Background National Institute of Clinical Excellence (NICE) Chronic Heart Failure Guideline NG106 recommends NTproBNP measurement in patients with suspected heart failure (HF). NTproBNP ≥400ng/L mandates referral to a rapid access HF clinic (RAHFC). Target wait is determined byNTproBNP concentration (400–2000ng/L 6 weeks and >2000ng/L within 2 weeks).

In our institution, RAHFC referrals have doubled in a year. There is little published national data regarding adherence to NICE waiting targets. Initial service evaluation found that only 47% of patients were seen within the target waiting time. However, many patients with lower range NT proBNP (<1000ng/L) had no significant cardiac pathology and were discharged. It was proposed this lower range NTproBNP population (400- 1000ng/l) could be safely managed in a cardiac physiologist-delivered RAHFC overseen by a HF specialist. Additonal benefits would be to upskill cardiac physiologists, free consultant time for more severe HF patients and improve waiting times.

Aim To introduce a supervised cardiac physiologist-led HF clinic for patients with a NTproBNP ≥400ng/L but <1000ng/L and monitor outcomes.

Method An electronic form was developed to guide clinical questioning and data collection. The clinic was initially run by 2 cardiac physiologists and a specialist HF fellow. All clinics were overseen by a consultant HF cardiologist. Demographics, NYHA class, NTproBNP concentration, waiting time, final diagnosis, further investigations and echo results were recorded. Outcomes at 3, 6 and 8 months were retrospectively assessed for safety.

Results 34 patients were seen in the physiologist-delivered HF clinic between Jun’18 and Jan’19. The proportion seen within target waiting time rose from 47% to 70%. Mean age 81 and 50% female. Mean NTproBNP was 730ng/L. 26.5% (n=9) were diagnosed with HFPEF and 2.9% (n=1) HFREF. 32.4% (n=11) had AF or paroxysmal AF. In 41.2% (n=14) NTproBNP was felt to be a false positive. Diagnoses included: pulmonary hypertension (n=1), moderate and severe aortic stenosis (n= 2), moderate aortic regurgitation (n=1), bradyarrhythmia requiring pacing (n=1), hypertrophic cardiomyopathy (n=2), atrial tachycardia (n=1), ectopy (n=2). As cardiac physiologists gained experience, they began to review patients independently and time slots were reduced. No adverse events were recorded.

Conclusion Demand for RAHFC is high and NICE waiting times are often difficult to meet with current service provision. A physiologist-delivered HF clinic proved safe, effective and dramatically reduced waiting times. There is a national shortage of cardiac physiologists, and staff retention and recruitment is difficult. Expanding the role and skill set of our cardiac physiologists has proved popular and good for staff morale.

NTproBNP threshold mandating urgent referral to RAHFC for patients with AF and those of advanced age may require further research and consideration.

Conflict of Interest None Declared