1. 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

2. 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

3. 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

4. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. Incidence of LVSD / HEFPEF by NTproBNP category

16. 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?

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