Tuberc Respir Dis.  2013 Jan;74(1):15-22.

Predictors of Cardiogenic and Non-Cardiogenic Causes in Cases with Bilateral Chest Infiltrates

• Lee YJ
• Lee J
• Park YS
• Lee SM
• Yim JJ
• Yoo CG
• Kim YW
• Han SK
• Lee CH

Abstract

BACKGROUND
Differentiating cardiogenic pulmonary edema from other bilateral lung diseases such as pneumonia is frequently difficult. We conducted a retrospective study to identify predictors for cardiogenic pulmonary edema and non-cardiogenic causes of bilateral lung infiltrates in chest radiographs.
METHODS
The study included patients who had newly developed bilateral lung infiltrates in chest radiographs and patients who underwent echocardiography. Cases were divided into two groups based on the echocardiographic findings: the cardiogenic pulmonary edema group and the non-cardiogenic group. Clinical characteristics and basic laboratory findings were analyzed to identify predictors for differential diagnosis between cardiogenic and non-cardiogenic causes of bilateral chest infiltrates.
RESULTS
We analyzed 110 subjects. Predictors of cardiogenic pulmonary edema were higher brain natriuretic peptide (BNP) levels, lower C-reactive protein (CRP) levels on the day of the event (<7 mg/dL), age over 60 years, history of heart disease, and absence of fever and sputum. CRP on the day of the event was an independent factor to differentiate cardiogenic and non-cardiogenic causes of newly developed bilateral chest infiltrates. Also, the validity was comparable to BNP.
CONCLUSION
Clinical symptoms (sputum and fever), medical history (dyslipidemia and heart disease), and laboratory findings (BNP and CRP) could be helpful in the differential diagnosis of patients with acute bilateral lung infiltrates in chest radiographs.

Keyword

C-Reactive Protein; Natriuretic Peptide, Brain; Pulmonary Edema

MeSH Terms

C-Reactive Protein
Diagnosis, Differential
Echocardiography
Fever
Heart
Heart Diseases
Humans
Lung
Lung Diseases
Natriuretic Peptide, Brain
Pneumonia
Pulmonary Edema
Retrospective Studies
Sputum
Thorax
C-Reactive Protein
Natriuretic Peptide, Brain

Figure

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  Figure 1 Changes in C-reactive protein (CRP) values over days between the two groups. CRP values (mg/dL) of the cardiogenic group are expressed by the solid line and those of the non-cardiogenic group by the dotted line. *p<0.05.

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  Figure 2 Comparison of the C-reactive protein (CRP) model and brain natriuretic peptide (BNP) model for predicting cardiogenic diseases. Filled circles represent the CRP model and open diamonds the BNP model. No significant difference was detected in discrimination power (area under the curve, 0.909 vs. 0.986; p=0.535).

Reference

1. Lerman A, Gibbons RJ, Rodeheffer RJ, Bailey KR, McKinley LJ, Heublein DM, et al. Circulating N-terminal atrial natriuretic peptide as a marker for symptomless left-ventricular dysfunction. Lancet. 1993. 341:1105–1109.

2. McDonagh TA, Robb SD, Murdoch DR, Morton JJ, Ford I, Morrison CE, et al. Biochemical detection of left-ventricular systolic dysfunction. Lancet. 1998. 351:9–13.

3. Groenning BA, Nilsson JC, Sondergaard L, Kjaer A, Larsson HB, Hildebrandt PR. Evaluation of impaired left ventricular ejection fraction and increased dimensions by multiple neurohumoral plasma concentrations. Eur J Heart Fail. 2001. 3:699–708.

4. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002. 347:161–167.

5. Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med. 2004. 350:647–654.

6. Castell JV, Gomez-Lechon MJ, David M, Fabra R, Trullenque R, Heinrich PC. Acute-phase response of human hepatocytes: regulation of acute-phase protein synthesis by interleukin-6. Hepatology. 1990. 12:1179–1186.

7. Clyne B, Olshaker JS. The C-reactive protein. J Emerg Med. 1999. 17:1019–1025.

8. Almirall J, Bolibar I, Toran P, Pera G, Boquet X, Balanzo X, et al. Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia. Chest. 2004. 125:1335–1342.

9. Stolz D, Stulz A, Muller B, Gratwohl A, Tamm M. BAL neutrophils, serum procalcitonin, and C-reactive protein to predict bacterial infection in the immunocompromised host. Chest. 2007. 132:504–514.

10. Castro-Guardiola A, Armengou-Arxe A, Viejo-Rodriguez A, Penarroja-Matutano G, Garcia-Bragado F. Differential diagnosis between community-acquired pneumonia and non-pneumonia diseases of the chest in the emergency ward. Eur J Intern Med. 2000. 11:334–339.

11. Sato Y, Takatsu Y, Kataoka K, Yamada T, Taniguchi R, Sasayama S, et al. Serial circulating concentrations of C-reactive protein, interleukin (IL)-4, and IL-6 in patients with acute left heart decompensation. Clin Cardiol. 1999. 22:811–813.

12. Mueller C, Laule-Kilian K, Christ A, Brunner-La Rocca HP, Perruchoud AP. Inflammation and long-term mortality in acute congestive heart failure. Am Heart J. 2006. 151:845–850.

13. Windram JD, Loh PH, Rigby AS, Hanning I, Clark AL, Cleland JG. Relationship of high-sensitivity C-reactive protein to prognosis and other prognostic markers in outpatients with heart failure. Am Heart J. 2007. 153:1048–1055.

14. Milo O, Cotter G, Kaluski E, Brill A, Blatt A, Krakover R, et al. Comparison of inflammatory and neurohormonal activation in cardiogenic pulmonary edema secondary to ischemic versus nonischemic causes. Am J Cardiol. 2003. 92:222–226.

15. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J. 2005. 26:1115–1140.

16. Maeder MT, Kaye DM. Heart failure with normal left ventricular ejection fraction. J Am Coll Cardiol. 2009. 53:905–918.

17. Campbell GD. Overview of community-acquired pneumonia: prognosis and clinical features. Med Clin North Am. 1994. 78:1035–1048.

18. Tripathi M, Pandey M, Nepal B, Rai H, Bhattarai B. Evaluation of lung infiltration score to predict postural hypoxemia in ventilated acute respiratory distress syndrome patients and the lateralization of skin pressure sore. Indian J Med Sci. 2009. 63:392–401.

19. Cowie MR, Struthers AD, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet. 1997. 350:1349–1353.

20. Davis M, Espiner E, Richards G, Billings J, Town I, Neill A, et al. Plasma brain natriuretic peptide in assessment of acute dyspnoea. Lancet. 1994. 343:440–444.

21. Yu CM, Sanderson JE, Shum IO, Chan S, Yeung LY, Hung YT, et al. Diastolic dysfunction and natriuretic peptides in systolic heart failure: higher ANP and BNP levels are associated with the restrictive filling pattern. Eur Heart J. 1996. 17:1694–1702.

22. Maeda K, Tsutamoto T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction. Am Heart J. 1998. 135(5 Pt 1):825–832.

23. Joffe E, Justo D, Mashav N, Swartzon M, Gur H, Berliner S, et al. C-reactive protein to distinguish pneumonia from acute decompensated heart failure. Clin Biochem. 2009. 42:1628–1634.