Patient Number 2

Chief Complaint:
Shortness of breath (SOB)

Present Illness:
A 64-year-old patient presented to the emergency department (ED) on 8/30/99 at 8:10 a.m. with complaints of difficulty breathing and SOB first starting in July. Patient can only take 10 steps. Coughing up brownish small particles of tenacious sputum. Patient reported episode of SOB two nights prior to ED visit while walking, after exposure to some barbecue smoke. Patient has been sensitive to smoke and perfume in the past 10 years. Patient took four puffs of Atrovent^® (ipratropium bromide) inhaler with partial relief but had difficulty sleeping. SOB disappeared 8/29/99 at noon.

Past Medical History:
Chronic obstructive pulmonary disease (COPD)
Myocardial infarction 5/98
Tobacco use: Smoked 11/2 packs per day x 45 years and quit 11/2 years ago
No alcohol use or IV drug abuse

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

Physical Exam
Temperature: 96.9
Pulse: 80
Respiratory Rate: 24
Blood Pressure: 132/91
O2 Saturation: 98 percent on room air
General: Alert and oriented, comfortable
Neck: No jugular vein distention
Chest: Lungs clear
Cardiovascular: Regular heart rate and rhythm
Extremities: No pedal edema

Initial Labs and Studies
ECG: Old left bundle branch block, inferior lateral T wave inversions
Labs: HDL 43, LDL 149, cholesterol 230, triglycerides 190, chemistry was unremarkable
Chest X-ray: None performed

Clinical Diagnosis and Treatment Plan For Patient Number 2

Diagnosis and Treatment Plan:
ED diagnosis: Asthma and COPD
ED physician’s HF probability: Low

Patient was sent home from the ED with instructions to use albuterol inhaler two puffs every four hours as needed and to follow-up with primary care provider.

Cardiologist’s HF probability: Unable to determine, no cardiac work-up done (retrospective chart review by cardiology)

B-Type Natriuretic Peptide (BNP) Result: 711 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 2, the blinded BNP value was 711 pg/mL, which is highly suggestive of HF and reflects significant ventricular pressure and dysfunction. In this case the patient’s chart history and negative signs and symptoms contributed to a missed HF diagnosis. The 15-minute Triage BNP Test not only could have elevated clinical suspicion for HF, but could have expedited appropriate cardiac work-up and consultation. Because the patient was considered not to have had HF, the patient was treated with an Atrovent inhaler and sent home. The patient was readmitted six weeks later with decompensated heart failure and a 12 percent ejection fraction.