Patient Number 1

Chief Complaint:
Shortness of breath (SOB) and concomitant chest pain.

Present Illness:
A 77-year-old patient presented to the emergency department (ED) with a complaint of recent SOB on exertion. Patient has concomitant intermittent chest pain for at least 1.5 months, usually within 20-30 minutes after breakfast, lasting one to three minutes, occurring at rest only. Six days prior to admission, patient experienced an episode of chest pain increasing in intensity, and lasting six minutes. Patient was in ED two days prior and sent home with prescriptions for isosorbide and diltiazem. Patient denies a history of orthopnea but sleeps on two pillows secondary to gastroesophageal reflux disease (GERD) symptoms.

Past Medical History:

• Myocardial infarction in 1977
• Three prior strokes
• Chronic obstructive pulmonary disease (COPD) 7/99 (PFTs showed mild obstruction)
• GERD
• Smoking: 120 pack/year history
• Heavy alcohol use until 1995; no drug use

Emergency Department Assessment:
The patient was assessed in the ED beginning at 8:10 a.m. A baseline ECG was performed.

Physical Exam
Temperature: 97.9
Pulse: 76
Respiratory Rate: 18
Blood Pressure: 168/84
General: Alert and oriented, comfortable
Chest: Lungs clear
Cardiovascular: Regular heart rate and rhythm; no murmurs, gallops, or rubs
Extremities: Trace lower extremity edema
Medications Given in the ED: ASA, heparin, nitroglycerin

Initial Labs and Studies
ECG: Normal sinus rhythm, no change from previous
Chest X-ray: No acute changes compared to 2/99
Labs: WBC 5.2, cardiac enzymes were negative

Clinical Diagnosis and Treatment Plan For Patient Number 1.

Diagnosis and Treatment Plan:
ED diagnosis: Unstable angina
ED physician’s HF probability: Medium

Patient was admitted to the Direct Observation Unit five hours after initial presentation. The patient was stable on admission and continued on the previous regimen of medications. The patient was noted to have mild untreated COPD.

Cardiologist’s heart failure probability: No heart failure, SOB is angina equivalent, LV function is normal (retrospective chart review by cardiology)

B-Type Natriuretic Peptide (BNP) Result: 34 pg/mL

Value of the Triage® BNP Test (blinded during this study)
The Triage BNP Test as a diagnostic test for HF can provide immediate and valuable information.

In the case of Patient Number 1, the Triage BNP Test’s negative predictive value (=98 percent utilizing 100 pg/mL cutoff) would have had clinical and economic significance. A 15-minute Triage BNP Test with a result of 34 pg/mL rapidly suggested that this patient’s symptoms were not attributable to HF. This information could have quickly allowed the ED physician to exclude HF and focus on other origins of SOB. The Triage BNP Test also may have obviated the need for cardiology consult or echocardiography, providing more efficient resource utilization.