ArticlesValue of natriuretic peptides in assessment of patients with possible new heart failure in primary care
Introduction
Heart failure is commonly misdiagnosed, and the validity of the diagnosis in primary care is poor.1, 2 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.3
Natriuretic peptides are released in response to increased intracardiac volume or pressure.4 They have a natriuretic and vasodilatatory effect and suppress the renin-angiotensin-aldosterone system.5 A prohormone, stored in the atria, on release is cleaved into the active C- terminal 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.6, 7, 8, 9, 10, 11 Measurements of these peptides could therefore provide valuable information about underlying cardiac function.5 Previous work has focused on their role in detecting symptomless left-ventricular dysfunction after myocardial infarction,12, 13 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.14, 15 Measurement of natriuretic peptides might indicate whether referral for further cardiological assessment is necessary.
NT-ANP and BNP are more stable than ANP4, 16 and therefore are more suitable for use in primary care. Both of these peptides seem to be more sensitive and specific than ANP for detection of ventricular dysfunction.13, 17, 18, 19, 20 We report the utility of measurements of ANP, NT-ANP, and BNP in predicting the presence of heart failure in a consecutive series of 122 patients with a new primary-care diagnosis of heart failure.
Section snippets
Study population and identification of cases
This study was part of the Hillingdon Heart Failure Study, which identified incident (new) cases of clinical heart failure developing in a population of 151 000 served by 81 general practitioners in 31 practices in Hillingdon District, west London.21 The general practitioners agreed to refer all suspected cases of new heart failure to a rapid-access study clinic, preferably before patients had started treatment. 122 patients were referred within the 15-month study period (April 6, 1995, to July
Results
122 patients (59 male, 63 female; age range 24–87 years) were referred to the study clinic with a new diagnosis of heart failure suspected by the general practitioner. The median delay between the general practitioner's suspicion of heart failure and the patient's attendance at the clinic was 4 days (IQR 2–15). 38 of these patients were receiving long-term diuretic treatment for hypertension or long-standing ankle oedema. Of the remaining 84 patients, 26 (31%) were started on diuretic treatment
Discussion
Heart failure is difficult to diagnose in primary care. Our finding that fewer than 30% of referred patients had heart failure accords with previous studies in Finland1 and Scotland,2 which suggested that only 25–50% of patients with a primary-care diagnosis of heart failure have evidence of this disorder on further cardiological assessment. The false-positive rate was higher in women than in men in our study and in the Finnish study.1 Without further assessment (such as echocardiography), more
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