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Mid-regional pro-adrenomedullin improves disposition strategies for patients with acute dyspnoea: results from the BACH trial
  1. Martin Möckel1,
  2. Julia Searle1,
  3. Oliver Hartmann2,
  4. Stefan D Anker3,4,
  5. W Frank Peacock5,
  6. Alan H B Wu6,7,
  7. Alan Maisel8,9,
  8. on behalf of the BACH Writing group
  1. 1Department of Cardiology and Emergency Medicine Unit, Charité—Universitätsmedizin Berlin, Berlin, Germany
  2. 2Thermo Scientific Biomarkers, Thermo Fisher Scientific/BRAHMS GmbH, Hennigsdorf, Germany
  3. 3Department of Cardiology Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
  4. 4Centre for Clinical and Basic Research IRCCS San Raffaele Roma, Italy
  5. 5Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
  6. 6Department of Laboratory Medicine, University of California, San Francisco, California, USA
  7. 7San Francisco General Hospital, Laboratory Medicine, San Francisco, California, USA
  8. 8University of California, San Diego, California, USA
  9. 9VA San Diego Healthcare System, San Diego, California, USA
  1. Correspondence to Dr Julia Searle, Emergency Medicine Unit CVK, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; julia.searle{at}


Objectives To assess the value of mid-regional pro-adrenomedullin (MR-proADM) in guiding patient disposition from the emergency department (ED), as one of the key factors of hospital resource utilisation, in undifferentiated patients with acute dyspnoea.

Methods We used clinical and outcome data from a large international biomarker study (BACH trial) and analysed data of all 1557 patients of the European and US sites presenting with acute dyspnoea. Patients were discharged or transferred from the ED to different levels of care (general ward, monitoring unit, intensive care unit). This original patient disposition was compared with the hypothetical disposition based on an adapted method of net reclassification improvement (NRI), which upgraded or downgraded patients from one level of care to the other based on the MR-proADM test result.

Results MR-pro-ADM was significantly higher in patients who died during the follow-up than in survivors (p<0.0001). When applying the adapted NRI model, 30 additional patients from the European Union (EU) and 55 additional patients from USA were theoretically discharged (increase of 16.5%) if MR-proADM had been used for patient management. The overall NRI, adding up the rates of upgrades and downgrades, in the EU was 16.0% (95% CI 8.2% to 23.9%). A total of n=72 (9.9%) patients changed disposition when adding MR-pro ADM. In the USA, the overall NRI was 12.0% (5.7%–18.4%) and a total of n=81 (11.2%) patients changed disposition.

Conclusions MR-proADM has the potential to guide initial disposition of undifferentiated ED patients with acute dyspnoea and might therefore be helpful to improve resource utilisation and patient care.

  • Diagnosis
  • airway
  • statistics
  • cost effectiveness
  • emergency department

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  • BACH Writing Group: Anna Slagman(Charité—Universitätsmedizin Berlin, Dept. of Cardiology and Emergency Medicine Unit, Berlin, Germany); Jörn Ole Vollert(Charité—Universitätsmedizin Berlin, Dept. of Cardiology and Emergency Medicine Unit, Berlin, Germany; Thermo Scientific Biomarkers, Thermo Fisher Scientific/BRAHMS GmbH, Hennigsdorf, Germany); Jana Papassotiriou(Thermo Scientific Biomarkers, Thermo Fisher Scientific/BRAHMS GmbH, Hennigsdorf, Germany); Inder Anand(VA Minneapolis, Minnesota, USA); Robert Christenson (University of Maryland, Baltimore, Maryland, USA); Lori B Daniels(University of California, San Diego, California, USA); Gerasimos S. Filippatos (Athens University Hospital Attikon, Athens, Greece); Christopher Hogan (Virgina Commonwealth University, Richmond, Virginia, USA); Nils Morgenthaler, (Thermo Scientific Biomarkers, Thermo Fisher Scientific/BRAHMS GmbH, Hennigsdorf, Germany); Christian Mueller, (University Hospital Basel, Basel Switzerland); Sean-Xavier Neath (University of California, San Diego, California, USA); Leong Ng (University of Leicester, Leicester, UK); Richard Nowak, (Henry Ford Health System, Detroit, Michigan, USA); Mark Richards (University of Otago, Christchurch, New Zealand); Salvatore Di Somma (Sant'Andrea Hospital, University La Sapienza, Rome Italy) and Piotr Ponikowski (Medical University, Faculty of Public Health, Wroclaw).

  • MM and JS authors contributed equally to this paper.

  • Funding BRAHMS GmbH, Biotechnology Centre Hennigsdorf/Berlin, Germany, was sponsor of the trial and provided the funding.

  • Competing interests Oliver Hartmann, Joern Ole Vollert, Jana Papassotiriou and Nils Morgenthaler are employees of BRAHMS GmbH.

  • Ethics approval The BACH-trial was approved by the institutional review boards of all 15 participating centers.

  • Provenance and peer review Not commissioned; externally peer reviewed.