Suspected Heart Failure – Serum natriuretic peptides or Echocardiogram?

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A recent snapshot audit of referrals through DRSS (Western locality) for echocardiograms suggested the majority of patients did not have serum natriuretic peptide (serum NP) testing as recommended by the NICE guideline for chronic heart failure (2010). The Atlas of Variation for Diagnostics clearly shows that the Western locality is a particularly low requester of Serum NP and a high requester of Echoes. Although not such an acute problem in the Northern and Eastern localities this guide is still very relevant.

Early, accurate diagnosis of heart failure in the community allows for earlier treatment, symptom relief, and offers patients a more convenient solution closer to home, but diagnosis is not simple and heart failure referrals to outpatients currently cost the NHS £51 million per year.

Simple blood tests for serum NP, costing £15–25, can rule out heart failure and reduce the need for further investigations by 30–40%. The NICE 'Chronic heart failure' guideline recommends use of serum NP testing in the diagnostic pathway to decide both the need for referral and how quickly the specialist assessment needs to take place.

For suspected heart failure with previous history of MI – arrange echo within two weeks
Suspected heart failure with no previous history of MI - do a NTproBNP blood test or BNP
- NTproBNP level less than 400 pg/ml or BNP of less than 100 in an untreated patient makes a diagnosis of heart failure unlikely
- NTproBNP = 400 2000pg/ml or BNP of 100-400ng/l is an indication of heart failure. Refer patients with suspected heart failure to have transthoracic Doppler 2D echocardiography within 6 weeks
- NTproBNP = greater than 2000pg/ml or BNP of more than 400ng/l is a significant indication of heart failure and should be referred within 2 weeks

Source: NICE - [NICE CG108]

Specialist: Sean Costelloe| GP: Lucy Harris

Published:December 2016