• Beatrice Drexler, Corinna Heinisch, Cathrin Balmelli, Johan Lassus, Krista Siirilä-Waris, Nisha Arenja, Thenral Socrates, Markus Noveanu, Mihael Potocki, Christophe Meune, Philip Haaf, Christian Degen, Tobias Breidthardt, Tobias Reichlin, Markku S Nieminen, Harjola Veli-Pekka, Stefan Osswald, and Christian Mueller.
• Department of Internal Medicine, University Hospital Basel, Basel, Switzerland.
• Circ Heart Fail. 2012 Jan 1;5(1):17-24.

BackgroundThe early and noninvasive differentiation of ischemic and nonischemic acute heart failure (AHF) in the emergency department (ED) is an unmet clinical need.Methods And ResultsWe quantified cardiac hemodynamic stress using B-type natriuretic peptide (BNP) and cardiomyocyte damage using 2 different cardiac troponin assays in 718 consecutive patients presenting to the ED with AHF (derivation cohort). The diagnosis of ischemic AHF was adjudicated using all information, including coronary angiography. Findings were validated in a second independent multicenter cohort (326 AHF patients). Among the 718 patients, 400 (56%) were adjudicated to have ischemic AHF. BNP levels were significantly higher in ischemic compared with nonischemic AHF (1097 [604-1525] pg/mL versus 800 [427-1317] pg/mL; P<0.001). Cardiac troponin T (cTnT) and sensitive cardiac troponin I (s-cTnI) were also significantly higher in ischemic compared with nonischemic AHF patients (0.040 [0.010-0.306] μg/L versus 0.018 [0.010-0.060] μg/L [P<0.001]; 0.024 [0.008-0.106] μg/L versus 0.016 [0.004-0.044 ] μg/L [P=0.002]). The diagnostic accuracy of BNP, cTnT, and s-cTnI for the diagnosis of ischemic AHF, as quantified by the area under the receiver-operating characteristic curve, was low (0.58 [95% CI, 0.54-0.63], 0.61 [95% CI, 0.57-0.66], and 0.59 [95% CI,0.54-0.65], respectively). These findings were confirmed in the validation cohort.ConclusionsAt presentation to the ED, patients with ischemic AHF exhibit more extensive hemodynamic cardiac stress and cardiomyocyte damage than patients with nonischemic AHF. However, the overlap is substantial, resulting in poor diagnostic accuracy.

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