Acute Heart Failure Mortality Prediction Using Copeptin: Results of the Biomarkers in ACute Heart Failure Trial

Study Objectives: Emergency physicians have few tools providing objective accurate prediction of short term mortality risk in patients presenting to the emergency department (ED) with acute heart failure (AHF). Our purpose was to describe whether plasma C-terminal pro-vasopressin fragment (Copeptin), a surrogate for circulating arginine vasopressin (AVP), is associated with short term death rates in ED patients presenting with AHF. Methods: The Biomarkers in ACute Heart failure (BACH) trial was a prospective, 15-center, international study of patients presenting to the ED with nontraumatic dyspnea. Copeptin values were blinded. All other lab testing was per standard of care and, when used clinically at the discretion of the treating emergency physician, employed the local hospital reference range. For copeptin, BNP and NTproBNP, a core lab was utilized. Creatinine was measured in the local hospital laboratory. Gold standard diagnoses were determined by 2 cardiologists, blinded to copeptin results, reviewing all data available 90 days post ED visit. Results: Of the 1641 BACH patients, 568 (34.6 %) had a gold standard diagnosis of AHF, 52% were male, and 36% had a prior history of HF. Overall, 21 (3.5%) died within the first 14 days, and 65 (11.4%) were dead by 90 days. Mortality prediction is described by C- statistic; all p values 0.05, except when noted by * where pNS. In a multivariable model including systolic and diastolic blood pressure, creatinine (1.6 mg/dL), and troponin (high/low), copeptin added significantly to the base model (Chi210.5, HR 3.3, p0.0012). Neither BNP nor NT-proBNP were significant in univariate Cox regression (both p 0.1). Conclusion: Copeptin demonstrates superior short term mortality prognostic ability when compared to natriuretic peptides, and is independent of other clinical covariates. Objective determination of mortality risk may provide opportunities to improve emergency department acute heart failure decisionmaking and consequent clinical outcome