EBM ACTIVITY DOCUMENTATION

Resident: Alparas, Paruñgo, Valencia Date: February 13, 2020

Topic: 2d echocardiogram vs BNP
EBM Type:  THERAPEUTIC  DIAGNOSTIC  HARM  PROGNOSIS

CASE SCENARIO Accuracy of BNP vs 2d echocardiogram in the diagnosis of heart failure

COMPLETE QUESTION What is the more sensitive test in the diagnosis of CAD in patients presenting with acute chest pain but
with negative Troponin
Population Patients who has heart failure
Intervention Brain natriuretic peptide
Comparison 2D echocardiography
Outcome Diagnosis of Acute Dyspnea
Methodology Prospective Cohort Study
JOURNAL ABSTRACT
Objective Diagnostic performance of emergency Doppler echocardiography (EDecho) performed by
emergency physicians (EPs) for the diagnosis of aLVHF in patients with acute dyspnea.

Methods A convenience sample of acute dyspneic patients was evaluated. For each patient, the Boston
criteria score for heart failure was calculated, and N ‐terminal prohormone brain natriuretic peptide (NT ‐
proBNP) and EDecho were contemporaneously performed. Four investigators, after a limited
echocardiography course, performed EDechos and evaluated for a “restrictive” pattern on pulsed Doppler
analysis of mitral inflow and reduced left ventricular (LV) ejection fraction. 

Results Among 145 patients, 64 (44%) were diagnosed with aLVHF. The median time needed to perform
EDecho was 4 minutes. Pulsed Doppler analysis was feasible in 125 patients (84%). The restrictive
pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific
than the Boston criteria and NT‐proBNP for the diagnosis of aLVHF. Considering noninterpretable values
of the restrictive pattern and uncertain values (“gray areas”) of Boston criteria (4 < Boston criteria
score < 7) and of NT‐proBNP (300 < NT‐proBNP < 2,200 pg/mL) as false results, the
accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for
both NT‐proBNP and Boston criteria.

Conclusion  EDecho, particularly pulsed Doppler analysis of mitral inflow, is a rapid and accurate
diagnostic tool in the evaluation of patients with acute dyspnea.
 CRITICAL APPRAISAL
RELEVANCE Primary Validity Guides Yes No Not
mentioned
1. Is/are the objective/s of the article relevant to your clinical question?   

VALIDITY GUIDES Primary Validity Guides Yes No Not

mentioned
1. Was there an independent and blind comparison with the reference   
standard?
2. Was a representative sample of subjects to whom the diagnostic  
test is supposed to be administered gathered?
Secondary Validity Guides   
1. Was the reading or interpretation of the diagnostic test or reference   
standard done independently?
2. Was the diagnostic test and reference standard described in detail to   
permit reliable replication?
Validity of the Study Yes No Not
mentioned
Is the study valid?   
WHAT ARE THE RESULTS 2. What are the likelihood ratios for the different test results?

Ex ECG SE

LR (+) = Sn/1-Sp LR (+) = Sn/1-Sp

= .82/1-0.67 =0.77/1-0.92
= 2.48 = 9.63
Weak evidence to rule in the disease Moderate evidence to rule in the disease
LR (-) = 1-Sn/Sp LR (-) = 1-Sn/Sp
=1-0.82/.067 =1-0.77/0.92
= 0.27 =0.25
Weak evidence to rule out the disease Weak evidence to rule out the disease
APPLICABILITY Yes N Not
o mentioned
3. Are the medical, social, & economic resources needed to perform   
the diagnostic test available in your setting?
4. Was the diagnostic test & accuracy in the evidence preferred by the   
patient & the family
5. Is the patient, family, and community willing to accept and pay for   
the diagnostic test?
CASE RESOLUTION Among patients presenting with acute chest pain with negative Troponin, stress echocardiography is a
more sensitive non-invasive test in diagnosing CHF compared to BNP.

COMMENTS

Signed
__________________________________
Marie Ruth A. Echavez MD, DFM, FPAFP