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Shortness of breath is a common complaint among adults presenting to the emergency department (ED). The most frequent diagnosis made in this context is heart failure (HF). The prognosis for patients with HF remains poor, with only 45% to 60% of patients surviving 5 years after the diagnosis is made, a rate comparable to that of colorectal cancer. Given the high incidence of HF, its poor prognosis and the existence of therapies that improve the duration and quality of life, it is important that emergency physicians make the diagnosis as rapidly and accurately as possible. Point-of-care assays for brain natriuretic peptide (BNP) and its N-terminal pro-peptide (NT-proBNP) are now available. There is literature to support the utility of these assays for the ED diagnosis of HF. However, most publications have been based on post hoc subgroup analyses of a few large industry-sponsored prospective studies. In this issue of the Canadian Journal of Emergency Medicine, Murray and colleagues report the results of a small but innovative primary study that looked at the potential impact of incorporating NT-proBNP into emergency medicine practice. The results raise questions regarding the assumptions of previous research in this area and shed light on the challenges emergency physicians may face if they choose to adopt natriuretic peptide testing. Clinical uncertainty is the raison d’être for any new diagnostic test. If clinical uncertainty does not exist, additional diagnostic tests are not warranted. The degree of clinical certainty (or uncertainty) is determined by comparing the clinical impression with an independent validated criterion (gold) standard. Because there is no validated criterion standard for the diagnosis of HF, previous natriuretic peptide studies have compared the ED diagnosis with a retrospective diagnosis by 2 cardiologists who reviewed the medical records and were blinded to natriuretic peptide results and ED diagnoses. This unvalidated criterion standard has been assumed, although never proven, to be more accurate than the diagnostic impression of physicians in the ED. Ironically, the studies that used a retrospective criterion standard call into question the assumption that emergency physicians face diagnostic uncertainty for all patients presenting with shortness of breath. Although it is clear that emergency physicians are uncertain of the diagnosis in approximately 30% of dyspneic patients, they are rarely wrong when they rate the probability of HF as very high or very low. In a study of 1586 patients, the prevalence of disease in patients who were rated by emergency physicians as very likely to have HF was 95%. Conversely, the prevalence in patients who were rated as very unlikely to have HF was only 8%. At these extremes of pretest probability, it would be difficult for any diagnostic test to improve upon the clinical impression of emergency physicians. In fact, in a post hoc analysis of the BNP [Breathing Not Properly] Multinational Study Group data, the accuracy of BNP in very high and very low probability patients was found to be worse than clinical judgment alone. How do BNP or NTpro-BNP perform in clinically uncertain cases? All studies to date, including the one in this issue of CJEM, have evaluated diagnostic test performance in the entire spectrum of acutely dyspneic patients, including clinically certain ones. The appropriateness of extrapolating the findings from such studies to the subgroup of clinically uncertain patients is highly questionable. Two independent post hoc analyses of the BNP Multinational Study Group data calculated diagnostic test performance

Should natriuretic peptide testing be incorporated into emergency medicine practice?