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Although there is a range of symptoms and signs reported with heart failure, the combination of natriuretic peptide testing and echocardiography should help rule out or confirm the diagnosis1,2.

Barriers to early diagnosis

DIAGNOSTIC PROCESS

  • Symptoms of HF are often non-specific and clinical presentation can be complicated by comorbidities2
  • Unexplained shortness of breath is the most common presentation, but neither specific nor sensitive for predicting HF2
  • The non-specificity of the signs and symptoms of HF can make the process challenging2
  • Only 66% of GPs reported feeling confident in their ability to diagnose LVSD3

DIAGNOSTIC TESTS

  • In addition to clinical history and physical examination, electrocardiogram (ECG) is recommended as an initial assessment when HF is suspected
  • The guidelines also recommend using NT-proBNP combined with echocardiography to diagnose HF1,2
  • Less than 50% of GPs reported feeling confident in their ability to interpret results of an ECG3
  • Natriuretic peptides are not extensively used, with GPs expressing a need for access to natriuretic peptide tests3

Unexplained shortness of breath is a typical symptom of heart failure1,2

SYMPTOMS AND SIGNS TYPICAL OF HEART FAILURE

Typical symptoms

  • Breathlessness
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Reduced exercise tolerance
  • Fatigue, tiredness, increased time to recover after exercise
  • Ankle swelling

More specific signs

  • Elevated jugular venous pressure
  • Hepatojugular reflux
  • Third heart sound (gallop rhythm)
  • Laterally displaced apical impulse

Early diagnosis is important to improve patient outcomes4

  • Various diseases can lead to HF*, including coronary artery disease, cardiomyopathy, hypertension, congenital heart disease, pericardial disease, pulmonary hypertension, pulmonary arterial hypertension (PAH), diabetes, HIV, hyper-and hypo-thyroidism1,5

1 in 20

Patients presenting in the primary care setting with chronic unexplained shortness of breath have heart failure as the cause6

Natriuretic peptide testing is a key tool in combination with echocardiography. However, it is important to follow guidance on NP testing2.

Natriuretic peptides testing guidance

Key tools for rapid and accurate HF diagnosis

KEY GUIDANCE

  • Always use NPs in conjunction with all other clinical information and never as a stand-alone test2
  • NPs are reasonable surrogates for intracardiac volumes and filling pressures2
  • NPs cannot identify the underlying cause of HF; if elevated then cardiac imaging must be used2
  • If BNP or NT-proBNP levels are abnormal, further diagnostic tests are required2
  • Combined with echocardiography, BNP or NT-proBNP enable rapid and accurate diagnosis of HF and its phenotypes2

RECOMMENDATIONS

  • ESC Guideline for the diagnosis of acute and chronic heart failure states NPs can be used as an initial diagnostic test, especially in the non-acute setting, when echocardiography is not immediately available1
  • Class recommendation (strong evidence) for use of NPs in ambulatory patients with new onset unexplained shortness of breath7

    - Refer for echocardiography, based on the results1

    - Other tests required only if diagnosis remains uncertain1

  • Available as point-of-care test or via local pathways to central laboratories2

Natriuretic peptide testing is an integral part of assessment to rule out a heart failure diagnosis7.

Ruling out heart failure

  • Diagnosis of new-onset HF at the community level can be difficult2
  • Physical findings only have limited sensitivity (50-60%)2
  • While an abnormal ECG increases the likelihood of a HF diagnosis, it is not reliable as a test to diagnose HF because of low specificity1
  • Biomarkers, and more specifically testing for natriuretic peptides (NP), are important components of the diagnosis of HF1

Heart failure investigations include clinical findings, ECG and Chest X-ray findings and the results of natriuretic peptide testing.2

Diagnosis and evaluation of heart failure phenotype can be confirmed from echocardiography2.

If levels of NT-proBNP or BNP are normal, then HF is unlikely1

Taking account of factors that affect NP levels, the following test results can indicate whether acute heart failure is a likely or unlikely diagnosis.

Natriuretic peptide cut-off points8

TO EXCLUDE ACUTE HF

BNP

Cut-off value
< 30-50 pg/mL

Sensitivity
97%

Specificity
62%

PPV
71%

NPV
96%

NT-proBNP

Cut-off value
<  300 pg/mL

Sensitivity
99%

Specificity
68%

PPV
62%

NPV
99%

TO IDENTIFY ACUTE HF - SINGLE CUT-OFF POINT

BNP

Cut-off value
<100 pg/mL

Sensitivity
90%

Specificity
76%

PPV
79%

NPV
89%

NT-proBNP

Cut-off value
< 900 pg/mL

Sensitivity
90%

Specificity
85%

PPV
76%

NPV
94%

TO IDENTIFY ACUTE HF - MULTIPLE CUT-POINT

BNP

Cut-off value
< 100 pg/mLTo exclude HF

100-400 pg/mL"Grey zone"

> 400 pg/mLTo rule in HF

 

Sensitivity
90%

*

63%

 

Specificity
73%

*

91%

 

PPV
75%

*

86%

 

NPV
90%

*

74%

 
NT-proBNP

Cut-off value < 450 pg/mLFor age < 50 yr

< 900 pg/mLFor age 50-75 yr

< 1800 pg/mLFor age > 75 yr

 

Sensitivity
90%

   

Specificity
84%

   

PPV
88%

   

NPV
66%

   

References

BNP: a-type natriuretic peptide; CDR. clinical decision rules, ECG: electrocardiogram; GPs: general practitioners; HF: heart failure; LVH: left ventricular hypertrophy; LVSD: left ventricular systolic dysfunction; NPV: negative predictive value; NT-proBNP: N-terminal pro-B type natriuretic peptide; PAH: pulmonary arterial hypertension; PH: pulmonary hypertension; PPV: positive predictive value; yr; years.

  1. Ponikowski P, et al. Eur Heart J 2016;
  2. Mueller C, et al_ Eur J Heart Fail 2019; 21: 715-31;
  3. Hancock HC et al_ BMJ open 2014; 4: e003866;
  4. Taylor KS, et al BMJ 2018; 361: k1450;
  5. Merck Manual. Accessed Sept 2021 at: https://www.merckmanuals.com/en-ca/professional/cardiovascular-disorders/heart-failure/heart-failure-hf#v935980;
  6. Berliner D, et al_ Dtsch Arztebl Int 2016, 113: 834-45;
  7. Yancy CW. et al_ Circulation 2017; 136: e137-e161;
  8. Gaggin HK and Januzzi JL. Accessed Sept 2021 at: https://www.acc.org/%2Flatest-in-cardiology%2Farticles%2F2015%2F02%2F09%2F13%2F00%2Fcardiac-biomarkers-and-heart-failure.

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