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NICE considers new score to prioritise GP heart failure referrals

By Lilian Anekwe

A four-point clinical assessment tool to help GPs prioritise which patients with suspected heart failure to fast-track for echocardiography could be included in new NICE guidance currently being developed.

The tool, developed by leading primary care researchers, uses four clinical symptoms – sex, a history of myocardial infarction, lung crepitation and oedema – to identify patients who should be referred for specialist assessment.

Draft NICE guidance, published in January, recommends GPs refer anyone who has had an MI with suspected heart failure for urgent echocardiography- and also anyone else with symptoms and a raised BNP.

But the developers of the new tool used five primary care studies to develop a clinical decision model based on simple clinical features, used with or without BNP testing, to try and predict for accurately who needs urgent referral.

This model was simplified into a scoring system by weighting four different clinical features: being male scored two points, a history of myocardial infarction six points, lung crepitations five points, and ankle oedema three points.

Patients with a score between zero and three do not need further investigation but should be monitored for any change in symptoms. GPs should request a BNP test for patients with a score of five to eight and refer for echocardiography depending on the BNP test result (see below). Patients with a score between nine and eleven should be referred straight for echocardiography.

Lead researcher Professor Jonathan Mant, professor of primary care research at the University of Cambridge and chair of the NICE heart failure guideline development group told Pulse said he was hopeful the score would still be included in the final NICE guidance, after the consultation closed last week.

‘The group as a whole was concerned about how practical the guidance would be and my own view is that I would like to see this tool included,' he said.

‘For patients in whom GPs suspect heart failure it looks as if a better policy than what is done currently would be for GPs to send some patients for echo on the basis of clinical features alone.

‘If a patient present and has a history of myocardial infarction, lung crepitations, or a male with ankle oedema you should send them straight for echo.

‘In other cases they should have a NPT and the decision should be based on NPT and clinical features. NPT should be available for GP use and there are also implications for service provision.'

The clinical assessment tool will help GPs prioritise which patients with suspected heart failure to fast-track for echocardiography The MICE clinical prediction rule

MICE (Male gender, history of myocardial Infarction, basal Crepitations, oEdema)

In a patient presenting with symptoms such as breathlessness in whom heart failure is suspected, refer directly to echocardiography if the patient has any one of:

• history of myocardial infarction
• basal crepitations
• male with ankle oedema

Otherwise, carry out a BNP test and refer for echocardiography depending on the results of the test:

• female without ankle oedema – refer if BNP > 210–360 pg/ml depending upon local availability of echocardiography (or NT-proBNP > 620–1060 pg/ml)
• male without ankle oedema – refer if BNP > 130–220 pg/ml (or NT-proBNP > 390–660 pg/ml)
• female with ankle oedema – refer if BNP > 100–180 pg/ml (or NT-proBNP > 190–520 pg/ml)

Source: Development and validation of a clinical decision rule to diagnose heart failure in primary care: the MICE score, presented at the Society for Academic Primary Care regional meeting, February 2010