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Adherence to guidelines in management of symptoms suggestive of heart failure in primary care
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    caveats to reliance on natriuretic peptide levels to trigger referral to secondary care

    An imprtant caveat to reliance on brain natriuretic peptide(BNP) levels > 100 pg/ml to trigger referral to secondary care(1) is that there exists a clinical phenotype of congestive heart failure(CHF) characterised by BNP equal to or less than 100 pg/ml(2).. In the latter study 46 out of 1159 subjects with CHF and left ventricular ejection fraction(LVEF) > 50%, 46 subjects were characterised by BNP equal to or less than 100 pg/ml. Heart failure symptoms such as effort dyspnoea were equally prevalent(93% vs 90%) in subject with BNP equal to or less than 100 pg/ml vs counterparts with BNP > 100 pg/ml(2). The same was true of orthopnoea(48% vs 48%) and paroxysmal nocturanal dyspnoea(28% vs 29%)(2).
    The other caveat is that constrictive pericarditis(CP), an entity characterised by symptoms such as effort dyspnoea and pedal oedema, similar to those in CHF, may be characterised by BNP as low as 50 pg/ml and 88 pg/ml, respectively, in spite of coexistence of New York Heart Association functional class III and IV symptoms(3), and natriuretic propeptide tyype B 147 pg/ml in spite of worsening dyspnoea(4). An overriding consideration is the "diagnostic value of physical examination....in primary care"(5) which includes evaluation of jugular venous pressure(JVP)(5). In the latter study elevation of JVP contributed 12 points towards a score of >54 needed to generate a >70% probability of CHF(5). In CP marked elevation of JVP is almost universal(6)....

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    None declared.