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Summary
Wider use of NT-proBNP testing in general practice could help ensure that more patients are referred to the correct specialist for further assessment1,2.
Improved quality of referrals
Cardiac cause
Pulmonary cause
Unclear cause
Currently cardiologists receive referrals for patients who do not go on to be diagnosed with a cardiac cause of unexplained shortness of breath
According to a study, only 51% of patients with chronic shortness of breath were appropriately referred to the speciality clinic associated with their final diagnosis3.
Whilst increased testing may lead to PCPs referring more patients with a cardiac cause, this burden is counter-balanced by reduction of incorrect pulmonary referrals and less need to reschedule appointments due to missing test results2.
Greater interpretation of patients with a cardiac cause through PCP education would further lower concern of cardiologists being overwhelmed by an increasing workload2.
Factors affecting NT-proBNP levels
NT-proBNP levels may be raised in patients with conditions other than cardiac disease. Levels may also be reduced in some patients. These factors should be taken into account when testing as shown below2,4.
FACTORS THAT MAY IMPEDE THE INTERPRETATION OF RESULTS
Increased NT-proBNP levels5-7
- Age
- Comorbidities* (e.g., PAH, diabetes, renal dysfunction, anemia, pulmonary embolism, acute coronary syndrome)
*When estimated glomerular filtration rate (eGFR) is < 60 mL/min, cut-offs for detecting HF may need to be raised1.
Decreased NT-proBNP levels5,6,8,9
- Obesity**
- African or African-Caribbean family origin
**In obese patients, lower natriuretic peptide concentrations mandate the use of lower cut-off values (about 50% lower)1.
Accelerate journey to correct diagnosis
By including NT-proBNP testing in general practice, more patients at risk may be correctly identified. In this way, the patient journey from initial assessment to diagnosis may be made earlier.
NT-proBNP evaluation early in the diagnostic pathway
- According to the ESC guidelines for the diagnosis of acute and chronic heart failure, the plasma concentration of natriuretic peptides can be used as an initial diagnostic test in patients with unexplained shortness of breath to rule out the possibility of heart failure6,10
- As the measurement of natriuretic peptides is even available as a point-of-care test, it can be used in routine primary care practice with minimal training10
Reduction of diagnostic delays
In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can be readily performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis10
DIAGNOSIS OF HEART FAILURE: A DELPHI CONSENSUS10
Referral for echocardiography
If heart failure is not suspected as the cause of symptoms, an NT-proBNP test can help further rule out HF or identify patients who require referral for echocardiography and a confirmed diagnosis6,10.
Combined with echocardiography, testing of BNP or NT-proBNP levels enables rapid and accurate diagnosis of HF and its phenotypes5
*Assuming HF has not been excluded after assessment of HF probability (based on clinical history, physical history and ECG).
References
BNP: B-type natriuretic peptide; ECG: electrocardiogram; HF: heart failure; NT-proBNP: N-terminal pro-B type natriuretic peptide; PCP: primary care physician.
- Berliner D, et al_ Dtsch Arztebl Int 2016, 113: 834-45;
- Wieshammer S, al. Respiration 2009; 77: 370-80;
- Ferry OR, et al. J Thorac Dis 2019; 11: S2117-S2128;
- Galie N, et al. Eur Respir J 2015; 46: 903–975;
- Mueller C, et al. Eur J Heart Fail 2019; 21: 715-31;
- Ponikowski P, et al. Eur Heart J 2016; 37: 2129-200;
- Lewis RA, et al. Eur Respir Rev 2020; 29: 200009;
- Gupta DK, et al. J Am Heart Assoc 2015; 4: e001831;
- NICE guidelines, Chronic heart failure in adults: diagnosis and management, 2018;
- Verhestraeten C, et al. PLOS ONE 2020; 15: e0244485.
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