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Rev Esp Cardiol (Engl Ed). 2013 Jul;66(7):532-8. doi: 10.1016/j.rec.2012.11.004. Epub 2013 Jan 29.

N-terminal pro-brain natriuretic peptide and high-sensitivity troponin in the evaluation of acute chest pain of uncertain etiology. A PITAGORAS substudy.

Author information

  • 1Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain. Electronic address:
  • 2Servicio de Cardiología, Hospital Universitari Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain.
  • 3Servicio de Cardiología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
  • 4Servicio de Cardiología, Hospital Josep Trueta, Girona, Spain.
  • 5Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain.
  • 6Servicio de Cardiología, Hospital Gregorio Marañón, Madrid, Spain.
  • 7Servicio de Cardiología, Hospital do Meixoeiro, Vigo, Pontevedra, Spain.
  • 8Servicio de Cardiología, Hospital General de Asturias, Oviedo, Asturias, Spain.
  • 9Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain.
  • 10Servicio de Cardiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.
  • 11Servicio de Bioquímica Clínica, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.
  • 12Servicio de Cardiologia, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.



High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients.


A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event.


Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P=.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P=.004). N-terminal pro-brain natriuretic peptide elevation (>125ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P=.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P=.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide.


In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.

Copyright © 2012 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.


ACS; Acute coronary syndrome; ECG; Hs-TnT; N-terminal pro-brain natriuretic peptide; NT-proBNP; Natriuretic peptides; PITAGORAS; Péptidos natriuréticos; Síndrome coronario agudo; Troponin; Troponina; acute coronary syndrome; electrocardiogram; high-sensitivity troponin T; troPonIna ulTrAsensible en pacientes atendidos en urGencias por dOlor toRácico en hospitales espAñoleS (in English: High-Sensitivity Troponin in Patients With Chest Pain Presenting To Spanish Emergency Departments)

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