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Diagnosis of new onset heart failure in the community: the importance of a shared-care approach and judicious use of BNP

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Abstract

Background

Brain natriuretic peptide (BNP) may help general practitioners (GPs) to “rule-out” heart failure (HF) and reduce referral burden on specialist assessment clinics.

Aims

To determine the diagnostic value of BNP in HF referrals by GPs to a specialist unit.

Methods

From 2003 to 2007, 327 GP referrals were made to a HF new patient diagnostic clinic (NDC) with a provisional diagnosis of HF. The NDC provides rapid assessment of potential HF patients and ensures appropriate therapy and follow-up for those with a confirmed diagnosis. HF diagnosis was confirmed by the Framingham criteria.

Results

HF was present in 39% of cases referred (mean age 75 ± 10 years, 49% male). The inclusion of BNP as a “rule-out” test with a cut-off value of 100 pg/mL would have reduced the number of patients originally referred to the NDC by 175. However, this would have resulted in delayed diagnosis and treatment of 20 (16%) “false-negative” patients.

Conclusions

Availability of BNP to GPs would improve referral patterns but with high risk of delayed diagnosis. The data underline the need for a shared-care approach to the new diagnosis of HF.

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References

  1. Fuat A, Hungin AP, Murphy JJ (2003) Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 326(7382):196. doi:10.1136/bmj.326.7382.196

    Article  PubMed  Google Scholar 

  2. Khunti K, Hearnshaw H, Baker R, Grimshaw G (2002) Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. Eur J Heart Fail 4(6):771–777. doi:10.1016/S1388-9842(02)00119-8

    Article  PubMed  Google Scholar 

  3. Sparrow N, Adlam D, Cowley A, Hampton JR (2003) The diagnosis of heart failure in general practice: implications for the UK National Service Framework. Eur J Heart Fail 5(3):349–354. doi:10.1016/S1388-9842(03)00046-1

    Article  PubMed  Google Scholar 

  4. Zaphiriou A, Robb S, Murray-Thomas T et al (2005) The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study. Eur J Heart Fail 7(4):537–541. doi:10.1016/j.ejheart.2005.01.022

    Article  PubMed  CAS  Google Scholar 

  5. Fox KF, Cowie MR, Wood DA, Coats AJ, Poole-Wilson PA, Sutton GC (2000) A Rapid Access Heart Failure Clinic provides a prompt diagnosis and appropriate management of new heart failure presenting in the community. Eur J Heart Fail 2(4):423–429. doi:10.1016/S1388-9842(00)00108-2

    Article  PubMed  CAS  Google Scholar 

  6. Shah S, Davies MK, Cartwright D, Nightingale P (2004) Management of chronic heart failure in the community: role of a hospital based open access heart failure service. Heart 90(7):755–759. doi:10.1136/hrt.2002.006460

    Article  PubMed  CAS  Google Scholar 

  7. Atisha D, Bhalla MA, Morrison LK et al (2004) A prospective study in search of an optimal B-natriuretic peptide level to screen patients for cardiac dysfunction. Am Heart J 148(3):518–523. doi:10.1016/j.ahj.2004.03.014

    Article  PubMed  CAS  Google Scholar 

  8. Fuat A, Murphy JJ, Hungin AP et al (2006) The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. Br J Gen Pract 56(526):327–333

    PubMed  Google Scholar 

  9. O’Hanlon R, O’Shea P, Ledwidge M et al (2007) The biologic variability of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide in stable heart failure patients. J Card Fail 13(1):50–55. doi:10.1016/j.cardfail.2006.09.003

    Article  PubMed  CAS  Google Scholar 

  10. Ho KK, Pinsky JL, Kannel WB, Levy D (1993) The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 22(4 Suppl A):6A–13A

    Article  PubMed  CAS  Google Scholar 

  11. The SOLVD Investigators (1992) Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 327(10):685–691

    Google Scholar 

  12. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT (2005) Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 294(15):1944–1956. doi:10.1001/jama.294.15.1944

    Article  PubMed  CAS  Google Scholar 

  13. Mueller C, Frana B, Rodriguez D, Laule-Kilian K, Perruchoud AP (2005) Emergency diagnosis of congestive heart failure: impact of signs and symptoms. Can J Cardiol 21(11):921–924

    PubMed  Google Scholar 

  14. Stevenson LW, Perloff JK (1989) The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 261(6):884–888. doi:10.1001/jama.261.6.884

    Article  PubMed  CAS  Google Scholar 

  15. Remes J, Miettinen H, Reunanen A, Pyorala K (1991) Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 12(3):315–321

    PubMed  CAS  Google Scholar 

  16. Sim V, Hampton D, Phillips C et al (2003) The use of brain natriuretic peptide as a screening test for left ventricular systolic dysfunction-cost-effectiveness in relation to open access echocardiography. Fam Pract 20(5):570–574. doi:10.1093/fampra/cmg513

    Article  PubMed  Google Scholar 

  17. Heidenreich PA, Gubens MA, Fonarow GC, Konstam MA, Stevenson LW, Shekelle PG (2004) Cost-effectiveness of screening with B-type natriuretic peptide to identify patients with reduced left ventricular ejection fraction. J Am Coll Cardiol 43(6):1019–1026. doi:10.1016/j.jacc.2003.10.043

    Article  PubMed  CAS  Google Scholar 

  18. Nielsen OW, McDonagh TA, Robb SD, Dargie HJ (2003) Retrospective analysis of the cost-effectiveness of using plasma brain natriuretic peptide in screening for left ventricular systolic dysfunction in the general population. J Am Coll Cardiol 41(1):113–120. doi:10.1016/S0735-1097(02)02625-6

    Article  PubMed  Google Scholar 

  19. Steg PG, Joubin L, McCord J et al (2005) B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea. Chest 128(1):21–29. doi:10.1378/chest.128.1.21

    Article  PubMed  CAS  Google Scholar 

  20. Steg PG, Joubin L, McCord J et al (2005) B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea. Chest 128(1):21–29. doi:10.1378/chest.128.1.21

    Article  PubMed  CAS  Google Scholar 

  21. Francis CM, Caruana L, Kearney P et al (1995) Open access echocardiography in management of heart failure in the community. BMJ 310(6980):634–636

    PubMed  CAS  Google Scholar 

  22. Khunti K (2004) Systematic review of open access echocardiography for primary care. Eur J Heart Fail 6(1):79–83. doi:10.1016/j.ejheart.2003.10.002

    Article  PubMed  Google Scholar 

  23. Murphy JJ, Frain JP, Ramesh P, Siddiqui RN, Bossingham CM (1996) Open-access echocardiography to general practitioners for suspected heart failure. Br J Gen Pract 46(409):475–476

    PubMed  CAS  Google Scholar 

  24. Fung JW, Yu CM, Yip G et al (2003) Effect of beta blockade (carvedilol or metoprolol) on activation of the renin-angiotensin-aldosterone system and natriuretic peptides in chronic heart failure. Am J Cardiol 92(4):406–410. doi:10.1016/S0002-9149(03)00658-1

    Article  PubMed  CAS  Google Scholar 

  25. Johnson W, Omland T, Hall C et al (2002) Neurohormonal activation rapidly decreases after intravenous therapy with diuretics and vasodilators for class IV heart failure. J Am Coll Cardiol 39(10):1623–1629. doi:10.1016/S0735-1097(02)01814-4

    Article  PubMed  CAS  Google Scholar 

  26. Murdoch DR, McDonagh TA, Byrne J et al (1999) Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy. Am Heart J 138(6Pt 1):1126–1132. doi:10.1016/S0002-8703(99)70079-7

    Article  PubMed  CAS  Google Scholar 

  27. Yoshimura M, Mizuno Y, Nakayama M et al (2002) B-type natriuretic peptide as a marker of the effects of enalapril in patients with heart failure. Am J Med 112(9):716–720. doi:10.1016/S0002-9343(02)01121-X

    Article  PubMed  CAS  Google Scholar 

  28. Bayes-Genis A, Lloyd-Jones DM, van Kimmenade RR et al (2007) Effect of body mass index on diagnostic and prognostic usefulness of amino-terminal pro-brain natriuretic peptide in patients with acute dyspnea. Arch Intern Med 167(4):400–407. doi:10.1001/archinte.167.4.400

    Article  PubMed  CAS  Google Scholar 

  29. Daniels LB, Clopton P, Bhalla V et al (2006) How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure. Results from the Breathing Not Properly multinational study. Am Heart J 151(5):999–1005. doi:10.1016/j.ahj.2005.10.011

    Article  PubMed  CAS  Google Scholar 

  30. Wang TJ, Larson MG, Levy D et al (2004) Impact of obesity on plasma natriuretic peptide levels. Circulation 109(5):594–600. doi:10.1161/01.CIR.0000112582.16683.EA

    Article  PubMed  CAS  Google Scholar 

  31. Krauser DG, Lloyd-Jones DM, Chae CU et al (2005) Effect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: a ProBNP investigation of dyspnea in the Emergency department (PRIDE) substudy. Am Heart J 149(4):744–750. doi:10.1016/j.ahj.2004.07.010

    Article  PubMed  CAS  Google Scholar 

  32. Maisel AS, McCord J, Nowak RM et al (2003) Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly multinational study. J Am Coll Cardiol 41(11):2010–2017. doi:10.1016/S0735-1097(03)00405-4

    Article  PubMed  Google Scholar 

  33. http://www.fda.gov/cdrh/ode/guidance/1072.html. 30/11/2000. Internet Communication

  34. Zaphiriou A, Robb S, Murray-Thomas T et al (2005) The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study. Eur J Heart Fail 7(4):537–541. doi:10.1016/j.ejheart.2005.01.022

    Article  PubMed  CAS  Google Scholar 

  35. McCullough PA, Nowak RM, McCord J et al (2002) B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from breathing not properly (BNP) multinational study. Circulation 106(4):416–422. doi:10.1161/01.CIR.0000025242.79963.4C

    Article  PubMed  Google Scholar 

  36. Steg PG, Joubin L, McCord J et al (2005) B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea. Chest 128(1):21–29. doi:10.1378/chest.128.1.21

    Article  PubMed  CAS  Google Scholar 

  37. Nielsen OW, Cowburn PJ, Sajadieh A, Morton JJ, Dargie H, McDonagh T (2007) Value of BNP to estimate cardiac risk in patients on cardioactive treatment in primary care. Eur J Heart Fail 9(12):1178–1185. doi:10.1016/j.ejheart.2007.10.004

    Article  PubMed  CAS  Google Scholar 

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Conflict of interest statement

None declared.

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Authors and Affiliations

  1. Heart Failure Unit, St. Vincent’s University Hospital, Elm Park, Dublin 4, UK

    G. Mak, M. Ryder, N. F. Murphy, C. O’Loughlin, D. McCaffrey, M. Ledwidge & K. McDonald

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  1. G. Mak
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  2. M. Ryder
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  3. N. F. Murphy
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  4. C. O’Loughlin
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  5. D. McCaffrey
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  6. M. Ledwidge
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  7. K. McDonald
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Correspondence to G. Mak.

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Mak, G., Ryder, M., Murphy, N.F. et al. Diagnosis of new onset heart failure in the community: the importance of a shared-care approach and judicious use of BNP. Ir J Med Sci 177, 197–203 (2008). https://doi.org/10.1007/s11845-008-0186-3

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  • DOI: https://doi.org/10.1007/s11845-008-0186-3

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