Transcript 2012 Meeting - Natriuretic Peptide (NP) testing and Heart failure

Natriuretic Peptide (NP) testing
and heart failurewhat 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
 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
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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.