1. Catriona Clark and Clare MacRae
Natriuretic Peptide (NP) testing and heart failure- what should we be doing?
Catriona Clark and Clare MacRae

2. Natriuretic Peptides
Hormone secreted by ventricular myocardium during ventricular stretch, ↑ wall tension.
Role:
controls BP, blood volume, Na+ balance.
Raised in heart failure
Assays: BNP (active metabolite), NT-proBNP (biologically inactive)
Normal level virtually excludes heart failure

3. Why NP testing and why now?
Significant heart failure associated morbidity, mortality and cost
Ageing population
Current guidance recommends change in approach
Underdiagnosis is common (Newcastle 85+ study)
Lack of availability of diagnostic tests in Primary Care

4. NP testing vs. traditional diagnostic tools
Investigation
Sensitivity
Specificity
NT-proBNP
93%
65%
Chest X-ray (CXR)
68%
83%
ECG
89%
56%

5. NICE CG108 Previous MI + ? heart failure
= URGENT referral within 2 weeks for echocardiography and OP cardiology
NO previous MI + ? heart failure
= measure serum NP
NORMAL level
= heart failure very unlikely. Reassure and seek alternative cause
RAISED level
= referral within 6 weeks for echocardiography and OP cardiology
HIGH level
= referral within 2 weeks for echocardiography and OP cardiology

6. SIGN Guideline 95 2007 Guideline recommendation 2012 Review Conclusion
Natriuretic peptides and/or ECG recorded in patients with suspected heart failure
Echocardiography if either is abnormal
2012 Review Conclusion
BNP testing should be recommended over ECG in Primary care
Some patients referred straight for Echo

7. PLIG project 12 months research Local discussion
UK wide information gathering
Scotland
NHS Shetland only trust using in Primary Care,
Glasgow Secondary care, one stop Cardiology clinics
England
>50% Primary Care trusts using NP testing
Wide variability in numbers tested, gatekeeping methods , efficiency in use of the test

8. Improving services and reducing costs
Prevalence of heart failure
5547 patients in NHS Lothian
Inpatient admissions
962 inpatient stays (793 patients) in
Average length of stay 11 nights, cost £1567
Costs
883,000 population, test prevalence 3.8/1000
3355 tests per annum = £
54% negative acc to NICE Literature

9. Gatekeeping, audit, updates
Gate-keeping. Order Comms used to audit and control use, patients who:
1. otherwise be referred to cardiology for assessment of suspected heart failure
2. no previous MI
3. not had a NP test within the last year; rationing to one test per year per patient
Audit. Little performed in practice, electronic ordering systems key.
GP Updates. Resources available from NICE, GP update meetings, communication with practice managers, intranet.