To report our experience on the role of BNP in the etiological diagnosis of acute dyspnea (AD) in emergency room (ER) and to assess the cost-effectiveness ratio of such diagnosis strategy., Methods: A prospective study conducted in the ER of Rabta university teaching hospital of Tunis, from March 1st to June 20th 2010, involving 30 consecutive patients presenting to the emergency for AD. All patients underwent echocardiography in their acute phase and benefited from the dosage of BNP during the first 4 hours. The echocardiography parameters were collected by a single operator who was unaware of the results of the BNP dosage., Results: The mean age of patients was 72.8years with a sex ratio of 1.5. AD was of orthopnea type in 9 cases and stage III NYHA dyspnea in the other patients. Clinical and radiological signs of left heart failure were noted in 30% of cases. Ultrasound data have objectified systolic dysfunction in 4 cases, diastolic in 3 cases and systolic plus diastolic in 10 cases. The BNP levels were below 100 pg/ml in 10 cases with pulmonary origin of the AD. A BNP level between 100 and 400 pg/ml was noted in 3 cases. In our study, the clinical probability of AHF prior to performing the test was estimated at 53% and estimated at 100% after the BNP assay. The BNP assay has reduced the length of stay in the emergency department 4 to 5 days and saved nearly 50% of the cost of care per patient., Conclusion: The BNP assay, has allowed us to confirm the AHF all cases. Given the prognostic value and economic benefit of this test we recommend its use in ER of our country.

Heart failure is characterised by the inability of the heart to ensure sufficient blood flow to meet the metabolic needs of the body's tissues. Neurohormanal disorders are preponderant, leading to ventricular remodelingwhich enables the heart to compensate for the haemodynamic insufficiency, until the appearance of clinical symptoms of heartfailure.There are two types of physiopathological impairment: systolic and diastolic.

The dosage of natriuretic peptides improves diagnostic performance in patients with acute dyspnea when combined with clinical elements. The high sensitivity of this test allows reasonably excluding heart failure when the value is normal. Nevertheless, an increased level of this biomarker is not specific of heart failure and can be observed in different pathologies such as renal failure, sepsis or elevated pulmonary arterial pressure. We therefore analyse the diagnostic performance of natriuretic peptide in COPD patients and discuss its use for the detection of heart failure in this population.

Natriuretic peptides, particularly BNP and NT-proBNP, are increasingly used as screening test in patients with symptoms suggestive of heart failure (HF). Due to their high negative predictive values, natriuretic peptide determinations allow to exclude chronic HF with great certainty and to identify patients for whom echography is not necessary. These biomarkers are also useful for diagnostic purposes, high plasma levels being related to an increased risk of cardiovascular hospitalisation and death. Risk stratification in patients with HF symptoms is based on "low" and "high" cut-off limits, for which different values have been proposed. The aim of this paper is to discuss the delineation of the decision limits and the intermediate grey zone in comparison to NT-proBNP reference values obtained in a representative group of subjects living in the Liège area (Belgium). Data were analysed in relation to age and gender, two of the main parameters influencing the natriuretic peptide plasma levels.

Pulmonary embolism with choc carries a 25 to 50% mortality rate. Although no large randomized clinical trial is available, some insights of a meta-analysis suggest that thrombolysis decreases the mortality rate in these patients. In patients without clinical evidence of haemodynamic impairment, the mortality rate is much lower and does not justify more aggressive therapy other than anticoagulants. Recent data however suggest that among clinically stable patients, some may have a higher mortality risk. These so called sub-massive or intermediate-risk pulmonary embolism are defined either by right ventricular dysfunction assessed by echocardiography or by elevated troponin or brain natriuretic peptide. The role of thrombolytic treatment in these patients remains controversial. A large randomized controlled trial is underway to resume the debate., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Systemic AL amyloidosis is a rare complication of monoclonal gammopathies. Renal manifestations are frequent, mostly characterized by heavy proteinuria, with nephrotic syndrome and renal failure in more than half of the patients at diagnosis. Without treatment, median survival does not exceed 12 months. Amyloid heart disease and diffusion of amyloid deposits are associated with reduced survival. Treatment of systemic AL amyloidosis has been profoundly modified with the introduction of international criteria for the definition of organ involvement and hematologic response, and with the use of sensitive tests for the measurement of serum-free light chain levels. Melphalan plus dexamethasone is now established as the gold standard for first line treatment of systemic AL, with similar efficacy and reduced treatment-related mortality compared to high-dose therapy. Modern chemotherapy regimens, based on the use of novel agents such as bortezomib and lenalidomide, might further improve patient survival., (Copyright © 2011 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

This is a case of an 82 year old female patient with myasthenia gravis, who following treatment with Human Normal Immunoglobulin (Tegeline(®)), developed dyspnoea, chest pain without cardiac insufficiency, inverted T wave on ECG with slight increase in Troponine T 0.43ng/mL (<0.2ng/mL normal value in our hospital) and marked increase in Pro-BNP 4900 (Nl≤450pg/mL for an age greater than 65 years old). Her coronary angiogram showed hypokinesia of apical area but was otherwise normal. Also, MRI ruled out inflammatory and ischemic cardiac diseases. The most likely diagnosis for us was Tako-Tsubo syndrome in relation with injection of Human Normal Immunoglobulin (Tegeline(®)) according to the Mayo clinic criteria., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

The production of brain natriuretic peptide (BNP) by ventricular cardiomyocytes is increased in patients with left ventricular hypertrophy (LVH). Increased plasma levels of BNP or of the inactive fragment NP-proBNP are associated with an increased cardiovascular risk. The measurement of plasma concentrations of these peptides may be useful for stratifying the cardiovascular risk of hypertensive patients, particularly if there is no electrocardiographic evidence for LVH.

Laboratory tests contribute to patient length of stay in the emergency department. Therefore, rapid tests performed at the bedside (POCT or point of care testing) are attractive because they allow the emergency physician to obtain immediate biological, diagnostic and/or prognostic data. Userfriendly and with validated analytical performance, POCT have the potential to reduce laboratory time, patient length of stay and time to treatment or disposition. The expected benefit from POCT implementation will depend on the type of patients involved (inpatient or outpatient), their clinical condition and their overall care. Furthermore, logistical and economic implications should also be taken into account.

Introduction: High-risk pulmonary embolism (PE) is associated with a significant early mortality, approaching 25%, and is defined by the presence of cardiogenic shock., State of the Art: The high early mortality rate for patients with shock requires a rapid diagnostic approach with bedside tests. Right ventricular dilatation assessed by echocardiography in patients with a high clinical probability for PE confirms the diagnosis without the need for additional testing. Spiral CT pulmonary angiography remains the first line investigation for patients without shock. Anticoagulant treatment should be started as soon as pulmonary embolism is suspected. Fibrinolytic therapy is recommended for patients with high-risk pulmonary embolism. The prognostic value of cardiac biomarkers, such as B natriuretic peptide, troponins and right ventricular dilatation for early mortality has been demonstrated. These markers permit the identification of an intermediate risk group of patients with normotensive pulmonary embolism and prognostic scores have been developed., Perspectives: It remains to be established whether fibrinolysis can have a clinical benefit or reduce mortality in patients with intermediate risk pulmonary embolism. A large randomised placebo-controlled study is currently under way to answer this question. Further studies will more clearly define the role of various predictive rules to identify patients requiring hospital care or those who should be considered for outpatient management., (Copyright © 2011. Published by Elsevier Masson SAS.)

Aim of the Study: BNP levels are accurate in the diagnosis of heart failure and useful in clinical practice. Relationship between BNP, heart failure (HF) and renal function are little known in the elderly. Renal function influence the optimal cut point of BNP in patients with a Glomerular Filtration Rate (eGFR) lesser than 60 ml/min/1.73 m(2)., Methodology: A total of 71 patients (mean age = 85 years) were admitted in a Cardiogeriatric Unit. We noted several parameters, age, gender, the presence or the absence of Systolic Heart Failure (clinical history and physical examination), the echographic measure of the left ventricular ejection fraction, the eGFR value calculated by simplified MDRD formula and the BNP value. We divided these patients into six groups according the presence of HF and eGFR value higher than 60ml/min/1.73m(2),or between 30 and 60 or between 15 and 30., Results: Our results show that the BNP value is higher in all the three groups of patients with Heart Failure with or without diminution of the eGFR: for example, 1220 pg/ml in the presence of HF versus 788 pg/ml in the absence of HF in the two groups with the eGFR is calculated between 15 and 30 ml/min/1.73m(2)., Conclusion: BNP is a helpful tool in clinical practice for the diagnosis of Systolic Heart Failure in the presence of renal impairment in the elderly with a higher biomarker cut point., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The diagnosis of heart failure is based on strict process using clinical examination as well as other tests. The fine analysis of cardinal symptoms - tiredness and dyspnea--as well as of various signs is required. In cases of uncertainty, blood testing of BNP or NT-pro-BNP improves the diagnostic accuracy. Then the diagnosis is confirmed only after the assessment of evidence of cardiac abnormalities, using cardiac echography among others. Such process will be repeated in cases of significant changes in symptoms. The diagnostic process is associated with etiological investigations as well as the strict assessment of precipitating factors, because of their potential consequences on treatment.

Objective: To describe the features of pulmonary arterial hypertension (PAH) in elderly patients., Methods: A single centre, descriptive study of PAH patients consecutively referred to a regional centre, from September 2002 to February, 1st, 2009. The group of patients aged 65 and above at the time of the diagnosis was compared to the younger patients., Results: Sixty-six patients suffering from PAH (group 1) have been investigated by means of right heart catheterisation. There were 24 patients aged 65 and above. Mean pulmonary arterial pressure was lower in the patients aged over 65. The older patient group had more respiratory and/or cardiac co-morbidities, a lower median distance in the 6minute walk test and a higher median Pro-BNP level. Specific PAH treatments were prescribed in both groups. Fifteen patients aged 65 and above were on long-term oxygen therapy (vs four younger patients, p<0.0001). The elderly patients had a median survival of 32 months., Conclusion: The diagnosis of PAH in elderly patients is associated with a poor prognosis. The management of these patients needs further studies.

Objective: To address the clinical relevance of serum albumin and B-type natriuretic peptide (BNP) concentration in the prediction of in-hospital death in elderly patients with acute severe heart failure., Patients and Methods: Seventy-four consecutive patients >70 years of age admitted for acute heart failure in NYHA class IV were prospectively included. BNP concentration was measured on admission and serum albumin concentration after clinical stabilization., Results: Mean age was 86.6+/-5.7 years. Sixty-five percent of patients had a normal left ventricular ejection fraction. Eighteen patients died during the in-hospital stay. Those patients who died were older, had higher blood urea nitrogen and BNP concentration, had lower systolic blood pressure and serum albumin concentration than patients who survived. Heart rate, rhythm, left ventricular ejection fraction, serum creatinine and hemoglobin did not differ according to outcome. By multivariate analysis, albumin (p=0.0017), BNP (p=0.016) and age (p=0.03) were independent predictors of in-hospital death. Serum troponin I measured on admission in 71 patients was predictive of in-hospital death (p=0.01), as well as serum total cholesterol measured after stabilization in 66 patients (p=0.004). However, these two variables no longer predicted outcome in multivariate models, unlike serum albumin and BNP., Conclusion: Serum albumin and BNP offer independent, additional information for the prediction of in-hospital death in elderly patient with acute severe heart failure regardless of left ventricular ejection fraction.

Unlabelled: BNP levels are quantitative biomarkers of heart failure (HF), with accuracy in the diagnosis, prognosis of HF, and improve patient management in emergencies. But specific studies are necessary in the very elderly because of the lack of data. To access how BNP predicts immediate prognosis, we have included 167 inpatients (mean age=83 years) at their hospital admission with systematic blood measure of BNP by Biosite Assay and we divided these patients into three groups, according to BNP level: (1) normal BNP level less than 100 pg/ml; (2) BNP level in the grey zone: 100 to 300 pg/ml; (3) increased BNP level greater than 300 pg/ml. Cardiovascular mortality has been compared in these three groups of patients and results showed a significant increase of mortality in the two groups 2 and 3, when the BNP value was higher than 100 pg/ml., Conclusion: As a quantitative marker of HF, the use of BNP levels with a cut point of 100 pg/ml is helpful for prognosis evaluation in the elderly.

The use of biomarkers, such as type B natriuretic peptide (BNP, NT pro-BNP) to finely tune the treatment during the follow-up of patients with chronic heart failure is under investigation. The few existing studies published up to now suggest that this approach leads to fewer hospital readmissions and a lower mortality due to heart failure, except in patients over 75 years of age. The positive effects of the use of biomarkers seem to be due to a greater use of target doses of the medications recommended in heart failure (angiotensin converting enzyme, angiotensin receptor blockers, or beta-blockers) and to a better adhesion to guidelines. Thus, it may prove more efficient to develop efforts to increase physicians' adhesion to guidelines than to rely on the dosage of a biomarker.

Cardiac resynchronisation therapy (CRT) induces, among responders, an early but sustained decrease of BNP levels. The changes of this parameter at 6 months, as well as its relative variations over the same time period, allow identification of the patients susceptible to benefit from CRT. Measurements of BNP levels might offer a useful tool for treatment optimisation in this particularly frail group of patients.

Acute dyspnea is one of the leading causes of emergency hospitalization of elderly patients. Clinical diagnostic procedures are difficult in this geriatric population. Acute heart failure is the most frequent cause of acute dyspnea in geriatric patients. The use of plasma B natriuretic peptide (BNP) assays in the general population has profoundly improved its medical management. There has also been progress recently for other frequent causes of dyspnea in the elderly, including infection and venous thromboembolic disease. Procalcitonin assays may be useful as a prognostic factor for infectious disease. Nevertheless, the real value of BNP assays in geriatric populations must be clarified by interventional studies.

B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide are biomarkers secreted both in response to myocardial stretch and increased ventricular wall stress. They are now largely used in cardiovascular disease in adults, especially as diagnostic and prognostic tools. This article aims at synthesizing existing data concerning the usefulness of natriuretic peptides in elderly patients. With aging, co-morbidities such as renal failure are common and lead to an increase in circulating concentrations of natriuretic peptides. Nevertheless, their usefulness is relevant in geriatric practice. Their role has been well established in heart failure, not only in diagnosis, using two thresholds to decrease misclassification, but also in prognosis. In the future, natriuretic peptides could be used as prognosis tools in acute coronary syndrome, in cardiovascular risk assessment or in management of heart valve disease. However, further investigations in elderly people are needed before validating these indications in routine geriatric practice.

Since the introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This literature review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.

Since introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.

Massive pulmonary embolism is defined by systemic hypotension or cardiogenic shock. Clinically stable patients with right ventricular dysfunction on echocardiography, elevated brain natriuretic peptide or troponin are usually considered as having sub-massive pulmonary embolism, but this definition is not universally accepted. The time-lag to confirm massive pulmonary embolism should be kept as short as possible and every effort should be done to rely on bedside tests and to avoid patient transfer to the radiology department. D-dimer tests are useless in this setting and the diagnosis is mainly based on clinical probability and bedside echocardiography. When clinical probability is high, right ventricular dilatation assessed by echocardiography allows confirming the diagnosis without additional testing. On the other hand a normal echocardiography does not allow excluding pulmonary embolism. In this setting, a spiral computed tomography is mandatory after the patient has been stabilized. Anticoagulant treatment should be started as soon as pulmonary embolism has been suspected. Supportive care includes oxygen, fluid loading and inotropes. There is little doubt that thrombolytic treatment is of value in patients with massive pulmonary embolism. Conversely, the use of thrombolytic therapy in patients with so-called sub-massive pulmonary embolism remains controversial. Current data do not confirm that thrombolytic therapy decreases mortality in those patients but cannot exclude a clinically significant benefit. A large randomised comparison of heparin and thrombolysis in patients with sub-massive pulmonary embolism is underway to answer this question. Surgical or catheter embolectomy is nowadays only rarely performed in patients with pulmonary embolism. This method can be undertaken in the few patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy. Before new data are available there is no special indication for vena cava interruption in patients with massive pulmonary embolism.

We evaluated a natriuretic peptide NT-proBNP assay on total blood, thanks to unit strips read by an apparatus of delocalized biology, the Cardiac Reader (Roche Diagnostics). Using the principle of immuno-chromatography, (with reading of colour intensity) this test measures concentrations of NT-proBNP from 60 to 3.000 pg/mL. The evaluation of this test shows an excellent repeatability, the absence of hook effect for very high values of NT-proBNP, the absence of BNP recognition and a robustness compared to the interferences classically checked: haemolysis and turbidity. The correlation of this total blood assay with a plasmatic assay by electrochemiluminescence of NT-proBNP is excellent, as well at the analytical level as on the level of the respect of the clinical decisional thresholds classically used. The test's analytical qualities make it an interesting alternative to the assay usually practised on automats in central laboratory. Nevertheless, the provision of this assay in delocalized biology (point of care) must be done according to strict rules of use, to take into account certain analytical constraints guaranteeing results of quality, compared to the therapeutic decisions that can result from.

Objective: To evaluate the NT-proBNP as a biological diagnosis marker of the myocardial dysfunction in septic shock., Study Design: Non-randomized prospective clinical study with written assent. The analysis of the data obtained was retrospective., Patients and Methods: All the patients with septic shock in the beginning of evolution (less than 24h) were included. Patients with cardiac insufficiency, insufficient respiratory function and chronic renal insufficiency as well as cirrhotic patients were excluded. Among patients in shock, a NT-proBNP concentration measurement and a cardiac echography by transthoracic way were carried out at inclusion. The rates of NT-proBNP were compared with the data of the echography., Results: Thirty-three patients in septic shock were included. On the whole of the collective, whether or not there is a cardiac dysfunction, the rates of NT-proBNP are not significantly different (11,306+/-16,196 pg/ml versus 10,697+/-12,346 pg/ml). By eliminating the patients with severe renal failure, we show that the NT-proBNP is non-significantly increased in the event of right and/or left ventricular failure (5751+/-4180 pg/ml versus 1,256+/-999 pg/ml)., Conclusion: The NT-proBNP can help to detect the cardiogenic share sometimes implied in the haemodynamic failure of the septic shock. However, because of the influence of the renal insufficiency and the respiratory, cardiologic and hepatic comorbidities on its secretion, its use cannot be recommended for patients in septic shock.

Objectives: Based on the fact that NYHA class, plasma BNP level, and echocardiographic indices of left ventricular filling pressures are prognostic factors in chronic systolic heart failure, we evaluated their predictive value for acute decompensation following initiation and titration of bisoprolol in this illness., Methods and Results: Bisoprolol was initiated and/or increased according to the ESC/ACC/AHA recommendations in 50 patients with stable chronic systolic heart failure (age: 60+/-2 years, males: 88%) in NYHA class? 2 with a left ventricular ejection fraction (LVEF)<40% and a plasma creatinine<250 micromol/l. The clinical parameters, plasma BNP levels and echocardiographic indices were measured blind on the same day, on admission and then once a week for three weeks. On admission, the NYHA was 2.9+/-0.1, mean plasma creatinine 99+/-3 micromol/l, plasma BNP 503+/-57 pg/ml, LVEF 29+/-1%, E/A ratio 1.9+/-0.2, E/Ea ratio 8.8+/-0.3, E wave deceleration time 155+/-9 ms, systolic pulmonary artery pressure 40+/-2 mmHg and the diameter of the inferior vena cava was 16+/-1 mm. Over the course of follow up, an episode of acute decompensation occurred in 16% of the patients (8/50). Using univariate analysis, age and initial (admission) values for NYHA class, blood pressure, plasma BNP level, E/A ratio, E wave deceleration time, E/Ea ratio and the systolic pulmonary arterial pressure allowed prediction of the occurrence of acute decompensation following initiation and titration of bisoprolol. The use of the initial value of NYHA class alone allowed prediction of the occurrence of acute decompensation in just 56% of the patients, and the absence of an occurrence of acute decompensation in 93% of them. Normal results for the echocardiographic indices (systolic pulmonary arterial pressure<40 mmHg or E/A ratio<1.4 or E wave deceleration time>145 ms) as recorded on admission were associated with the absence of an occurrence of acute decompensation is 100% of cases. The combined use of NYHA class>3 and either a BNP>398 pg/ml or echocardiographic indices in favour of an elevation in left ventricular filling pressures (systolic pulmonary arterial pressure>40 mmHg, E/A ratio>1.4 or E wave deceleration time<145 ms) allowed prediction of the occurrence of acute heart failure in 100% of cases, Conclusion: The combined use of NYHA class, BNP level and echocardiographic indices for measuring left ventricular filling pressures is more pertinent than the isolated use of clinical parameters for predicting tolerance to bisoprolol in chronic heart failure with a LVEF<40%.

The recommendations from respected bodies concerning the treatment and follow up of patients undergoing coronary angioplasty for stable angina or acute coronary syndrome (ACS) are essential for reducing the risks related to the procedure, and for preventing the occurrence of long term complications. Measuring the levels of troponin and CK-MB is part of the diagnostic and prognostic strategy during the coronary angioplasty procedure. In this context, the frequent elevation of markers following uncomplicated angioplasty is a sign of minor irreversible myocardial damage, the prognostic significance of which remains under discussion. Recent data suggest that only a basal troponin elevation (more so than CK-MB) prior to angioplasty has a long term prognostic value in ACS ST- patients, and that troponin elevation occurring after the procedure in the presence of normal basal concentrations, is only associated with in-hospital complications. Determining the basal level of troponin would appear to be essential for interpreting any elevation in concentrations following angioplasty. The recommendations should integrate this fundamental point, if it is confirmed. On the other hand, the question has been raised whether other markers (CRP, BNP and/or NT-proBNP) should be systematically measured as a routine prior to angioplasty. An elevation of CRP before and/or after angioplasty is an unfavourable short and long term prognostic factor. Elevation of NT-proBNP before angioplasty is also an unfavourable long term prognostic factor. Recommending a multi-marker strategy might represent a future direction for identifying at risk patients prior to coronary angioplasty, thus enabling specific treatment to be proposed.

Blood measurements of BNP and NT-proBNP, its catabolite, improve diagnosis for patients admitted to emergency departments with dyspnoea. In this paper, we have compared the BNP to the NT-proBNP for 119 dyspnoeic patients using at random clear clinical status. Among the test group of 119 patients, 57 showed coherent biological results for the 2 markers. These results confirm the final clinical diagnosis. Nine patients with congestive heart failure had abnormally low BNP and NT-proBNP rates. Six of these patients experienced long delays (longer than 48 hours and less than 72 hours) between their admission in emergency and the biological measurement of the natriuretic biomarkers. Three of the other patients could be not only flash OAP cases with a fast growth and a fast normalisation of BNP but also could have existing genetical factors. These genetical factors leading to high variability in BNP synthesis are not related to physiological or cardiac factors. 43 patients showed a mismatch between BNP and NT-proBNP. BNP appeared to be unstable in vitro. The lack of stability in whole blood or plasma samples is increased by sampling in a glass EDTA collection tube and too long delays in transferring the samples from the emergency area and the laboratory in a big hospital. Ten patients showed a mismatch with abnormally high NT-proBNP or false positive results. Among these 10 patients, 5 had renal dysfunction with a high level of creatinine concentration. It is clear that all Diagnostics Manufacturers should now propose different cut-off for natriuretic peptides tests according to the degree of patients' renal impairment.

Nt-proBNP have emerged as useful biomarker for the diagnosis and prognostic of heart failure but also recently in acute coronary syndrome. Myocardial ischemia is probably an important stimulus for Nt-proBNP release. Transient myocardial ischemia is inducing by balloon inflation during percutaneous coronary intervention (PCI). The authors propose to determine the Nt-proBNP secretion after uncomplicated coronary intervention in patients with preserved cardiac function. Ninety patients were enrolled in this study. Plasma Nt-proBNP was increased significantly from 135.5 to 157.8 pg/ml and 202.5 pg/ml at 8 and 24 hours following PCI, respectively. History of myocardial infarction and complex lesions were the most powerful predictors of higher Nt-proBNP peak concentration. Prognostic value must be evaluated in larger studies.

In acute coronary syndromes, risk stratification is essential, particularly in those without ST-elevation, and is based upon clinical and biological markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponine levels) are strong predictors of untoward outcome. These variables can be used to construct risk scores, among which the TIMI and GRACE scores are the most widely used. These scores may prove helpful to define the optimal diagnostic and therapeutic management of the patients.

Background: B-type natriuretic peptide (BNP) has been largely validated in the etiologic diagnosis of acute dyspnea. Nevertheless, its reliability in the setting of a preserved left ventricular systolic function (ejection fraction >50%) has not been adequately established., Objective: the study addressed the usefulness of BNP in the diagnosis of new-onset heart failure with a preserved systolic function in hypertensive patients hospitalized for acute dyspnea., Methods: 59 consecutive hypertensive patients without history of heart failure and coronary disease were included. BNP was measured at presentation with the Triage system. Noninvasive estimation of left ventricular filling pressures by bedside tissue Doppler echocardiography at presentation was incorporated in the diagnostic criteria., Results: the 30 patients with heart failure were not significantly different from the 29 patients with noncardiac cause of acute dyspnea regarding age, gender, body mass index and ejection fraction. Median levels of BNP were significantly higher in heart failure (447 [245-644] versus 87 [43-139] pg/mL). By multivariate logistic regression analysis, BNP (odds ratio of 44, [3.6-531], p=0.003) provided independent and incremental diagnostic information over the clinical score of Boston criteria (2.25, [1.3-3.9], p=0.0037). A BNP value of >142 pg/mL (area under the ROC curve of 0.89, p<0.0001) was 93 sensitive and 79% specific for the diagnosis of heart failure in this setting., Conclusion: BNP is a reliable biomarker of new-onset heart failure with a preserved systolic function in hypertensive patients, in particular older, hospitalized for acute dyspnea and can be safely integrated in the diagnostic strategy.

The measurement of the N-terminal part of the proBNP (NT-proBNP) may be used to assess the secretion of the B-type natriuretic peptide (BNP), a marker of heart failure. In this study, we have evaluated the NT-proBNP immunoassay proposed by DPC Company for the Immulite 2500 analyzer and compared the results with those obtained with the two other immunoassays respectively commercialized by Roche Diagnostics (Elecsys 2010 analyzer) and Dade-Behring (Dimension RXL). The obtained results show very good general performance of the DPC's technique with a CV inferior to 8% for the values superior to 40 ng/L. The within run CVs are 3.1, 3.5 and 3.5% and the between run CVs are 3.8, 4.7 and 4.8% for the NT-proBNP levels of 151, 1601 and 5255 ng/L, respectively. We found a very good correlation between DPC's and Roche Diagnostics's assays (regression analysis: y = 0.88 x + 25.2 ; r = 0.998) and DPC's and Dade-Behring assays (regression analysis: y = 0.93 x + 16.4 ; r = 0.997). Although a small bias appeared between these assays, similar cut-points may be used to exclude both heart failure in ambulatory patients and cardiac origin in acute dyspnea.

Background: NT-proBNP is an efficient biomarker for the evaluation, management and prognosis of patients with heart failure., Methods: We evaluated the analytical performance of the NT-proBNP immunoenzymatic assay with the Stratus CS semi-automated analyzer in two hospital laboratories. The characteristics assessed included imprecision, functional sensitivity, linearity/recovery, interferences study, high-dose hook effect and a comparison of Acute Care(TM) pPBNP (on Stratus)CS) versus PBNP (on Dimension HM) results on patient heparinized plasma samples., Results: Total imprecision reached < 5% coefficient of variation at NT-proBNP concentrations of 186-19,649 ng/L; recovery values for diluted samples were between 89.0 and 110.0 %; functional sensitivity reached 21 ng/L; there was no high-dose hook effect at concentrations up to 400,000 ng/L; hemaoglobin affected negatively but <10% the NT-proBNP assay, while bilirubin and triglycerides did not affected it more than 5%; Stratus CS results were strongly correlated with Dimension HM results (R(2)=1,00)., Conclusion: The Stratus CS Acute Care pPBNP assay demonstrated excellent analytical performance which agreed with the Dimension HM PBNP assay. This analyzer is therefore suitable for use by low NT-proBNP test volume laboratories, and also by Emergency departments and Intensive care units.

Objectives: Acute dyspnea is frequent in emergency medicine. The B-type natriuretic peptide is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. Conversely, NT-proBNP has no physiological activity. BNP and NT-proBNP concentration closely correlate to various indicators of heart failure., Current Knowledge and Key Points: Numerous studies have demonstrated high usefulness of BNP and NT-proBNP to diagnose heart failure, which is the main cause of acute dyspnea in emergency medicine. The diagnostic accuracy of BNP and NT-proBNP seems similar, and is higher than that of the emergency physician. Bedside dosages are now available, with high sensibility and specificity for the diagnosis of heart failure. For BNP, threshold value is ranging from 100 to 300 pg/ml in patients aged over 65 years; for NT-proBNP the threshold value is 1000 to 2000 pg/ml in elderly patients. Briefly, heart failure is unlikely when BNP is below 100 pg/ml (NT-proBNP<500 pg/ml), and very likely when BNP is higher than 400 pg/ml (or NT-proBNP>2000 pg/ml)., Future Projects: Early rapid measurement of BNP could improved the evaluation and treatment of patients with acute dyspnea and reduce the total cost of treatment.