A new algorithm of suspected stroke patient management with brain natriuretic peptide/N-terminal pro-brain natriuretic peptide point of care testing platform in the emergency department.

Sir,

We read with interest the article by Naveen et al. on N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and short-term prognosis in acute ischemic stroke[1] and wish to make a few points about our clinical experience in the emergency department (ED).

Acute ischemic stroke is a time-sensitive disease and needs to be treated immediately. We have already known that elevated BNP and NT-proBNP level is an independent biomarker for cardioembolic stroke and is associated with unfavorable outcome.[234] In the ED, emergency physician can perform BNP/NT-proBNP test and get the result within 15 min using point of care testing platform. To keep effective and rapid assessment, we set up a new algorithm of suspected stroke patient management in the ED.[4] Patients' blood samples for BNP/NT-proBNP and other laboratory tests are collected together at the third step according to the goals for the management of patients with suspected stroke recommended by the AHA and ASA guidelines. Based on our clinical experience, the suspected stroke patients can obtain initial assessment and high-efficient management within 1 h in the ED.[4]

Patient's clinical grounds, neuroimaging, BNP/NT-proBNP level, and other emergency tests are reviewed by emergency physician and neurologist together. The suspected cardioembolic stroke patient and patient with high risk of paroxysmal atrial fibrillation, poor functional outcome, and in-hospital mortality can be preliminary recognized in the ED.[1234] In addition, several factors correlate with increased BNP/NT-proBNP levels, such as left atrial thrombus, heart failure, left atrial dysfunction, angina pectoris, cardiomyopathy, myocardial infarction, pulmonary embolism, and chronic renal failure.[1234] Therefore, if the plasma BNP/NT-proBNP level is much higher in the ED, such conditions should be carefully considered, and the related examinations could be preferentially performed after admission.

However, the suitable cutoff value of the BNP/NT-proBNP levels to distinguish cardioembolic stroke from other TOAST subtypes and predict unfavorable outcome is unclear.[5] There are two main reasons:First, the interval from stroke onset to blood samples collection was significantly different in these studies. Second, the proportion of TOAST subtypes is significantly different among territories due to the difference of regional patient's age, nationality, area, race, and traditional diet habit.[4] Hence, further larger multicenter studies including various ethnic groups are required to analyze the suitable levels of BNP/NT-proBNP to predict the TOAST subtypes and outcome in stroke management.

Through this new algorithm of suspected stroke patient management in the ED, emergency physicians are able to improve and accelerate the “stroke chain of survival,” provide more important clinical information for neurologist to start the optimal secondary prevention rapidly, and recognize the potential patient with high-risk in-hospital mortality. Therefore, we recommend to implement this algorithm in the ED and at admission.

Financial support and sponsorship

Funding for this study was provided by the Internal Grants from Science and Technology Foundation of Foshan City, China (no. 2014AB00328, no. 2014AG10002, and no. 2015AB00354), and Guangdong Province Science and Technology Foundation (no. 2014A020212002).

Conflicts of interest

There are no conflicts of interest.