Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study

Clare J Taylor; José M.  Ordóñez-Mena; Sarah L Lay-Flurrie; Clare R Goyder; Kathryn S. Taylor; Nicholas R Jones; Andrea K Roalfe; FD Richard Hobbs

doi:10.3399/BJGP.2022.0278

Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study

Clare J Taylor, José M. Ordóñez-Mena, Sarah L Lay-Flurrie, Clare R Goyder, Kathryn S. Taylor, Nicholas R Jones, Andrea K Roalfe, FD Richard Hobbs

Applied Health Research

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Abstract

BACKGROUND: Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.

AIM: To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.

DESIGN AND SETTING: Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018).

METHOD: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.

RESULTS: In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).

CONCLUSION: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

Original language	English
Pages (from-to)	e1-e8
Number of pages	8
Journal	British Journal of General Practice
Volume	73
Issue number	726
Early online date	21 Dec 2022
DOIs	https://doi.org/10.3399/BJGP.2022.0278
Publication status	Published - Jan 2023

Bibliographical note

Funding:
The study was funded by the National Institute for Health and Care Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication. Clare J Taylor is an NIHR Academic Clinical Lecturer. Andrea K Roalfe, Sarah L Lay-Flurrie, and José M Ordóñez-Mena are supported by the NIHR Oxford Biomedical Research Centre (BRC) and NIHR Oxford and Thames Valley Applied Research Collaboration (ARC OTV). FD Richard Hobbs acknowledges support from NIHR ARC OTV and the NIHR Oxford BRC. This work was also supported by the NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative (MIC) at Oxford Health NHS Foundation Trust as part of the long-term condition theme led by Clare J Taylor and FD Richard Hobbs. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Copyright:
© The Authors.

Keywords

Humans
Heart Failure/diagnosis
Natriuretic Peptide, Brain
Predictive Value of Tests
Secondary Care
Referral and Consultation
Chronic Disease
Peptide Fragments
Primary Health Care
Biomarkers

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Cite this

@article{a2af87041fb54139b97ae843b6e770a8,

title = "Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study",

abstract = "BACKGROUND: Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.AIM: To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.DESIGN AND SETTING: Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018).METHOD: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.RESULTS: In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).CONCLUSION: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.",

keywords = "Humans, Heart Failure/diagnosis, Natriuretic Peptide, Brain, Predictive Value of Tests, Secondary Care, Referral and Consultation, Chronic Disease, Peptide Fragments, Primary Health Care, Biomarkers",

author = "Taylor, {Clare J} and Ord{\'o}{\~n}ez-Mena, {Jos{\'e} M.} and Lay-Flurrie, {Sarah L} and Goyder, {Clare R} and Taylor, {Kathryn S.} and Jones, {Nicholas R} and Roalfe, {Andrea K} and Hobbs, {FD Richard}",

note = "Funding: The study was funded by the National Institute for Health and Care Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication. Clare J Taylor is an NIHR Academic Clinical Lecturer. Andrea K Roalfe, Sarah L Lay-Flurrie, and Jos{\'e} M Ord{\'o}{\~n}ez-Mena are supported by the NIHR Oxford Biomedical Research Centre (BRC) and NIHR Oxford and Thames Valley Applied Research Collaboration (ARC OTV). FD Richard Hobbs acknowledges support from NIHR ARC OTV and the NIHR Oxford BRC. This work was also supported by the NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative (MIC) at Oxford Health NHS Foundation Trust as part of the long-term condition theme led by Clare J Taylor and FD Richard Hobbs. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. Copyright: {\textcopyright} The Authors.",

year = "2023",

month = jan,

doi = "10.3399/BJGP.2022.0278",

language = "English",

volume = "73",

pages = "e1--e8",

journal = "British Journal of General Practice ",

issn = "0960-1643",

publisher = "Royal College of General Practitioners",

number = "726",

}

TY - JOUR

T1 - Natriuretic peptide testing and heart failure diagnosis in primary care

T2 - diagnostic accuracy study

AU - Taylor, Clare J

AU - Ordóñez-Mena, José M.

AU - Lay-Flurrie, Sarah L

AU - Goyder, Clare R

AU - Taylor, Kathryn S.

AU - Jones, Nicholas R

AU - Roalfe, Andrea K

AU - Hobbs, FD Richard

N1 - Funding: The study was funded by the National Institute for Health and Care Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication. Clare J Taylor is an NIHR Academic Clinical Lecturer. Andrea K Roalfe, Sarah L Lay-Flurrie, and José M Ordóñez-Mena are supported by the NIHR Oxford Biomedical Research Centre (BRC) and NIHR Oxford and Thames Valley Applied Research Collaboration (ARC OTV). FD Richard Hobbs acknowledges support from NIHR ARC OTV and the NIHR Oxford BRC. This work was also supported by the NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative (MIC) at Oxford Health NHS Foundation Trust as part of the long-term condition theme led by Clare J Taylor and FD Richard Hobbs. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. Copyright: © The Authors.

PY - 2023/1

Y1 - 2023/1

N2 - BACKGROUND: Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.AIM: To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.DESIGN AND SETTING: Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018).METHOD: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.RESULTS: In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).CONCLUSION: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

AB - BACKGROUND: Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.AIM: To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.DESIGN AND SETTING: Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018).METHOD: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.RESULTS: In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).CONCLUSION: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

KW - Humans

KW - Heart Failure/diagnosis

KW - Natriuretic Peptide, Brain

KW - Predictive Value of Tests

KW - Secondary Care

KW - Referral and Consultation

KW - Chronic Disease

KW - Peptide Fragments

KW - Primary Health Care

KW - Biomarkers

U2 - 10.3399/BJGP.2022.0278

DO - 10.3399/BJGP.2022.0278

M3 - Article

C2 - 36543554

SN - 0960-1643

VL - 73

SP - e1-e8

JO - British Journal of General Practice

JF - British Journal of General Practice

IS - 726

ER -

Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study

Abstract

Bibliographical note

Keywords

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