Abstract
BackgroundSymptoms of breathlessness, fatigue, and ankle swelling are common in general practice but deciding which patients are likely to have heart failure is challenging.AimTo evaluate the performance of a clinical decision rule (CDR), with or without N-Terminal pro-B type natriuretic peptide (NT-proBNP) assay, for identifying heart failure.Design and settingProspective, observational, diagnostic validation study of patients aged >55 years, presenting with shortness of breath, lethargy, or ankle oedema, from 28 general practices in England.MethodThe outcome was test performance of the CDR and natriuretic peptide test in determining a diagnosis of heart failure. The reference standard was an expert consensus panel of three cardiologists.ResultsThree hundred and four participants were recruited, with 104 (34.2%; 95% confidence interval [CI] = 28.9 to 39.8) having a confirmed diagnosis of heart failure. The CDR+NT-proBNP had a sensitivity of 90.4% (95% CI = 83.0 to 95.3) and specificity 45.5% (95% CI = 38.5 to 52.7). NT-proBNP level alone with a cut-off <400 pg/ml had sensitivity 76.9% (95% CI = 67.6 to 84.6) and specificity 91.5% (95% CI = 86.7 to 95.0). At the lower cut-off of NT-proBNP <125 pg/ml, sensitivity was 94.2% (95% CI = 87.9 to 97.9) and specificity 49.0% (95% CI = 41.9 to 56.1).ConclusionAt the low threshold of NT-proBNP <125 pg/ml, natriuretic peptide testing alone was better than a validated CDR+NT-proBNP in determining which patients presenting with symptoms went on to have a diagnosis of heart failure. The higher NT-proBNP threshold of 400 pg/ml may mean more than one in five patients with heart failure are not appropriately referred. Guideline natriuretic peptide thresholds may need to be revised.
Highlights
Heart failure is a chronic disease associated with significant mortality and poor quality of life.[1,2,3] Patients may present to primary care with symptoms of gradualonset breathlessness, fatigue, and ankle swelling.[4]
At the low threshold of NT-proBNP
Clinical decision rules (CDRs) can help clinicians to assess the probability that a patient has a particular condition.[11]
Summary
Heart failure is a chronic disease associated with significant mortality and poor quality of life.[1,2,3] Patients may present to primary care with symptoms of gradualonset breathlessness, fatigue, and ankle swelling.[4] These symptoms are not unique to heart failure and can be associated with other conditions.[5,6,7] Making an accurate and timely diagnosis is crucial, and requires referral for objective testing, but deciding who to refer can be challenging.[8,9,10]. Fatigue, and ankle swelling are common in general practice but deciding which patients are likely to have heart failure is challenging
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