‘Is heart failure being taken seriously in primary care?’

Responding to the recent episode of the Pulse podcast which asked if GPs are following heart failure referral guidance, retired GP and past president of the PCCS Dr Jim Moore examines the evidence on NT-proBNP testing, making the case for doing more in primary care to prevent late diagnosis

Is heart failure being taken seriously enough in primary care? This was the question I asked myself while listening to the recent episode of the Pulse in Focus podcast discussing the Alliance for Heart Failure’s report on transforming the diagnosis and treatment of the condition outside hospital.

I was reassured that they agreed with most of the recommendations. As a recently retired GP, I very much appreciate that there is only so much that we can do. The report was framed very much around the belief that it is ultimately policymakers and healthcare leaders who are responsible for acting on the growing, and unsustainable, burden of late diagnosed heart failure.

But an intriguing point was made regarding NT-proBNP usage, and one that I believe is ultimately one of the most important diagnostic issues facing the NHS. Was the report ‘behind the times’ in suggesting that at present primary care is not utilising the test properly to either rule out heart failure, or place a patient immediately on the right treatment pathway?

One of the key recommendations from the report was to mandate NT-proBNP testing as a means to access specialist services. This is based on our belief that at present, the test is not being used routinely to place patients on the right treatment pathway.

Our communications with the British Society for Echocardiography, a national organisation representing cardiac specialists and physiologists undertaking echocardiograms, suggest that at many centres patients with suspected heart failure are being referred without a natriuretic blood test. Since publishing the report, ongoing conversations with colleagues across PCN networks indicate that there is a great deal of interest on how they might mandate the test in primary care.

Historically we know usage has been poor. A recent retrospective cohort study published at the end of last year found that in 80,824 individuals presenting with suspected heart failure between 2015 and 2019, only 12.5% underwent natriuretic peptide testing in the six months prior to their diagnosis.

Another analysis of IQVIA data has found that between 2011 and 2021, only 18.3% of heart failure patients received an NT-proBNP prior to a diagnosis of heart failure.

Then of course came the pandemic. The same retrospective cohort study found that levels of testing unsurprisingly dipped dramatically, essentially reversing a decade of progress and returning us to levels not seen since 2011 when NICE first recommended it become available in GP settings.

Has this picked up since and is it now on an upwards trajectory to tackle the growing numbers – 400,000 at the last estimate – with undiagnosed heart failure? The podcast is right to point out that we have no large scale data set for the country post-pandemic but I remain unconvinced that primary care is utilising the test to its fullest potential in order to tackle the growing crisis of late diagnosed heart failure. 

This is where the BEAT acronym – Breathlessness, Exhaustion, Ankle swelling, Time to tell your GP or Time for a simple NT-proBNP blood test – comes in. Perhaps the wording of the recommendation in the report may have implied screening, but this was simply not the intention. BEAT is a national heart failure campaign to raise awareness around heart failure including the use of natriuretic peptide testing.

Instead, the Heart Failure Alliance wants to bring about a cultural shift in recognising heart failure symptoms and promoting routine use of NT-proBNP testing. We know the BEAT campaign has already been successfully trialled in GP surgeries across the East, Yorkshire, North and North East and the North West of England regions and adopted by Cardiovascular Networks and Regional Health Innovation Networks. It has also been included in the recent Heart Failure national plan launched by the Health Innovation Network.

Recent studies have also highlighted what proactive efforts at detection can achieve. A feasibility study for THINK-HF, an electronic health record tool designed to flag potential missed heart failure diagnoses, found increases in detection of up to 10% in practices with a low baseline prevalence.

With my background in primary care, I completely understand the pressures we face as the front door to the health service. But an increased awareness of the symptoms of heart failure, coupled with a greater understanding of the value of natriuretic peptide testing, increase the likelihood of an early diagnosis. As the patient case studies in the Alliance’s report show, this can transform outcomes for patients and prevent the enormous emotional and financial burden of late stage heart failure.

Dr Jim Moore is a recently retired GP and immediate past president of the Primary Care Cardiovascular Society. He wrote the preface to the Heart Failure Alliance’s ‘Primary Care: A call to action’ report