1. NTproBNP for the Exclusion of Heart Failure Richard Blakey

2. BNP and NTproBNP PROTEASE

3. Action of BNP Increased Natriuresis Decreased peripheral vascular resistance (decreased BP) Supression of Renin-angiotensin and endothelin Release of BNP From ventricles Release of ANP from atria Release of CNP From vascular endothelium

4. NTproBNP predictor of mortality Cumulative Survival Days from presentation 0 10 20 30 40 50 60 70 80 0.70 0.75 0.80 0.85 0.90 0.95 1.00 NTproBNP >5180 NT pro BNP <5180 High BNP

5. Evidence Reference: (1) Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Eng J Med 2002; 347:161-7.(1) Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Eng J Med 2002; 347:161-7. (2) Rev Cardiovasc Med 2001;2 Suppl 2:S13-8 (3) NICE (August 2010). chronic heart failure (4) Mueller T et al. Diagnostic accuracy of B type natiuretic peptide and amino terminal proBNP in the emergency diagnosis of heart failure. Heart 2005; 91: 606-12(4) Mueller T et al. Diagnostic accuracy of B type natiuretic peptide and amino terminal proBNP in the emergency diagnosis of heart failure. Heart 2005; 91: 606-12 (5) Moe GW et al. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study.Circulation. 2007 Jun 19;115(24):3103-10.(5) Moe GW et al. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study.Circulation. 2007 Jun 19;115(24):3103-10. (6) Marz W et al. N-terminal pro-B-type natriuretic peptide predicts total and cardiovascular mortality in individuals with or without stable coronary artery disease: the Ludwigshafen Risk and Cardiovascular Health Study.Clin Chem. 2007 Jun;53(6):1075-83.Marz W et al. N-terminal pro-B-type natriuretic peptide predicts total and cardiovascular mortality in individuals with or without stable coronary artery disease: the Ludwigshafen Risk and Cardiovascular Health Study.Clin Chem. 2007 Jun;53(6):1075-83. (7) Doust JA et al. How well des B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ 2005;330:625(7) Doust JA et al. How well des B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ 2005;330:625 (8) Kragelund C et al. N-terminalpro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Eng J Med 2005;352:666-75(8) Kragelund C et al. N-terminalpro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Eng J Med 2005;352:666-75 (9) Steg PG et al. B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea. Chest 2005;128:21-9.(9) Steg PG et al. B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea. Chest 2005;128:21-9. (10) Knudsen CW et al. Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide concentration in dyspneic patients: an analysis from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2005;46:838-44.Knudsen CW et al. Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide concentration in dyspneic patients: an analysis from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2005;46:838-44. (11) Commentary. Evidence Based Medicine 2006; 11:117. (12) British Heart Foundation (November 2008). The roel of B-type natriuretic peptide (BNP) in the management of heart failure. (13) Daniels LB et al. Minimally elevated cardiac troponin T and elevated N-terminal pro-B-type natriuretic peptide predict mortality in older adults: results from the Rancho Bernardo StudyJ Am Coll Cardiol. 2008 Aug 5;52(6):450-9.Daniels LB et al. Minimally elevated cardiac troponin T and elevated N-terminal pro-B-type natriuretic peptide predict mortality in older adults: results from the Rancho Bernardo StudyJ Am Coll Cardiol. 2008 Aug 5;52(6):450-9.

6. Relevance to Primary Care Low levels of NP make heart failure unlikely Very high levels of NP are associated with poor prognosis Heart Failure is not the only cause of raised NP Though affected by multiple factors – these are unlikely to be of significance if the correct cut off level is used.

7. Factors affecting NP levels Sex Age ACE I BB Renal Function BMI

8. Suspected Heart Failure If patient has (new / changing) symptoms suggestive of heart failure – SOB / peripheral oedema – Code as Suspected HF (1J60) – If history of MI do not request NTproBNP but refer urgently for echo and specialist assessment –If no h/o MI - request NT pro BNP

9. Requesting NTproBNP Minimum 3ml Plain (Ochre) or Li Heparin (Green)

10. Cut-off Levels Heart failure is unlikely if the NTproBNP level is... Men under 70y <100pg/ml Women under 70y<150pg/ml All 70y or over<300pg/ml If so, consider an alternative diagnosis However if still think heart failure – ask for specialist advice

11. Why not use NICE cut off level? NICE cut off level for NTproBNP is 400pg/ml This is based on European data for untreated patients. Most patients at high risk and suspected of heart failure –MI / DM / hypertension / renal disease - will be on treatment at time of referral

12. Raised NTproBNP If NTproBNP is above the cut off levels but below 2000pg/ml – refer routinely for echocardiography and specialist opinion If > 2000pg/ml – refer urgently for echocardiography and specialist opinion

13. What does urgent mean? The expectation of NICE is that those who require urgent assessment –h/o MI –NTproBNP >2000pg/ml Should be scanned and assessed within 2 weeks of referral

14. What is a ‘specialist’ “A physician with a special interest in heart failure, who will usually be a cardiologist” Includes –Cardiologists –Care of elderly –General physicians –GPwSIs With a special interest in heart failure

15. Why do they need a specialist opinion? LVSD –Consideration for revascularisation –Consideration for device therapy –Optimising drug therapy HFPEF –Risks of treatment –Complexity of treatment Cardiomyopathy/valves / arrhythmias / extra-cardiac

16. Pathway for Suspected Heart Failure *>100pg/ml men <70y, >150pg/ml women <70y, >300pg/ml all >70y **> 2000pg/ml

18. Heart failure - Interventions Time to first event in usual care vs nurse Intervention groups 12/06/2016Dr Ivan Benett GPwSI Cardiology Blue L et al BMJ 2001;323:715-718 Fewer people died or were re-admitted, Fewer days spent in hospital. NURSES Management of Heart Failure

19. Enhancing Quality Programme Heart Failure - Community & Primary Care 4 indicators of quality –Diagnosis – BNP/echo/CXR/baseline bloods –Treatment LVSD – optimised ACE & BB –All HF patients – personalised care plans –End Stage HF – end of life plan

20. Enhancing Quality Programme Volunteers required –Data on baseline drug doses for LVSD –1 st wave practices for pilot of community HF

21. Any Questions?