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. 2019 Jul 1;5(3):218-224.
doi: 10.1093/ehjqcco/qcy053.

Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care

John Gierula  1 , Richard M Cubbon  1 , Maria F Paton  1 , Rowenna Byrom  1 , Judith E Lowry  1 , Sarah F Winsor  2 , Melanie McGinlay  2 , Emma Sunley  2 , Emma Pickles  2 , Lorraine C Kearney  1 , Aaron Koshy  1 , Thomas A Slater  1 , Hemant K Chumun  1 , Haqeel A Jamil  1 , Kristian M Bailey  2 , Julian H Barth  2 , Mark T Kearney  1 , Klaus K Witte  1
Affiliations

Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care

John Gierula et al. Eur Heart J Qual Care Clin Outcomes. .

Abstract

Aims: The UK National Institute for Health and Care Excellence (UK-NICE) and European Society of Cardiology (ESC) guidelines advise natriuretic peptide (NP) assessment in patients presenting to primary care with symptoms possibly due to chronic heart failure (HF), to determine need for specialist involvement. This prospective service evaluation aimed to describe the diagnostic and prognostic utility of these guidelines.

Methods and results: We prospectively collected clinical, echocardiography and outcomes data (minimum 5 years) from all patients referred to the Leeds HF Service for 12 months of following the initiation of the NP-guideline-directed pathway. Between 1 May 2012 and 1 August 2013, 1020 people with symptoms possibly due to HF attended either with a raised NT-pro-BNP or a previous myocardial infarction (MI) with an overall rate of left ventricular systolic dysfunction (LVSD) of 33%. Of these, 991 satisfied the ESC criteria (NT-pro-BNP ≥125 pg/mL) in whom the rate of LVSD was 32%, and 821 the UK-NICE criteria in whom the rate of LVSD was 49% in those with a previous MI, 25% in those with NT-pro-BNP concentration 400-2000 pg/mL, and 54% in those with NT-pro-BNP concentration of >2000 pg/mL. An NT-pro-BNP concentration 125-400 pg/mL had a 12% risk of LVSD. Specificity was poor in women >70 years, who made up the largest proportion of attendees. Elevated NT-pro-BNP levels were associated with lower survival even in the absence of LVSD.

Conclusion: In people referred through the ESC and UK-NICE guidelines, elevated NT-pro-BNP is a marker of increased mortality risk, but there is wide variation in specificity for LVSD. Age- and sex-adjusted criteria might improve performance.

Keywords: B-type natriuretic peptide; Heart failure; Left ventricular dysfunction.

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Figures

Figure 1
Figure 1
(A and B) The performance of European Society of Cardiology (ESC) (A), and United Kingdom Institute for Health and Care Excellence (UK-NICE) NT-pro-BNP concentrations (B) to identify people with heart failure due to left ventricular systolic dysfunction, divided by age and sex.
Figure 2
Figure 2
All-cause mortality of attendees by European Society of Cardiology (ESC) and United Kingdom Institute for Health and Care Excellence (UK-NICE) referral category.
Figure 3
Figure 3
(A and B) All-cause mortality of attendees by European Society of Cardiology (ESC) (A) and United Kingdom Institute for Health and Care Excellence (UK-NICE) (B) referral category by presence of left ventricular systolic dysfunction.
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