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European Journal of Heart Failure 2005 7(6):953-957; doi:10.1016/j.ejheart.2005.06.003
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© 2005 European Society of Cardiology

Clinical deterioration in established heart failure: What is the value of BNP and weight gain in aiding diagnosis?

Jennifer Lewin, Mark Ledwidge, Christina O'Loughlin, Clare McNally and Ken McDonald*

St Vincent's University Hospital Heart Failure Unit Elm Park, Dublin 4, Ireland

* Corresponding author. Tel.: +353 1 2304629; fax: +353 1 2304639. E-mail address: kenneth.mcdonald{at}ucd.ie


   Abstract
Top
 Abstract
1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Background: Weight gain and increase in B-Type Natriuretic Peptide have been advocated as means of aiding diagnosis of heart failure. However, there are few data to support the use of these criteria in diagnosing clinical deterioration in patients with established disease.

Aims: This prospective study examines the sensitivity and specificity of absolute and relative changes in BNP and weight in determining the early onset of clinical deterioration in patients with established heart failure.

Methods: All patients who presented to the outpatient clinic with completed self-reported daily weight books, baseline BNP measurement, outpatient BNP measurement and assessment by a cardiologist blinded to BNP and weight were included. Each patient was determined as clinically stable (CS) or in clinical deterioration (CD). Receiver operating characteristic (ROC) curves and sensitivity and specificity calculations for various absolute and relative BNP and weight changes were carried out.

Results: Weight and BNP changes were examined in 34 CS presentations (mean age 69.5±16.1 years) and 43 CD presentations (mean age 70.0±10.6 years). ROC analysis demonstrated that neither weight nor BNP changes in absolute or relative values predicted clinical deterioration in this study population adequately (AUC values ranging from 0.64 to 0.66).

Conclusions: These data demonstrate that increase in body weight and BNP in isolation are not sensitive in assessing clinical deterioration in established heart failure. These observations may need to be emphasized in patient education and to physicians involved in assessment of heart failure patients.

Key Words: Beta type natriuretic peptide • Heart failure • Clinically stable • Receiver operating characteristic • Systolic dysfunction • Weight gain • Clinical deterioration

Received October 27, 2004; Revised April 18, 2005; Accepted June 8, 2005


   1. Background
Top
 Abstract
 1. Background
2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Accurate diagnosis of clinical deterioration in heart failure can be difficult [1]. To prevent development into overt congestion, which often requires hospitalisation, early diagnosis is of paramount importance. There is a need for objective measurements to aid early diagnosis in a setting where symptoms may be non-specific and abnormalities on physical examination often subtle and minor [2]. Moreover, any proposed measurements must be evaluated for sensitivity and specificity in this particular setting.

Heart failure guidelines recommend the use of weight gain monitoring to help in this task, with the added advantage that patient self-care is encouraged [3]. It is advised that an increase of 2 Kg over stable body weight over a period of 48–72 h should initiate contact with medical or nursing personnel. However, there are no data in the literature assessing the usefulness of weight gain in predicting clinical deterioration.

Of late there has been increasing interest in the role of BNP in the diagnosis and management of heart failure [4–7]. Even though BNP has been used to guide-up-titration of heart failure therapy in a small study there are no data to support the use of BNP in identifying early clinical deterioration in patients with established heart failure [8]. Indeed the few available data on inter- and intra individual variability of BNP demonstrate significant biological variability possibly compromising its utility in helping diagnose early clinical deterioration in patients with established heart failure [9,10].

The purpose of this prospective study is to analyse the sensitivity and specificity of changes in body weight and BNP in supporting the clinical diagnosis of confirmed deterioration of heart failure status.


   2. Methods
Top
 Abstract
 1. Background
 2. Methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
2.1. Patient population
Patients admitted to St Vincent's University Hospital, Dublin, with NYHA Class IV heart failure were enrolled in an in-patient and out-patient heart failure program as previously described [11] In accordance with the European Guidelines we advised patients to report unexpected weight gain of 2 Kg occurring over a period of 2–3 days [3].

2.2. Inclusion and exclusion criteria
In this prospective study, consecutive patients seen at the out-patient heart failure clinic for scheduled or unscheduled review were eligible for enrolment. Patients were excluded it they did not have a completed weight book, if they did not have a prior BNP assessment in their file at a time of documented clinical stability and if their weight and/or BNP status was made known to the assessing physician, thus un-blinding him to these factors while making the decision on clinical stability.

2.3. Assessment of clinical deterioration
A diagnosis of clinical deterioration or stability was made based on symptoms, physical examination and the optional use of chest X-Ray in uncertain cases. In making the diagnosis of clinical deterioration the physician was blinded to the BNP value taken at the clinic visit and to the patients weight record book. On completion of the clinical assessment the patient was weighed and a BNP value was obtained. Patients with confirmed clinical deterioration were treated at outpatient level with the option to hospitalise if clinically needed. Physician review determined whether treatment resulted in the return of clinical stability.

2.4. Body weight and BNP measurements
All patients participating in our multidisciplinary care of heart failure program are provided with daily weight record books and are asked to record their dry weight daily in the morning following urination. The weight record book of each patient included in the present study was audited for weight change over the three days prior to presentation at the clinic. The change in weight over this three day period was expressed both as an absolute change and a percentage change over baseline values.

Plasma BNP was measured in the clinic using the "Triage" point-of-care assay (Biosite, CA). Method of analysis, precision, analytical sensitivity, interference and stability have all been previously reported [12,13]. The patient's chart was reviewed to obtain the most recent BNP level taken during a period of noted clinical stability. The change in BNP between this baseline value and that taken during clinical deterioration was calculated and expressed as absolute and percent values over baseline.

2.5. Statistical analyses
Demographic characteristics of the sample are expressed in frequencies and percentages for categorical and/or nominal data. Receiver Operating Characteristic (ROC) curves are plotted to assess the usefulness of both absolute and percentage changes in weight and BNP in predicting clinical deterioration. ROC curves are also plotted for those with creatinine levels less than 150 µmol/L and excluding remote baseline BNP values (more than 6 months before enrolment clinic visit). The adequacy of these curves is assessed by comparing the Area Underneath the Curve (AUC) statistics (Area, P Value and 95% Confidence interval).

The sensitivity and specificity of both reported weight change and BNP changes in predicting clinical deterioration are presented using a range of absolute and relative criteria. All statistics were carried out using SPSS version 11 statistical software.


   3. Results
Top
 Abstract
 1. Background
 2. Methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
Demographics (Table 1): A total of 77 patients met the inclusion criteria by presenting to the Heart Failure Unit for scheduled or unscheduled review on 100 separate occasions. Sixty six of these presentations (43 patients) were determined by the attending cardiologist to have evidence of clinical deterioration (CD group). Thirty four patients presented to the clinic on 34 separate occasions and were found to be clinically stable (CS group).


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  		Table 1 Demographics of clinically stable (CS) and clinically deteriorated (CD) sample (N=72)

 
3.1. Diagnosis of clinical deterioration
Features noted to confirm the clinical diagnosis of deterioration in heart failure (CD group) status are outlined in Table 2. Two or more features were present in 80% of presentations, 3 or more features in 47%, and 4 or more were present in 21% of the cohort.


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  		Table 2 Diagnosis of clinical deterioration

 
The medical therapy used to treat patients with clinical deterioration and the ultimate outcomes of the clinical visits are presented in Table 3. There were no deaths. Three patients required hospitalisation and all but one of these had received maximal therapy with IV and oral diuretic changes.


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  		Table 3 Changes in medical therapy used to resolve deterioration in 66 confirmed presentation of early deterioration of heart failure

 
All CD presentations showed some weight gain from baseline. Seventy six percent of CD presentations showed some BNP increase from baseline. Absolute and percentage changes from baseline to clinic visit in weight and BNP were assessed using ROC analyses (Fig. 1A and B respectively). The AUC values, all of which are below 0.66 indicate that neither weight nor BNP in absolute or relative terms are good predictors of clinical deterioration in an outpatient HF population.


Figure 1
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  		Fig. 1 Receiver operating curve for absolute and percentage changes in weight (1A) and BNP (1B). For each of the analyses the Area, Standard Error; Asymptotic Significance; Lower 95% Confidence Interval and Upper 95% Confidence Interval respectively were: 0.653, 0.057, 0.015, 0.540, 0.765 (Weight-Absolute Change); 0.638, 0.059, 0.028, 0.522, 0.754 (Weight-Percent Change); 0.640, 0.058, 0.024, 0.526, 0.753 (BNP-Absolute Change); 0.660, 0.057, 0.010, 0.548, 0.772 (BNP-Percent Change).

 
Analysis of the sensitivity and specificity values for a range of different thresholds of weight and BNP changes demonstrate variable specificity and consistently poor sensitivity for clinical deterioration. For example, the commonly used ≥2 Kg weight gain over 48–72 h has a specificity of 97%, but a sensitivity of only 9%. Alternatively, using a ≥2% weight gain criterion, specificity is 94% and sensitivity increases modestly to 17%, but remains poor. Using a change in BNP of ≥100 pg/ml the sensitivity and specificity were 47% and 77% respectively.

Absolute and relative combinations of BNP and weight change improve sensitivity at the expense of specificity, but nonetheless sensitivity remains poor. For example, using the criteria ≥2 Kg or BNP ≥100 pg/ml, the sensitivity and specificity were 55% and 74% respectively.

A total of 4 (12.1%) patient visits in the stable group and 33 (50%) patient visits in the CD group had serum creatinine levels equal to or above 150 µmol/L.

Excluding these patient presentations, the ROC analyses suggest improved AUC values (0.715, 95% CI 0.584:0.846, p=0.004) but again these remain below values considered suitable for effective screening.

The baseline BNP measurements in 7 (20.6%) patient visits in the CS group and 10 (15.2%) patient visits in the CD group were considered to be remote from the clinic visit values (>6 months). We excluded this group and reanalysed the data since the reliability of such remote baseline values could partially explain the poor performance of ROC curves observed for the total group. These curves demonstrate little improvement in AUC values (0.614 and 0.637) and the values remained below levels considered suitable for effective screening.

Finally, there was no significant relationship between BNP and weight change for the patients included in the study (R=0.002, P=0.983).


   4. Discussion
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The data from this report demonstrate that neither weight gain nor increase in BNP are adequately sensitive as a screen for clinical deterioration in patients with established heart failure. Weight gain, no matter how defined, is very insensitive though an increase of 2 Kg or 2% demonstrates high specificity for clinical deterioration. Although BNP change appears to provide better sensitivity than weight change it has poor specificity for CD in an established heart failure population. Overall the AUC calculations for weight gain and BNP underline the difficulties in reliably applying these objective measures to the task of identification of early clinical deterioration.

It should not be surprising that the advice regarding weight gain provided in guidelines is not sensitive for clinical deterioration. It would be difficult to expect that an absolute value of 2 Kg increase could have the same clinical meaning in patients with significantly different dry weights. However, the data presented here indicate that change in weight remains insensitive even when expressed as a proportion of dry weight. The explanation for these observations remains unknown. Although we did not prospectively collect data on the aetiology of clinical deterioration, it is likely that abrupt changes in clinical status, occurring within hours or one day, often precipitated by ischaemia or arrhythmia, may not manifest measured weight gain. More gradual clinical deterioration, brought on by infection or non-compliance, may be more likely to demonstrate sustained weight gain. Finally, in some individuals weight gain from fluid retention may be masked because of weight loss secondary to cachexia associated with heart failure unless dry weight values are regularly adjusted [14].

While of value in other settings in heart failure and ventricular dysfunction, the value of change in BNP values as an aid to diagnosis of clinical deterioration in patients with established heart failure has not been assessed [15,16]. It remains unknown what increase in BNP represents a clinically significant change. The limited data on biological variation of BNP assays, obtained from normal subjects and a small number of patients with heart failure, underlines a potential difficulty in using serial change in this parameter for determination of clinical deterioration [9,10]. Intra-individual variation was as great as 60%, a far wider biological variation than that observed with other laboratory analyses [9,10]. Despite these observations, data from Lee et al. demonstrated that changes in BNP correlated with changes in NYHA status [17]. However, data presented here indicate that changes in BNP are not a sensitive predictor of deterioration in patients with established heart failure. The explanation remains unclear but may reflect the multiple variables involved in the homeostasis of natriuretic peptides, from transcription of the genetic message, to cellular secretion, metabolism, clearance and medical therapy all of which can effect the final value [18,19] . In this regard it is of interest that the AUC analysis improved in this population when patients with impaired renal function, defined as a creatinine >150 µmols/L, were omitted from the analysis.

These data underline the need to be aware that early clinical deterioration can occur in the absence of measurable weight gain or increase in BNP and that absolute reliance on these parameters may result in mis-diagnosis. Indeed, 24% of patients with proven clinical deterioration demonstrated a reduction in BNP varying from 3% to 77%.

The observations regarding weight gain are also of importance for patient education. While guidelines state that unexplained weight gain should alert the patient to impending problems it must also be stated to the patient and family members that absence of weight gain does not rule out clinical deterioration.

Several limitations need to be recognised in interpreting the results of these data. The number of events is relatively small which may, in particular, compromise analysis of subsets of this population based on renal parameters and recent or remote baseline BNP measurement. Secondly the diagnosis of heart failure was based on clinical assessment and this formed the gold standard against which the sensitivity and specificity of weight gain and changes in BNP were assessed. While always open to individual error, this method is at least consistent with the standard approach to care of this group. Moreover, the fact that almost all cases of deterioration improved in response to change in therapy directed at worsening heart failure status supports the clinical diagnoses in this report. Finally our data provide no information on the value of N-Terminal pro-BNP as a guide to clinical deterioration, and the response of this peptide may not mirror that of BNP. Further work on this area would be of interest.


   5. Conclusions
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
These data demonstrate the lack of sensitivity of changes in weight and BNP as aids in diagnosing clinical deterioration in patients with established heart failure. Consequently, while regular weight measurement is an important facet of care involving the patient in management, it should be emphasized to patients and families that lack of weight change does not exclude impending clinical deterioration. Moreover, the data also underline that BNP change can only be used as a part of the clinical analysis where history and physical examination still appear to be the most critical assessment.


   References
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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