Purpose To find out the number of inappropriate echocardiogram requests made despite a negative NT pro-BNP test (<400 pg/l) and in even more negative test (<300 pg/l).

To estimate the cost burden on NHS.

To look at the impact on waiting times in the department from these requests.

Method We conducted a retrospective audit reviewing the NT pro-BNP requests in

Abertawe BroMorgannwg University Health Board. Data was collected from all NT pro-BNP assays from January 2013 to January 2014. The criteria of NT pro-BNP level of less than 400 ng/l was set according to the NICE Guidelines for Chronic heart failure 2010. We also looked if any requests were made when BNP levels were less than 300 ng/l.

Findings 370 NT pro-BNP requests were done during this period and 334 (90.27%) requests were from primary care. 300 assays were less than 400 ng/l and essentially ruled out heart failure. Regardless of the results, 190 requests were made for an echocardiogram to assess Left Ventricular function. 137 out of 190 (72%) of these echo requests were made in patients with a BNP level of less than 400 ng/l. The mean BNP level in patients with values of less than 400 ng/l was 120 ng/l. 278/370 assays had a BNP value of <300pg/l making heart failure very unlikely, but 120 echo requests were made in this group.

Conclusion Despite high negative predictive value of NT pro-BNP levels, significant amount of echo requests are made. The burden on our echo department is an extra 137 requests which amounts to 34.5 sessions by a sonographer/year. This amounts to 6,400 wasted echo sessions in NHS/year. The financial burden to NHS is estimated at around 137 inappropriate echo requests in 160 NHS Foundation Trust/Health Board at a cost of £75/ scan = £ 1.6 million/year.

Recommendation Health professionals requesting the above tests should be made aware of the above findings and educated especially in the primary care setting.

The echo department should have strict criteria to perform echocardiograms in patients with normal NT pro-BNP levels.