Catriona Clark and Clare MacRae Natriuretic Peptide (NP) testing and heart failure- what should we be doing? Catriona Clark and Clare MacRae

Natriuretic Peptides Hormone secreted by ventricular myocardium during ventricular stretch, ↑ wall tension. Role: controls BP, blood volume, Na+ balance. Raised in heart failure Assays: BNP (active metabolite), NT-proBNP (biologically inactive) Normal level virtually excludes heart failure

Why NP testing and why now? Significant heart failure associated morbidity, mortality and cost Ageing population Current guidance recommends change in approach Underdiagnosis is common (Newcastle 85+ study) Lack of availability of diagnostic tests in Primary Care

NP testing vs. traditional diagnostic tools Investigation Sensitivity Specificity NT-proBNP 93% 65% Chest X-ray (CXR) 68% 83% ECG 89% 56%

NICE CG108 Previous MI + ? heart failure = URGENT referral within 2 weeks for echocardiography and OP cardiology NO previous MI + ? heart failure = measure serum NP NORMAL level = heart failure very unlikely. Reassure and seek alternative cause RAISED level = referral within 6 weeks for echocardiography and OP cardiology HIGH level = referral within 2 weeks for echocardiography and OP cardiology

SIGN Guideline 95 2007 Guideline recommendation 2012 Review Conclusion Natriuretic peptides and/or ECG recorded in patients with suspected heart failure Echocardiography if either is abnormal 2012 Review Conclusion BNP testing should be recommended over ECG in Primary care Some patients referred straight for Echo

PLIG project 12 months research Local discussion UK wide information gathering Scotland NHS Shetland 2004- only trust using in Primary Care, Glasgow Secondary care, one stop Cardiology clinics England >50% Primary Care trusts using NP testing Wide variability in numbers tested, gatekeeping methods , efficiency in use of the test

Improving services and reducing costs Prevalence of heart failure 5547 patients in NHS Lothian Inpatient admissions 962 inpatient stays (793 patients) in 2010-11 Average length of stay 11 nights, cost £1567 Costs 883,000 population, test prevalence 3.8/1000 3355 tests per annum = £47271.95 54% negative acc to NICE Literature

Gatekeeping, audit, updates Gate-keeping. Order Comms used to audit and control use, patients who: 1. otherwise be referred to cardiology for assessment of suspected heart failure 2. no previous MI 3. not had a NP test within the last year; rationing to one test per year per patient Audit. Little performed in practice, electronic ordering systems key. GP Updates. Resources available from NICE, GP update meetings, communication with practice managers, intranet.