THE LANCET Contributors Devra Lee Davis, World Resources Institute (WRI); Tord Kjellstrom and Rudi Slooff, World Health Organization, and Albert McGartland, Environmental Protection Agency (EPA) organised this study. Analyses were provided by Dwight Atkinson, Wiley Barbour, William Hohenstein, Peter Nagelhout, and Tracey Woodruff, EPA, Frank Divita and Jim Wilson, Pechan Associates, Leland Deck, Abt Associates; and Joel Schwartz, Harvard University School of Public Health. All contributed to the writing of this report. Acknowledgments Funding was provided by USA EPA, the Agency for International References Houghton JT, Callander BA, Varney SK. Climate change 1992: the supplementary report to the Intergovernmental Panel on Climate Change scientific assessment. Cambridge: Cambridge University Press, 1992. 2 Houghton JT, Meiro Filho LG, Callander BA, Harris N, Kattenberg A, Maskell K. Climate change 1995: the science of climate change. 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Washington, DC: World Resources Institute, 1997. 55 McMichael AJ. Healthy world, healthy people. People Planet, 1997; 6: 6-9. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care Martin R Cowie, Allan D Struthers, David A Wood, Andrew JS Coats, Simon G Thompson, Philip A Poole-Wilson, George C Sutton Summary Background The reliability of a clinical diagnosis of heart failure in primary care is poor. Concentrations of natriuretic peptides are high in heart failure. This population-based study examined the predictive value of natriuretic peptides in patients with a new primary-care diagnosis of heart failure. Methods Concentrations of plasma atrial (ANP and Nterminal ANP) and B-type (BNP) natriuretic peptides were measured by radioimmunoassay in 122 consecutive patients referred to a rapid-access heart-failure clinic with a new primary-care diagnosis of heart failure. On the basis of clinical assessment, chest radiography. and transthoracic echocardiography. a panel of three cardiologists decided that 35 (29%) patients met the case definition for new heart failure. ANP and NT-ANP results were available for 117 patients (34 with heart failure) and BNP results for 106 (29 with heart failure). Findings Geometric mean concentrations of natriuretic peptides were much higher in patients with heart failure than in those with other diagnoses (29-2 vs 12-4 pmol/L for ANP: 63.9 vs 13-9 pmol/L for BNP: 1187 vs 410-6 pmol/L for NT-ANP; all p<0.001). At cut-off values chosen to give negative predictive values for heart failure of 98% (ANP 18-1 pmol/L, NT-ANP 537-6 pmol/L, BNP 22-2 pmol/L), the sensitivity, specificity, and positive predictive value for ANP were 97%, 72%, and 55%; for NT-ANP 97%, 66%, and 54% ; and for BNP 97%, 84%, and 70%. Addition of ANP or NT-ANP concentration or both did not improve Cardiac Medicine, Imperial College School of Medicine, National Heart and Lung institute, London SW3 6LY, UK (M R Cowie MRCP, DA Wood FRCP, A JS Coats FRCP, P A Poole-Wilson FRCP); Department of Clinical Pharmacology and Therapeutics, Ninewells Hospital and Medical School, Dundee (A D Struthers FRCP); Department of Medical Statistics and Evaluation, Royal Postgraduate Medical School, London (SG Thompson osc); and Hillingdon Hospital, Uxbridge, Middlesex (G C Sutton FRCP) Correspondence to: Dr Martin R Cowie the predictive power of a logistic regression model containing BNP concentration alone. Interpretation In patients with symptoms suspected by a general practitioner to be due to heart failure, plasma BNP concentration seems to be a useful indicator of which patients are likely to have heart failure and require further clinical assessment. Lancet 1997; 350: 1347-51 Introduction το Heart failure is commonly misdiagnosed, and the validity of the diagnosis in primary care is poor. The symptoms are non-specific and the clinical signs, although reasonably specific, are not at all sensitive. Consequently, even experienced physicians disagree on the diagnosis in individual cases, especially when the heart failure is mild.' Natriuretic peptides are released in response increased intracardiac volume or pressure. They have a natriuretic and vasodilatatory effect and suppress the renin-angiotensin-aldosterone system. A prohormone, stored in the atria, on release is cleaved into the active Cterminal atrial natriuretic peptide (ANP) and the inactive and less rapidly cleared N-terminal atrial natriuretic peptide (NT-ANP). B-type natriuretic peptide (BNP) is secreted mainly by the ventricle. The plasma concentration of these peptides is higher than normal in patients with heart failure and also, but to a lesser extent, in patients with symptomless cardiac impairment." Measurements of these peptides could therefore provide valuable information about underlying cardiac function.' Previous work has focused on their role in detecting symptomless left-ventricular dysfunction after myocardial infarction," but little attention has been paid to the role of the natriuretic peptides in assessment of whether a patient's symptoms are due to heart failure at the time of first presentation to primary care. Measurement of natriuretic peptides might indicate whether referral for further cardiological assessment is necessary. NT-ANP and BNP are more stable than ANP and therefore are more suitable for use in primary care. Both of these peptides seem to be more sensitive and specific Q22.2 What level of reductions in greenhouse gas emissions and in the number of deaths associated with exposure to fine particles will result from EPA's recently promulgated fine particles standard? A22.2 In the Regulatory Impact Analysis of the revised PM, Ozone and Regional Haze NAAQS, EPA estimated that partial attainment of the new PM 2.5 NAAQS would annually prevent between 3,300 to 15,600 premature deaths. EPA based the primary NAAQS for fine particles on scientific evidence of adverse health effects from exposure to fine particles. The Administrator did not consider reductions in greenhouse gas emissions when making her decision on the level of the fine particles standard. When the standard is implemented by States, to the extent that sources rely on enhanced energy efficiency and fuel switching to comply with the standard, such compliance strategies would tend to reduce greenhouse gas emissions. At this time, however, the Agency has not determined the magnitude of greenhouse gas reductions that will come as a result of compliance with the fine particle standard. Multiple steps are required before States will even determine which sources will need to be regulated: fine particle monitoring data must be collected, each area's attainment status must be determined, and States must decide on appropriate control strategies. Appendix H of the Regulatory Impact Analysis (RIA) for Ozone, PM, and Regional Haze includes an illustrative analysis for electric power plants, based on the Integrated Planning Model (IPM). EPA uses the IPM model to forecast emissions of several pollutants (NOx, SO2, Hg, and CO2) from such plants if a control program were implemented for one or a combination of such pollutants. The illustrative scenario found in Appendix H assumed a 60% reduction in SO2 beyond levels required by the acid rain program, in concert with specified reductions in NOx, achieved through a cap-andtrade program. The IPM model forecasts base case carbon emissions from the electric power sector as 621 million metric tons (MMT) in 2010; under this control scenario, emissions fall to 589 MMT. It should be emphasized that this is just one illustrative control scenario, and that the level of SO2 reductions needed from electric power sources in order to meet the fine particle standard has yet to be determined, for the reasons explained above. Q22.3 Please document the figures provided in the response to question 22.2 above. A22.3 See the Regulatory Impact Analysis of the revised PM, Ozone and Other Benefits of Reducing Greenhouse Gases Q23. On page 11 of your written testimony, you state: “In addition to health benefits, greenhouse gas mitigation would lead to improved visibility, more and better recreational opportunities, and reduced nitrogen deposition in vulnerable water bodies (such as the Chesapeake Bay)." Please document these claims. A23. Improved visibility, enhanced recreational opportunities and reductions in estuarine nitrogen deposition are identified as benefit categories in the Regulatory Impact Analysis of the revised PM, Ozone and Regional Haze NAAQS. To the extent that greenhouse gas mitigation results in reductions in emissions of PM and its precursors, these benefits would be realized as well. While the qualitative relationship between greenhouse gas mitigation and criteria air pollutant emissions is clear, its quantitative impact has not yet been assessed. Reduction of NOx Emissions Due to CCTI Programs Q24. On page 11 of your written testimony, you state: “In 1999, EPA's CCTI programs alone are expected to also reduce NOx emissions by 90,000 tons per year, improving both air and water quality.” Please document these claims. A24. See attachment, 1998 Budget Narrative. 1999 Annual Performance Goals carbon Reduce U.S. greenhouse gas emissions by 40 million metric ton equivalent (MMTCE) per year through partnerships with businesses, schools, state and local governments, and other organizations. Improve national air quality through reductions in criteria air pollutants, including annual reductions of over 90,000 tons of nitrogen oxides (NOx), a major contributor to ground-level ozone. Reduce U.S. energy consumption by over 45 billion kilowatt hours per year, including annual energy bill savings to consumers and businesses of over $3 billion. Encourage more widespread adoption of low greenhouse gas emitting technologies. Work with representatives of companies and industries interested in developing roadmaps of actions in the public and private sectors that can lead to improvements in energy use and reductions in GHG emissions. Conduct bilateral dialogues with 10-12 key developing countries to bring them toward meaningful participation under the Kyoto protocol. Reduce greenhouse gas emissions internationally. Advance the understanding and communicate the risks of climate change by working with state constituencies to assess economic and environmental impacts, develop strategies for reducing vulnerabilities, build the infrastructure to overcome existing impediments to mitigation, implement technology-based options. and Guide the development of the rules and guidelines to operationalize emissions trading, the Clean Development Mechanism, joint implementation, and early reduction credits. Assess greenhouse gas implications of major sector-based policies (e.g., utility deregulation, subsidy removal, revenue recycling, land use policy). Assess economic and technological advances to evaluate and establish domestic policies and measures to meet U.S. obligations under the Framework Convention on Climate Change and the December 1997 Kyoto Protocol. Demonstrate that an American family car can attain over 60 miles per gallon (MPG) on the Federal Test Procedure (FTP) without loss in utility, safely, and emissions control performance. Begin process to optimize prototype vehicle and to apply knowledge gained through PNGV program to trucks. Research Develop reports on problem formulation for ecosystem services sector assessment and on the use of climate change indicators. |