Natriuretic Peptide Testing in Primary Care: The Evidence is Settled, Implementation is Not.

AimsHeart failure (HF) is a malignant condition with poor outcomes and is often diagnosed on emergency hospital admission. Natriuretic peptide (NP) testing in primary care is recommended in international guidelines to facilitate timely diagnosis. We aimed to report contemporary trends in NP testing and subsequent HF diagnosis rates over time.Methods and resultsCohort study using linked primary and secondary care data of adult (≥45 years) patients in England 2004–18 (n = 7 212 013, 48% male) to report trends in NP testing (over time, by age, sex, ethnicity, and socioeconomic status) and HF diagnosis rates. NP test rates increased from 0.25 per 1000 person-years [95% confidence interval (CI) 0.23–0.26] in 2004 to 16.88 per 1000 person-years (95% CI 16.73–17.03) in 2018, with a significant upward trend in 2010 following publication of national HF guidance. Women and different ethnic groups had similar test rates, and there was more NP testing in older and more socially deprived groups as expected. The HF detection rate was constant over the study period (around 10%) and the proportion of patients without NP testing prior to diagnosis remained high [99.6% (n = 13 484) in 2004 vs. 76.7% (n = 12 978) in 2017].ConclusionNP testing in primary care has increased over time, with no evidence of significant inequalities, but most patients with HF still do not have an NP test recorded prior to diagnosis. More NP testing in primary care may be needed to prevent hospitalization and facilitate HF diagnosis at an earlier, more treatable stage.

Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis. To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds. Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed. In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8). At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

ObjectivesHeart failure is an important health problem and patients are generally older with several comorbidities. Multidisciplinary heart failure care is therefore recommended. However, there is little evidence in real-world settings on how to involve primary care health professionals and how to evaluate such programmes. The main objective of this study is to integrate and evaluate several disease management interventions in a primary care setting.DesignProspective, non-randomised, observational implementation study with a mixed-methods process evaluation conducted over 3 years (2020–2022).SettingPrimary care practices and two regional hospitals (one tertiary, one secondary) in the Leuven region, Belgium, serving approximately 100 000 inhabitants.Participants100 general practitioners (GPs) from 19 practices participated. A total of 96 patients were included in the disease management programme. Inclusion criteria for patients included high-risk status for heart failure (HF) readmission, based on clinical criteria. Exclusion criteria were not explicitly defined but participation required informed consent.InterventionsFour interventions were implemented: (1) online HF education for GPs, (2) reimbursed natriuretic peptide (NP) testing, (3) patient education by trained primary care HF educators and (4) a structured transitional care protocol posthospital discharge.Primary and secondary outcome measuresPrimary outcomes included GP self-efficacy in HF management, NP testing rates, HF registration in electronic health records and patient self-efficacy (9-item European Heart Failure Self-Care Behaviour Scale (EHFScB-9)). Secondary outcomes included patient quality of life (Short Form-12 questionnaire (SF-12)), hospital readmission rates and provider satisfaction.ResultsGPs felt more competent in the management of HF after an online education (eight point increase in self-efficacy score after 6 months follow-up, (CI 2.9 to 13, p<0.001)). GPs conducted 314 reimbursed NP tests, half of which scored above age-specific thresholds for referral. After initiation, there was a significant increase in NP testing (Bayes Factor 64), with a total rate of 5.4 tests per 1000 patient years. The proportion of registered HF in patients aged 40 years or older in GPs’ electronic health records increased from 2.27% to 2.57% between 2020 and 2022. 96 patients were included in the disease management programme, 75% of these inclusions followed the transitional protocol after discharge for HF. There was significant improvement in patients’ self-efficacy after 6-month follow-up (an EHFScB-9 score change of 2.7 points, 95% CI 0.62 to 4.8), but no significant change in quality of life (an SF-12 score change of 0.15 points, 95% CI −1.1 to 1.4). Adherence to the transitional protocol depended on the presence of a specialist HF nurse during admission, 84% of all patients were seen within 14 days after discharge by their general practitioner. Time-trend analysis revealed an increase of HF as a secondary rather than primary cause of admission. Participating healthcare professionals reported satisfaction with the programme.ConclusionsThe IMPACT-B study demonstrated that an integrated disease management programme for HF could be implemented and assessed in routine clinical practice. The programme resulted in increased awareness and registration of HF in primary care, increased self-management of patients and improved follow-up after discharge, although these results should be interpreted cautiously given the uncontrolled pre-post study design.Trial registrationTrial registration NCT04334447 (clinicaltrials.gov).

THE FACTORS ASSOCIATED WITH NATRIURETIC PEPTIDES (BNP AND NT-proBNP) TESTING IN PATIENTS PRESENTING TO EMERGENCY DEPARTMENTS OF ALBERTA WITH SUSPECTED HEART FAILURE

### A. Context of Biochemical Marker Testing in Heart Failure Biochemical marker testing has revolutionized the approach to diagnosis and management of heart failure over the past decade. There is an unsurpassed excitement in the heart failure community that significant advances in our understanding of currently available and future cardiac biomarkers will facilitate improved characterization of heart failure disease states and promote individualized therapy in heart failure and beyond. However, like most novel diagnostic tests, the promising findings from pivotal trials have met with ongoing challenges when applied in the clinical setting. The material discussed in this guidelines document addresses clinical use of BNP/NT-proBNP and cardiac troponin testing in the context of heart failure diagnosis, risk stratification and management, including therapeutic guidance in adult (>18 year-old) patients. Together with the associated document titled “ National Academy of Clinical Biochemistry and IFCC Committee for Standardization of Markers of Cardiac Damage Laboratory Medicine Practice Guidelines: Analytical Issues for Biomarkers of Heart Failure ”, …

This survey investigates natriuretic peptide (NP) testing in community and hospital settings, assessing awareness, accessibility, and utilization. This investigator-initiated survey, conceived within the HFA of the European Society of Cardiology, comprised 14 questions. It underwent validation and pilot testing to ensure question readability and online system functionality. The survey was accessible for 87days, from 5 April 2023 to 1 July 2023 via a web platform. There were 751 healthcare professionals across 99 countries who responded. Of them, 92.5% had access to NPs testing in hospital whereas 34.3% had no access to NTproBNP in community settings. Access to point of care NP testing was uncommon (9.6%). Public insurance fully covered NPs testing in 31.0% of cases, with private insurance providing coverage in 37.9%. The majority (84.0%) of participants believed that the medical evidence supporting NPs testing was strong, and 54.7% considered it cost-effective. Also, 35.8% found access, awareness, and adoption to be in favour of NPs testing both in hospital and community settings. Strategies to optimize NP testing involved regular guideline updates (57.9%), prioritizing NPs testing for dyspnoea assessment (36.4%), and introducing clinician feedback mechanisms (21.2%). Notably, 40% lacked a community-based HF diagnostic pathway for referring high-NP patients for echocardiography and cardiology evaluation. This survey reveals NP awareness, access, and adoption across several countries. Highlighting the importance of community-based early heart failure diagnosis and optimizing HF diagnostic pathways remains a crucial, unmet opportunity to improve patient outcomes.

This study aimed to describe patterns of outpatient natriuretic peptide (NP) testing and levels, including brain NP (BNP) and N-terminal pro-BNP (NT-proBNP), among pregnant patients with and without heart disease (HD) and the association between NP and severe maternal morbidity (SMM).A nationwide sample of pregnant patients delivering at ≥20 weeks in the Epic Cosmos dataset from 2017 to 2023 was extracted. Outpatient NP levels drawn between 24 and 34 weeks' gestation were identified, categorized as normal or elevated (BNP ≥ 100 or NT-proBNP ≥ 300 pg/mL), and described according to the presence or absence of congenital or acquired HD based on ICD-10 codes. The primary outcomes were CDC-defined SMM and nontransfusion SMM. Among those with NP testing, the association between elevated levels and SMM was assessed using logistic regression after applying stabilized inverse probability treatment weights (SIPTW) that included demographic characteristics, HD, obesity, and other medical comorbidities.Of 3,935,745 unique pregnancies, 3,920,088 (99.6%) had no NP testing, 14,180 (0.4%) had normal NP, and 1,477 (0.04%) had elevated NP. Of those with any HD, 1.6% underwent NP testing. A greater proportion of those with normal NP (N = 1,287 [9.1%]) and elevated NP (N = 406 [27.5%]) experienced SMM compared with those without NP testing (N = 99,176 [2.5%]; p < 0.001), with similar results for nontransfusion SMM. The odds of SMM and nontransfusion SMM were higher in patients with elevated NP levels; this association persisted, but was attenuated, in SIPTW-adjusted models (SMM crude odds ratio [OR]: 14.6, 95% confidence interval [CI]: 13.0, 16.4, and adjusted odds ratio [aOR]: 1.2, 95% CI: 1.1, 1.2; nontransfusion SMM crude OR: 25.4, 95% CI: 22.6, 28.6 and aOR: 1.2, 95% CI: 1.2, 1.2).NP testing remains underutilized during pregnancy, even among patients with heart disease. Elevated levels are associated with higher SMM risk, although the attenuation in association after covariate adjustment suggests its additive value in predicting SMM may be limited. · BNP testing remains underutilized in pregnancy.. · BNP testing ranged from only 1 to 6% of individuals with heart disease in pregnancy.. · Elevated BNP levels obtained prior to delivery are associated with SMM, although this association is attenuated after adjustment for other clinical risk factors..

Some UK GPs are acquiring access to natriuretic peptide (NP) testing or echocardiography as diagnostic tests for heart failure. This study developed appropriateness ratings for the diagnostic application of these tests in routine general practice. To develop appropriateness ratings for the diagnostic application of NP testing or echocardiography for heart failure in general practice. An appropriateness ratings evaluation in UK general practice. Four presenting symptoms (cough, bilateral ankle swelling, dyspnoea, fatigue), three levels of risk of cardiovascular disease (low, intermediate, high), and dichotomous categorisations of cardiovascular/chest examination and electrocardiogram result, were used to create 540 appropriateness scenarios for patients in whom NP testing or echocardiography might be considered. These were rated by a 10-person expert panel, consisting of GPs and GPs with specialist interests in cardiology, in a two-round RAND Appropriateness Method. Onward referral for NP testing or echocardiography was rated as an appropriate next step in 217 (40.2%) of the 540 scenarios; in 194 (35.9%) it was rated inappropriate. The ratings also show where NP testing or echocardiography were ranked as equivalent next steps and when one test was seen as the more appropriate than the other. NP testing should be the routine test for suspected heart failure where referral for diagnostic testing is considered appropriate. An abnormal electrocardiogram status makes referral to echocardiography an accompanying, or more appropriate, next step alongside NP testing, especially in the presence of dyspnoea. Abnormal NP testing should subsequently be followed up with referral for echocardiography.

Heart failure (HF) is a prevalent syndrome with considerable disease burden, healthcare utilization and costs. Timely diagnosis is essential to improve outcomes. This study aimed to compare the diagnostic performance of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in detecting HF in primary care. Our second aim was to explore if personalized thresholds (using age, sex, or other readily available parameters) would further improve diagnostic accuracy over universal thresholds. A retrospective study was performed among patients without prior HF who underwent natriuretic peptide (NP) testing in the Amsterdam General Practice Network between January 2011 and December 2021. HF incidence was based on registration out to 90 days after NP testing. Diagnostic accuracy was evaluated with AUROC, sensitivity and specificity based on guideline-recommended thresholds (125 ng/L for NT-proBNP and 35 ng/L for BNP). We used inverse probability of treatment weighting to adjust for confounding. A total of 15,234 patients underwent NP testing, 6,870 with BNP (4.5 % had HF), and 8,364 with NT-proBNP (5.7 % had HF). NT-proBNP was more accurate than BNP, with an AUROC of 89.9 % (95 % CI: 88.4-91.2) vs. 85.9 % (95 % CI 83.5-88.2), with higher sensitivity (95.3 vs. 89.7 %) and specificity (59.1 vs. 58.0 %). Differentiating NP cut-off by clinical variables modestly improved diagnostic accuracy for BNP and NT-proBNP compared with a universal threshold. NT-proBNP outperforms BNP for detecting HF in primary care. Personalized instead of universal diagnostic thresholds led to modest improvement.

Loop diuretics are commonly prescribed in primary care. We explored HF assessment, diagnosis, and outcomes following a loop diuretic prescription. The Clinical Practice Research Datalink Gold database linked to Hospital Episode Statistics (HES) and Office for National Statistics mortality registry in the UK was used to identify patients prescribed loop diuretics, and subsequent HF diagnoses. HF assessment was defined as natriuretic peptide (NP) testing, echocardiography, or out-patient cardiology referral. NP thresholds recommended by National Institute of Health and Care Excellence (NICE) and European Society of Cardiology (ESC) were explored. The primary endpoint was HF events (presentation to primary care with symptoms of HF, HF hospitalisation, or all-cause mortality). A total of 71,847 patients were prescribed a loop diuretic without a diagnosis of HF; 9876 (14%) underwent HF assessment and 1483 (15%) were diagnosed with HF within five years. Of those who were assessed, 5316 (54%) had NP testing: 1937 (36%) and 3200 (60%) patients had NP concentrations above the NICE and ESC referral thresholds, respectively. Of those above the NICE threshold, 701 (36%) were referred to cardiology. Compared to those who were not referred, there was a lower rate of all-cause mortality (47% vs. 57%; P<0.001; hazard ratio=0.87 (95% confidence interval 0.76-0.99); P=0.04). One in seven patients without HF prescribed a loop diuretic undergo HF assessment, one in six of those assessed had a HF diagnosis. Specialist referral in patients with raised NP was associated with a lower risk of death.

International guidelines have recommended the use of echocardiography and natriuretic peptides (NP) testing in the diagnostic evaluation of heart failure (HF) for more than 10 years. However, real-world utilization of these diagnostic tests in the US is not known. We sought to assess contemporary trends in echocardiography and NP testing for diagnosing HF in the US. The TriNetX datawere queried for the total number of first HF diagnoses in adults aged >18 years in the US from 2016 to 2019 with exclusions applied. NP testing and echocardiography any time before through 1 year following the index diagnosis were assessed. Temporal trends significance was evaluated using Cochran-Armitage trend tests. A total of 124 126 patients were included. Mean age was 68 ± 13 years, 53% were male, and 71% were White. Overall, 61 023 (49%) incident diagnoses were made in the outpatient and 63 103 (51%) in the inpatient setting with a significantly increasing trend toward inpatient diagnoses (p < 0.001). Of all incident HF diagnoses, 70 612 (57%) underwent echocardiography, 67 991 (55%) underwent NP testing, and 31 206 (25%) did not undergo either diagnostic test. There were increasing trends in the proportion of patients diagnosed in the inpatient versus outpatient setting that underwent echocardiography, NP testing, and either diagnostic test (p < 0.001 for all). We found low rates of echocardiography and NP testing in those with HF, with more of such testing performed amongst inpatient diagnoses. We also found increasing rates of inpatient HF diagnoses, indicating lost opportunities for earlier treatment initiation and better outcomes.

ObjectiveTo assess the diagnostic accuracy of point-of-care natriuretic peptide tests in patients with chronic heart failure, with a focus on the ambulatory care setting.DesignSystematic review and meta-analysis.Data sourcesOvid Medline, Cochrane...

IntroductionThe NICE guidelines on Chronic Heart Failure 2010 recommend the use of natriuretic peptide (NP) testing in patients with suspected heart failure without previous myocardial infarction (MI). NP testing is...

Amino-Terminal Pro–B-Type Natriuretic Peptide Testing for the Diagnosis or Exclusion of Heart Failure in Patients with Acute Symptoms

BackgroundDiagnosing heart failure (HF) is difficult, relying on medical history, symptoms, and signs only. Clinical guidelines recommend natriuretic peptides (NPs) as an additional diagnostic test, notably to exclude HF in suspected patients. NP testing has been available since 2003 for primary care in the Netherlands, but little is known about its uptake.AimTo evaluate the trend in ordering and appropriateness of NP testing in primary care.Design & settingAn observational study was performed between January 2005 and December 2013. Nine Dutch general practices participated, with 21 000 registered people (approximately 4300 aged ≥65 years).MethodThe total number of patients undergoing NP testing each year was calculated per 1000 patient years (PY) based on the total practice population. NP levels were used to assess whether NP testing was applied to exclude or confirm HF.ResultsThe number of NP testing increased from 2.5 per 1000 PY in 2005 to 14.0 per 1000 PY in 2013, with a peak in 2009 of 15.6 per 1000 PY. The proportion of participants with N-terminal B-type natriuretic peptide (NTproBNP) below 125 pg/ml (the exclusionary threshold recommended by the European Society of Cardiology [ESC] guidelines on HF) was on average 30%, and highest in the first year (47%).ConclusionAfter a rapid uptake of NP testing in primary care from 2005 onwards, the use of it seemed to stabilise after 2009, thus leaving patients who are prone to HF without an optimal diagnostic work-up.