Dorset Improving Diagnosis of Heart Failure Implementation of BNP Measuring in General Practice Ist Project Steering Group 13 th Sept 2011

Introduction to the BNP Project Dr Christopher Boos Consultant Cardiologist

Why Change the Current HF Diagnostic Pathway HF huge clinical burden – length of stay, admission diagnosis, yet sig proportion not getting access to specialist input Prognosis is improving but several aspects of care need to be improved HCC audit in 2007 reported that the delivery of HF diagnostic services is poor or only average in 50% of the UK Health Technology Assessment (HTA) in England - measuring NPs is the single most useful test to add to the diagnostic process in primary care - Mant J et al 2009 – –‘rule-out’ test in patients with suitable clinical presentation and suspected heart failure

NICE HF Guidelines 2003 <40% uptake Nationally by 2010

Suggested ESC Diagnostic Algorithm 2009 This related to untreated patients.

NICE Update 2010

ESC HF Guidelines 2009 Heart failure is a clinical syndrome in which patients have the following features: † Symptoms typical of heart failure (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling) and † Signs typical of heart failure (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly) and † Objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration

Why Change the Current HF Diagnostic Pathway Discovery interviews (Dec 2010) – integrated care pathway for HF and improve diagnosis – adopt BNP use into the diagnostic pathway Recent process mapping of HF patient pathways - huge variation in service provision and time to HF diagnosis across Dorset. GP ? HF patient might be referred for – –blood tests then wait results then refer – –One stop echo, breathlessness clinic – –Cardiology Outpatients (Cardiologist may do echo upstream or downstream)

Why Change the Current HF Diagnostic Pathway BNP only in RBCH breathless clinic Previously DCH - useful but stopped (funding, economies of scale) Huge variation in Echo waits across Dorset – –median of 5 -7 weeks wait for echo Difficulty in HF diagnosis (HFNEF/HFPEF) Under diagnosis Echo Pathway Audit Data – need for improved efficiency

Audit Sept 2011 Audited last 66 one stop echo clinic referrals to AAM 40 with ? Heart failure 52.5% male, mean age 72.2 years LV systolic dysfunction (EF<55%) – –3 / 40 (7.5%) HFNEF – –3 / 40 (7.5%) – one with HCM and sig diastolic dysfunction Any HF – –6/40 (15%) had diagnosis compatible with HF Other tests FBC RenalLFTSTFTS Glucose CXR 35/3935/3934/3920/3932/3925/39

Advantages of BNP V Good rule out test Raised level does not diagnose HF Absolute levels carry prognostic importance – –Very high levels carry a poor prognosis HFNEF vs HF reduced EF – – the level does not differentiate but can be helpful

Disadvantages of BNP Certain conditions can Reduce BNP – –Obesity – –Drugs - diuretics, ACE inhibitors, beta-blockers, ARBs and aldosterone antagonists Certain Conditions increase BNP – –LVH – –Ischaemia – –Right ventricular overload and hypoxaemia (including PE) – –GFR < 60 ml/minute – –Sepsis – –COPD, Diabetes and liver cirrhosis – –Increasing age particularly > 70

Proposed Clinical Pathway Discussion and Action Planning

Proposed Diagnostic Pathway Routine bloods, including BNP (ECG +/- CXR)

Action Planning Form Dorset Specific HF pathway - BNP central to this – –BNP in Primary care only, secondary care ambition – –Education ++ Gps, secondary care – –Identify and agree central laboratory / Assay (NT-proBNP) Diagnostic Cut offs? – – pg/mL – –Sample processing and information passage etc – –24 PARADIGM pts mean 539 pg/mL; median 289 pg/mL 4/24 <100 (16%) Secondary care trusts planning for delivery of time lines – –2 week and 6 week time points – –Specialist assessment