Rapid access diagnostic pathway for suspected HF in primary care: The first 3 months... Dr Alan Japp Dr Sara Jenks Dr Clare McRae Dr Sebastian Peter

Suspected new heart failure in community Both entry criteria met? No Not eligible for pathway: Consider general cardiology referral Exertional or nocturnal dyspnoea: new-onset or major worsening No echo or cardio review (for dyspnoea) within last 12 months Yes Key referral info Previous MI Response to diuretics Orthopnoea / PND High JVP, ankle oedema CXR abnormalities Abnormal ECG (LBBB/Q waves/LVH/AF N.B. CXR and ECG helpful but not essential prior to referral 1. Send bloods from Heart Failure Diagnosis ICE 2. SCI Referral Heart Failure (NRIE, Cardiology) – please include key referral info GP Action

Suspected new heart failure in community Both entry criteria met? No Not eligible for pathway: Consider general cardiology referral Exertional or nocturnal dyspnoea: new-onset or major worsening No echo or cardio review (for dyspnoea) within last 12 months Yes Key referral info Previous MI Response to diuretics Orthopnoea / PND High JVP, ankle oedema CXR abnormalities Abnormal ECG (LBBB/Q waves/LVH/AF N.B. CXR and ECG helpful but not essential prior to referral 1. Send bloods from Heart Failure Diagnosis ICE 2. SCI Referral Heart Failure (NRIE, Cardiology) – please include key referral info GP Action

Heart Failure Team Action NT-proBNP indicated as a rule-out test NT-proBNP not indicated Yes NT-proBNP ≥125 pg/mL Attend HF Clinic (ECG/echo) No Other significant abnormality Normal ECG/echo LVSD HF team will discharge: consider referral for non-cardiac assessment Cardiologist & HF nurse review Cardiologist review

Referrals: 3/10/17 – 5/1/18 80 referrals in first 3 months (6-7 per week) 18 assessed as unsuitable for pathway:

Referrals: 3/10/17 – 5/1/18 80 referrals in first 3 months (6-7 per week) 18 assessed as unsuitable for pathway: 62 suitable patients: 52% female; mean age 74

HF team perspective Enthusiastic input from heart failure nurses: triaging; corresponding Significant workload and clinic pressure but manageable Unanticipated delay from referral to NTproBNP samples Cumbersome NTproBNP request process

Outcomes - Summary Of 62 suitable referrals: 3 admitted prior to evaluation through pathway 2 days (HF with superadded pneumonia and severe sepsis) 5 days (decompensated HF) 15 days (suspected HF but discharge diagnosis CVI) 1 died prior to evaluation (cause of death COPD; NT proBNP only marginally elevated) Several not yet completed pathway 41 (66%) initially triaged to NTproBNP test

Outcomes - Summary Of 55 patients who have come through pathway: 22 (40%) diagnosed with heart failure 12 LVSD 10 HF with preserved EF Time from referral to NTproBNP sample Average = 5 days 6 samples > 13 days Time from referral (with blood sample) to diagnosis (rule in or rule out of HF): Overall average = 21 days Patients diagnosed with HF = 19 days

Outcomes by NTproBNP: 1. Negative BNP (<125 pg/ml) N = 11 patients Mean time to diagnosis (rule out of HF) = 8 days No subsequent deaths or hospital admissions 4 referred for resp evaluation 1 referred to weight management programme 1 assessed and treated for possible DVT 1 referred for general cardiology opinion (?IHD) 1 diagnosed obesity and hypertension 1 oedema due to CCB and CVI

Outcomes by NTproBNP: 2. ‘Grey zone’ BNP (126-400 pg/mL) N = 8 patients (mean age = 81 years) No LVSD x2 patients with HEFPEF x6 non-HF diagnoses

Outcomes by NTproBNP: 3. High BNP (>400 pg/mL) N = 16 patients 12 patients (75%) diagnosed with HF 7 patients LVSD 5 patients HEFPEF (x1 constrictive pericarditis) 2 admitted to hospital pre-evaluation (>10,000) 1 patient severe aortic stenosis (TAVI 6 weeks)

Outcomes by NTproBNP: 4. No BNP test N = 18 patients 9 patients (50%) diagnosed with HF 5 patients LVSD 4 patients HEFPEF 1 admitted to hospital pre-evaluation

Incidence of LVSD / HEFPEF by NTproBNP category

Conclusions Promising preliminary data Probably sustainable! Negative BNP patients – no harm; alternative Ix Room to improve on time to HF diagnosis Consider increasing NTproBNP threshold?

Thanks HF Nurses (esp Janet Reid, Shirley Robertson) Dr Martin Denvir Biochemistry labs team Referring GPs!