Compulsory NT-proBNP test before heart failure referral ‘would boost care’
NT-proBNP testing should become compulsory for referring patients to specialist heart failure services to improve diagnosis of the condition in primary care, an expert report has said.
The Alliance for Heart Failure said patients also being wrongly referred to specialist services which is putting ‘unsustainable pressure on specialist and echocardiography services’.
But heart failure is also being routinely missed in primary care, according to the coalition of health charities and expert groups, which could be improved if the test was used more consistently.
The report notes that 80% of heart failure patients are diagnosed in hospital, despite half of them having signs and symptoms that could have triggered an earlier assessment through their GP.
Early detection in primary care is not currently prioritised it found, with 2010 NICE guidelines requiring the use of NT-proBNP testing to rule out heart failure not being widely followed, the report found.
High readmission rates after discharge from hospital, also suggest patients with heart failure are not being appropriately managed, it continued.
Mandating the use of NT-proBNP testing would incentivise its use and improve knowledge and awareness of heart failure among primary care staff, the Alliance said.
It would also avoid unnecessary referrals and reduce the incidence of open access to echocardiography which is putting a strain on services.
Despite NHS England guidance, the majority of community diagnostic centres do not provide access to NT-proBNP testing, research by the Alliance found.
An NT-proBNP below 400 pg/mL makes heart failure very unlikely, the report said, while levels between 400 and 2000 pg/mL require urgent assessment and echocardiography within six weeks.
Results of more than 2000 pg/mL, warrant an urgent referral ‘akin to the priority we give to suspected cancer cases’, it advised.
Around one million people in the UK are living with the condition, with 200,000 new cases every year plus an estimated 385,000 people who are undiagnosed.
The report highlights several solutions to improving heart failure diagnosis and management in primary care including community services, audits to identify missing patients and specialist pharmacists based in the community to help care for patients.
An overhaul of the guidance recommends GPs having a greater role and initiating a wider range of drugs for heart failure.
Dr Jim Moore, GP with specialist interest in cardiovascular medicine and immediate past president of the Primary Care Cardiovascular Society, who wrote a preface to the report said despite advances in diagnostics and treatment, heart failure was not being properly prioritised in primary care in line with other major conditions.
‘The Alliance’s report presents a series of solutions and recommendations based on the highest performing services in the country that provide health leaders and the government with a roadmap to transform care and ensure we are ready for one of the major health challenges of the 21st century.
‘Better use of a simple diagnostic NT-proBNP is the key to this transformation. Too many who present with symptoms are not being offered the test which can quickly rule out heart failure.’
He added: ‘Training more healthcare professionals to correctly use this test, and expanding screening for heart failure in pharmacies and community diagnostic centres can save lives, ease pressure on hospitals and free up vital resources.’
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READERS' COMMENTS [4]
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I fully support this. I was a clinical director in Cardiology in Oldham and developed Heart Failure Clinic to improve the outcome. We agreed that NT-proBNP testing was mandatory and should be included in the referral letter and during triage of the referral letter we made sure the result was included.
We have to have done the pro-BNP and echo before referral to heart failure service, and in the majority of circumstances by the time I’ve referred a patient to them we’ve already got them on 3/4 pillars. Cardiac rehab, specialist meds, devices <30% and IV diuretics and stuff are all that we need them for really. It's on QOF and I don't think it's a particularly specialist area of practice, heart failure is proper general practice, isn't it?
We have used this in Bradford and Airedale for years and pretty much every breathless or oedematous patient has the test in primary care (if suspected cardiac involvement). If raised then the level determines how quickly they are seen and have ECHO then a community heart failure team titrates up the meds for us. I actually can’t believe some areas don’t have access to it- great care which avoids multiple appointments with a GP for titration
BNP =:Ticket for Echo.
I spent the last 12 years of my career preaching this mantra. I acknowledge my learned colleagues in Bradford and Oldham. The British Society for Headt Failure tried to promote its use but sadly we are still a long way from where we should be.
Such a valuable test