- Despite improvements in treatment the prognosis for patients with heart failure remains poor; the risk of death annually is 5–10 per cent in patients with mild symptoms and 30–40 per cent in those with advanced disease.
- There is a poor correlation between symptoms and signs of heart failure and echocardiogram findings.
- Although the echocardiogram is the gold standard investigation for heart failure, GPs are still limited by its accessibility.
What is the evidence?
- BNP testing can be used by GPs to rule out heart failure (Heart 2003; 89 (Suppl I): A38). A patient with normal NT-proBNP test is unlikely to have heart failure and other diagnoses should be considered. Patients with abnormal NT-proBNP levels should be referred for echocardiography for confirmation of heart failure.
- A systematic review analysed 19 studies looking at the prognostic value of BNP in patients in all stages of heart failure, all clinical settings and all lengths of follow-up (BMJ 2005; 330: 625).In patients with heart failure, each 100pg/ml increase in BNP was associated with a 35 per cent increase in the relative risk of death.
- A systematic review found BNP testing no more sensitive than an ECG at detecting left ventricular dysfunction (BJGP 2006; 56: 48–56).
- A recent study showed that elevated levels of NT-proBNP predict cardiovascular morbidity and mortality, independent of other prognostic markers, and identify at-risk individuals (JAMA 2007; 297: 169–76).
- A study of COPD patients found NT-proBNP levels and electrocardiography can help to identify concomitant heart failure in patients with stable COPD (BMJ 2005; 331: 1,379).
- One study showed that NT-proBNP testing had a marginally better negative predictive value than BNP testing (BJGP 2006; 56: 327–33).
- Using BNP levels to titrate beta-blocker dosage was not found to be more useful than using standard clinical assessment (Congest Heart Fail 2005; 11: 248–53).
Implications for practice
- NICE recommends that GPs investigate patients with suspected heart failure by referring them for an ECG and carrying out BNP testing where available.
- NICE suggests that if the patient’s ECG and blood levels of BNP are normal, the patient does not have heart failure
- However, BNP testing is still not widely available in the UK.