Introduction The NICE guidelines on Chronic Heart Failure 2010 recommend the use of natriuretic peptide (NP) testing in patients with suspected heart failure without previous myocardial infarction (MI). NP testing is felt to be the single most useful test to add to the diagnostic pathway for heart failure in primary care and has been shown to be cost effective. We evaluated the utility of NT-proBNP testing by GPs in BaNES (Bath and North East Somerset), Wiltshire and Somerset and their perceptions of this test.
Methods GPs from this region who requested an NT-proBNP test at the Royal United Hospital (RUH), Bath from 1/7/11–30/6/12 were asked to complete a questionnaire. The first 100 random responses formed our study sample. Patient outcome was assessed by reviewing their echo reports, clinic letters and discharge summaries.
Results There was an exponential rise in NT-proBNP requests over the study period (Figure 1). The majority of patients were female (66%) with a mean age of 77 (range 51–97). NT-proBNP was requested appropriately in 93% of our study sample. Seven patients had a previous MI.
Figure 2 shows a breakdown of NT-proBNP results, referral for echocardiography and outcome. GPs followed local RUH cut-off criteria, which are age-based and lower than NICE criteria. All echos performed in patients with a normal NT-proBNP result (by both criteria), were reassuringly ‘Normal’ (Good biventricular systolic function, no more than mild diastolic dysfunction and no more than mild valvular regurgitation). This implies it may be safe to follow NICE cut-off criteria, which would reduce echo referrals. The ESC optimum exclusion cut-off point is 125pg/ml for patients presenting in a non-acute way and 300pg/ml for acute heart failure.
Left ventricular systolic dysfunction was found in 10 patients (almost all had high NT-proBNP levels). A normal NT-proBNP level appears to reliably exclude heart failure with 100% sensitivity in our study sample, as none of these patients had an abnormal echocardiogram, heart failure diagnosis in cardiology outpatients or admission to hospital with heart failure.
Tables 1 and 2 illustrate the perception of GPs on NT-proBNP testing and their comments. Most GPs were familiar with the NICE algorithm and felt the test is useful. The majority (56%) also felt the test was more expensive than it actually is, with 3 GPs thinking it costs £100 pounds or more.
Conclusion GPs in BaNES, Wiltshire and Somerset are increasingly utilising NT-proBNP in patients with suspected heart failure. They are familiar with NICE guidelines, are using this test appropriately, and have very positive perceptions of it. This is despite also thinking the test is more expensive than it actually is.
A normal NT-proBNP in our study sample excluded heart failure with 100% sensitivity, by both local and NICE criteria. These results have been presented to GPs in this region, who have been encouraged to utilise this excellent test confidently and wisely.
- heart failure
- primary care
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