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Harskamp RE, De Clercq L, Veelers L, Schut MC, van Weert HCPM, Handoko ML, Moll van Charante EP, Himmelreich JCL. Diagnostic properties of natriuretic peptides and opportunities for personalized thresholds for detecting heart failure in primary care. Diagnosis (Berl) 2023; 10:432-439. [PMID: 37667563 DOI: 10.1515/dx-2023-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/25/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES Heart failure (HF) is a prevalent syndrome with considerable disease burden, healthcare utilization and costs. Timely diagnosis is essential to improve outcomes. This study aimed to compare the diagnostic performance of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in detecting HF in primary care. Our second aim was to explore if personalized thresholds (using age, sex, or other readily available parameters) would further improve diagnostic accuracy over universal thresholds. METHODS A retrospective study was performed among patients without prior HF who underwent natriuretic peptide (NP) testing in the Amsterdam General Practice Network between January 2011 and December 2021. HF incidence was based on registration out to 90 days after NP testing. Diagnostic accuracy was evaluated with AUROC, sensitivity and specificity based on guideline-recommended thresholds (125 ng/L for NT-proBNP and 35 ng/L for BNP). We used inverse probability of treatment weighting to adjust for confounding. RESULTS A total of 15,234 patients underwent NP testing, 6,870 with BNP (4.5 % had HF), and 8,364 with NT-proBNP (5.7 % had HF). NT-proBNP was more accurate than BNP, with an AUROC of 89.9 % (95 % CI: 88.4-91.2) vs. 85.9 % (95 % CI 83.5-88.2), with higher sensitivity (95.3 vs. 89.7 %) and specificity (59.1 vs. 58.0 %). Differentiating NP cut-off by clinical variables modestly improved diagnostic accuracy for BNP and NT-proBNP compared with a universal threshold. CONCLUSIONS NT-proBNP outperforms BNP for detecting HF in primary care. Personalized instead of universal diagnostic thresholds led to modest improvement.
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Affiliation(s)
- Ralf E Harskamp
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Lukas De Clercq
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Lieke Veelers
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn C Schut
- Department of Laboratory Medicine, Translational AI. Amsterdam UMC, Amsterdam, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam UMC Location VU University, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Eric P Moll van Charante
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
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Lapi F, Marconi E, Medea G, Parretti D, Piccinni C, Maggioni AP, Cricelli C. To support the use of NT-proBNP to better detect heart failure in patients with type 2 diabetes. Endocrine 2023; 82:42-46. [PMID: 37340284 DOI: 10.1007/s12020-023-03419-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/06/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE Heart failure (HF) is a chronic disease that causes approximately 300,000 and 250,000 deaths per year in Europe and United States, respectively. Type 2 Diabetes Mellitus (T2DM) is one the major risk factors of HF, and the investigation of NT-proBNP might support the early identification of HF in T2DM sufferers. Nevertheless, this parameter is poorly investigated. Thus, we aimed to demographically and clinically characterize diabetic patients which were prescribed with NT-proBNP in the primary care setting. METHODS Using a primary care database, we formed a cohort of patients aged ≥18 years diagnosed with T2DM between 2002 and 2021. A multivariate Cox model was adopted to assess the determinants associated with the prescription of NT-proBNP. RESULTS Among 167,961 T2DM patients, 7558 (4.5%, 95% CI: 4.4-4.6) were prescribed with NT-proBNP. Males and increasing age were expectedly associated with a higher propensity to be prescribed with NT-proBNP. In addition, a significant association was found for those suffering from obesity, ischemic cardiomyopathy, stroke, atrial fibrillation, hypertension, and with a Charlson Index of 2+. CONCLUSION These determinants might contribute to investigate the NT-proBNP in T2DM sufferers. A decision support system to appropriately ease the prescription of NT-proBNP might be therefore implemented in primary care settings.
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Affiliation(s)
- Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy.
| | - Ettore Marconi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Gerardo Medea
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Damiano Parretti
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Carlo Piccinni
- Fondazione ReS (Ricerca e Salute-Health and Research Foundation), Rome, Italy
| | - Aldo Pietro Maggioni
- Fondazione ReS (Ricerca e Salute-Health and Research Foundation), Rome, Italy
- ANMCO Research Center Heart Care Foundation, Florence, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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Docherty KF, Lam CSP, Rakisheva A, Coats AJS, Greenhalgh T, Metra M, Petrie MC, Rosano GMC. Heart failure diagnosis in the general community - Who, how and when? A clinical consensus statement of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2023; 25:1185-1198. [PMID: 37368511 DOI: 10.1002/ejhf.2946] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A significant proportion of patients experience delays in the diagnosis of heart failure due to the non-specific signs and symptoms of the syndrome. Diagnostic tools such as measurement of natriuretic peptide concentrations are fundamentally important when screening for heart failure, yet are frequently under-utilized. This clinical consensus statement provides a diagnostic framework for general practitioners and non-cardiology community-based physicians to recognize, investigate and risk-stratify patients presenting in the community with possible heart failure.
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Affiliation(s)
- Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Cardiology. ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study. Br J Gen Pract 2023; 73:e1-e8. [PMID: 36543554 PMCID: PMC9799346 DOI: 10.3399/bjgp.2022.0278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022] Open
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.
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Welsh P, Campbell RT, Mooney L, Kimenai DM, Hayward C, Campbell A, Porteous D, Mills NL, Lang NN, Petrie MC, Januzzi JL, McMurray JJ, Sattar N. Reference Ranges for NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) and Risk Factors for Higher NT-proBNP Concentrations in a Large General Population Cohort. Circ Heart Fail 2022; 15:e009427. [PMID: 36098049 PMCID: PMC9561238 DOI: 10.1161/circheartfailure.121.009427] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Demographic differences in expected NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentration are not well established. We aimed to establish reference ranges for NT-proBNP and explore the determinants of moderately elevated NT-proBNP under the universal definition of heart failure criteria. METHODS This is a cross-sectional study. NT-proBNP was measured in serum from 18 356 individuals without previous cardiovascular disease in the Generation Scotland Scottish Family Health Study. Age- and sex-stratified medians and 97.5th centiles were generated. Sex stratified risk factors for moderately elevated NT-proBNP (≥125 pg/mL) were investigated. RESULTS In males, median (97.5th centile) NT-proBNP concentration at age <30 years was 21 (104) pg/mL, rising to 38 (195) pg/ml at 50 to 59 years, and 281 (6792) pg/mL at ≥80 years. In females, median NT-proBNP at age <30 years was 51 (196) pg/mL, 66 (299) pg/mL at 50 to 59 years, and 240 (2704) pg/mL at ≥80 years. At age <30 years, 9.8% of females and 1.4% of males had elevated NT-proBNP, rising to 76.5% and 81.0%, respectively, at age ≥80 years. After adjusting for risk factors, an NT-proBNP ≥125 pg/mL was more common in females than males (OR, 9.48 [95% CI, 5.60-16.1]). Older age and smoking were more strongly associated with elevated NT-proBNP in males than in females (Psex interaction <0.001, 0.07, respectively). Diabetes was inversely associated with odds of elevated NT-proBNP in females only (Psex interaction=0.007). CONCLUSIONS An NT-proBNP ≥125 pg/mL is common in females without classical cardiovascular risk factors as well as older people. If NT-proBNP becomes widely used for screening in the general population, interpretation of NT-proBNP levels will require that age and sex-specific thresholds are used to identify patients with potential pathophysiology.
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Affiliation(s)
- Paul Welsh
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Ross T. Campbell
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Leanne Mooney
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Dorien M. Kimenai
- British Heart Foundation Centre for Cardiovascular Science (D.M.K., N.L.M.), University of Edinburgh, United Kingdom
| | - Caroline Hayward
- Medical Research Council Human Genetics Unit (C.H.), University of Edinburgh, United Kingdom
| | - Archie Campbell
- Institute of Genetics and Cancer (A.C., D.P.), University of Edinburgh, United Kingdom
| | - David Porteous
- Institute of Genetics and Cancer (A.C., D.P.), University of Edinburgh, United Kingdom
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (D.M.K., N.L.M.), University of Edinburgh, United Kingdom
- Usher Institute (N.L.M.), University of Edinburgh, United Kingdom
| | - Ninian N. Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Mark C. Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - James L. Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston (J.L.J.)
- Harvard Medical School, Boston, MA (J.L.J.)
| | - John J.V. McMurray
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
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Charman SJ, Okwose NC, Taylor CJ, Bailey K, Fuat A, Ristic A, Mant J, Deaton C, Seferovic PM, Coats AJS, Hobbs FDR, MacGowan GA, Jakovljevic DG. Feasibility of the cardiac output response to stress test in suspected heart failure patients. Fam Pract 2022; 39:805-812. [PMID: 35083480 PMCID: PMC9508869 DOI: 10.1093/fampra/cmab184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Diagnostic tools available to support general practitioners diagnose heart failure (HF) are limited. OBJECTIVES (i) Determine the feasibility of the novel cardiac output response to stress (CORS) test in suspected HF patients, and (ii) Identify differences in the CORS results between (a) confirmed HF patients from non-HF patients, and (b) HF reduced (HFrEF) vs HF preserved (HFpEF) ejection fraction. METHODS Single centre, prospective, observational, feasibility study. Consecutive patients with suspected HF (N = 105; mean age: 72 ± 10 years) were recruited from specialized HF diagnostic clinics in secondary care. The consultant cardiologist confirmed or refuted a HF diagnosis. The patient completed the CORS but the researcher administering the test was blinded from the diagnosis. The CORS assessed cardiac function (stroke volume index, SVI) noninvasively using the bioreactance technology at rest-supine, challenge-standing, and stress-step exercise phases. RESULTS A total of 38 patients were newly diagnosed with HF (HFrEF, n = 21) with 79% being able to complete all phases of the CORS (91% of non-HF patients). A 17% lower SVI was found in HF compared with non-HF patients at rest-supine (43 ± 15 vs 51 ± 16 mL/beat/m2, P = 0.02) and stress-step exercise phase (49 ± 16 vs 58 ± 17 mL/beat/m2, P = 0.02). HFrEF patients demonstrated a lower SVI at rest (39 ± 15 vs 48 ± 13 mL/beat/m2, P = 0.02) and challenge-standing phase (34 ± 9 vs 42 ± 12 mL/beat/m2, P = 0.03) than HFpEF patients. CONCLUSION The CORS is feasible and patients with HF responded differently to non-HF, and HFrEF from HFpEF. These findings provide further evidence for the potential use of the CORS to improve HF diagnostic and referral accuracy in primary care.
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Affiliation(s)
- Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Nduka C Okwose
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Research Centre (CSELS), Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Clare J Taylor
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Kristian Bailey
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ahmet Fuat
- Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust & School of Medicine, Pharmacy and Health, Durham University, Durham, United Kingdom
| | - Arsen Ristic
- Department of Cardiology, Faculty of Medicine, University of Belgrade, Clinical Centre of Serbia, Belgrade, Serbia
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Petar M Seferovic
- Department of Cardiology, Faculty of Medicine, University of Belgrade, Clinical Centre of Serbia, Belgrade, Serbia
| | - Andrew J S Coats
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - F D Richard Hobbs
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Guy A MacGowan
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Djordje G Jakovljevic
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Research Centre (CSELS), Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JG, Coats AJ, Crespo-Leiro MG, Farmakis D, Gilard M, Heyman S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CS, Lyon AR, McMurray JJ, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GM, Ruschitzka F, Skibelund AK. Guía ESC 2021 sobre el diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2022; 24:4-131. [PMID: 35083827 DOI: 10.1002/ejhf.2333] [Citation(s) in RCA: 785] [Impact Index Per Article: 392.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 12/11/2022] Open
Abstract
Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.
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Yii E, Fersia O, McFadyen A, Isles C. Assessment of the impact of different N terminal pro brain natriuretic peptide thresholds on echocardiography services. ESC Heart Fail 2021; 9:627-635. [PMID: 34877791 PMCID: PMC8788020 DOI: 10.1002/ehf2.13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/23/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Aims N terminal pro brain natriuretic peptide (NT‐proBNP) is considered a rule‐out test for patients with suspected heart failure. The NT‐proBNP thresholds recommended for echocardiography by the European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) are based on small studies of patients with heart failure and left ventricular (LV) systolic dysfunction (LVSD). The purpose of our study was to examine the relation between NT‐proBNP and LVSD in a larger number of patients with symptoms suggestive of heart failure in a non‐acute setting. Methods and results One thousand patients with suspected chronic heart failure underwent echocardiography within 6 months of NT‐proBNP measurement. NT‐proBNP was the strongest predictor of any form of LVSD in univariate (OR 2.52, 95% CI 2.19–2.91, P value < 0.001) and multivariate (OR 2.73, 95% CI 2.32–3.21, P value < 0.001) analyses. Negative predictive value (NPV) of NT‐proBNP for impaired LV systolic function (ejection fraction 35–49%) was 98% at 125 pg/mL (the ESC threshold), 93% at 400 pg/mL (the NICE threshold), 91% at 1000 pg/mL and 90% at 2000 pg/mL. Corresponding values for severe LVSD (ejection fraction <35%) were 100%, 99%, 98% and 96%. The number of patients per 1000 with suspected chronic heart failure requiring echocardiography at each threshold was 851, 543, 324, and 182, respectively. Conclusions N terminal pro brain natriuretic peptide thresholds recommended by ESC and NICE result in large numbers of patients with suspected chronic heart failure being referred for echocardiography. Raising the NT‐proBNP threshold would improve access to echocardiography with minimal negative impact on the clinical performance of this cardiac biomarker.
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Affiliation(s)
- Eric Yii
- Cardiology Department, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Omar Fersia
- Cardiology Department, Dumfries and Galloway Royal Infirmary, Dumfries, UK.,Cardiology Department, Forth Valley Royal Hospital, Larbert, UK
| | | | - Christopher Isles
- Cardiology Department, Dumfries and Galloway Royal Infirmary, Dumfries, UK
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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13
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021; 42:3599-3726. [PMID: 34447992 DOI: 10.1093/eurheartj/ehab368] [Citation(s) in RCA: 4877] [Impact Index Per Article: 1625.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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15
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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FASTer diagnosis: Time to BEAT heart failure. BJGP Open 2021; 5:BJGPO.2021.0006. [PMID: 33906895 PMCID: PMC8278515 DOI: 10.3399/bjgpo.2021.0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/04/2021] [Indexed: 11/24/2022] Open
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Roalfe AK, Taylor CJ, Kelder JC, Hoes AW, Hobbs FDR. Diagnosing heart failure in primary care: individual patient data meta-analysis of two European prospective studies. ESC Heart Fail 2021; 8:2193-2201. [PMID: 33755352 PMCID: PMC8120419 DOI: 10.1002/ehf2.13311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/27/2021] [Accepted: 03/02/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Natriuretic peptides are helpful in detecting chronic heart failure (HF) in primary care; however, there are a lack of data evaluating thresholds recommended by clinical guidelines. This study assesses the diagnostic accuracy of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) using combined individual patient data from two studies in the UK and the Netherlands. Methods and results Random effects methods were used to estimate the performance characteristics of NT‐proBNP thresholds recommended by the European Society of Cardiology (ESC) and the UK National Institute for Health and Care Excellence (NICE) guidelines. New onset HF was diagnosed in 313 of 1073 (29.2%) participants. Age, sex, and atrial fibrillation‐adjusted NT‐proBNP was a better predictor of HF with reduced ejection fraction (HFrEF) than HF preserved ejection fraction (HFpEF), with area under receiver operating characteristic curve of 0.82 95% CI (0.78 to 0.86) vs. 0.71 (0.66 to 0.75). In persons aged 70 years and over, the ESC threshold at 125 ng/L for detection of all‐cause HF had summary negative predictive value (NPV) of 84.9% (81.6 to 88.2), positive predictive value (PPV) 68.1% (63.1 to 73.3), sensitivity 74.9% (69.5 to 80.3), and specificity 80.1% (76.9 to 83.4); the NICE threshold at 400 ng/L had summary NPV of 74.7% (72.1 to 77.2), PPV 81.8% (73.3 to 89.5), sensitivity 43.5% (37.2 to 49.8), and specificity 94.5% (92.3 to 96.7). Conclusions N‐terminal pro‐B‐type natriuretic peptide is better at detecting HFrEF than HFpEF in a primary care setting. In persons aged 70 and over, the ESC threshold of 125 ng/L is more accurate at detecting and excluding HF than the higher level suggested in NICE guidelines. More prospective data are required to establish the optimal NP threshold for detecting chronic HF in general practice.
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Affiliation(s)
- Andrea K Roalfe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | | | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht/Utrecht University, Utrecht, The Netherlands
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Garg P, Dakshi A, Assadi H, Swift AJ, Naveed U, Fent G, Lewis N, Rogers D, Charalampopoulos A, Al-Mohammad A. Characterisation of the patients with suspected heart failure: experience from the SHEAF registry. Open Heart 2021; 8:openhrt-2020-001448. [PMID: 33431617 PMCID: PMC7802648 DOI: 10.1136/openhrt-2020-001448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To characterise and risk-stratify patients presenting to a heart failure (HF) clinic according to the National Institute for health and Care Excellence (NICE) algorithm. METHODS This is an observational study of prospectively collected data in the Sheffield HEArt Failure registry of consecutive patients with suspected HF between April 2012 and January 2020. Outcome was defined as all-cause mortality. RESULTS 6144 patients were enrolled: 71% had HF and 29% had no HF. Patients with N-terminal pro-brain-type natriuretic peptide (NT-proBNP) >2000 pg/mL were more likely to have HF than those with NT-proBNP of 400-2000 pg/mL (92% vs 64%, respectively). Frequency of HF phenotypes include: HF with preserved ejection fraction (HFpEF) (33%), HF with reduced ejection fraction (HFrEF) (29%), HF due to valvular heart disease (4%), HF due to pulmonary hypertension (5%) and HF due to right ventricular systolic dysfunction (1%). There were 1485 (24%) deaths over a maximum follow-up of 6 years. The death rate was higher in HF versus no HF (11.49 vs 7.29 per 100 patient-years follow-up, p<0.0001). Patients with HF and an NT-proBNP >2000 pg/mL had lower survival than those with NT-proBNP 400-2000 pg/mL (3.8 years vs 5 years, p<0.0001). Propensity matched survival curves were comparable between HFpEF and HFrEF (p=0.88). CONCLUSION Our findings support the use by NICE's HF diagnostic algorithm of tiered triage of patients with suspected HF based on their NT-proBNP levels. The two pathways yielded distinctive groups of patients with varied diagnoses and prognosis. HFpEF is the most frequent diagnosis, with its challenges of poor prognosis and paucity of therapeutic options.
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Affiliation(s)
- Pankaj Garg
- IICD, The University of Sheffield, Sheffield, UK
| | - Ahmed Dakshi
- Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Andrew J Swift
- Academic Unit of Radiology, The University of Sheffield, Sheffield, UK
| | - Umna Naveed
- IICD, The University of Sheffield, Sheffield, UK
| | - Graham Fent
- Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nigel Lewis
- IICD, The University of Sheffield, Sheffield, UK
| | - Dominic Rogers
- Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Abdallah Al-Mohammad
- IICD, The University of Sheffield, Sheffield, UK .,Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Shimizu N, Kotani K. Point-of-care testing of (N-terminal pro) B-type natriuretic peptide for heart disease patients in home care and ambulatory care settings. Pract Lab Med 2020; 22:e00183. [PMID: 33134469 PMCID: PMC7585141 DOI: 10.1016/j.plabm.2020.e00183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/16/2020] [Indexed: 12/28/2022] Open
Abstract
Objectives The role of point-of-care testing (POCT) out of hospital, especially in home care and ambulatory care settings, is an issue meriting further research. We reviewed studies reporting cardiovascular events as a result of the implementation of B-type natriuretic peptide or N-terminal pro B-type natriuretic peptide POCT (BNP/NT-proBNP POCT) for heart disease patients in the settings. Design Articles were searched via a PubMed engine until May 30, 2020. Results In total, six studies were selected. Three studies involving ambulatory care used the POCT to refer patients with suspected heart diseases to a specialist. The other three used the tests in home care to monitor patients with heart failure. In ambulatory care, the randomized controlled trials, in which referrals were made to a specialist, showed that the group using POCT had significantly fewer cardiovascular outcomes, such as hospitalizations and deaths, than the non-use group. In home care, adverse outcomes were predicted from changes in BNP levels. Conclusions In most studies, the use of BNP/NT-proBNP POCT in home care and ambulatory care settings demonstrated favorable results regarding the cardiovascular outcomes. The utility of POCT in the settings is suggested, while more investigations are required. Point-of-care testing of BNP can be useful for referral of patients to specialists as demonstrated in two randomized control trials. Point-of-care testing of BNP couldpredict acute heart failure as demonstrated in three observational studies. The findings should be generalized with care because of the limitation of available data.
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Key Words
- ADHF, acute clinical HF decompensation
- AUC, area under the curve
- BNP
- BNP, B-type natriuretic peptide
- HF, heart failure
- HFpEF, HF with preserved ejection fraction
- HFrEF, HF with reduced ejection fraction
- HR, hazard ratio
- Heart failure
- Home care
- IRR, incidence rate ratio
- MACE, major adverse cardiac events
- NT-proBNP
- NT-proBNP, N-terminal pro B-type natriuretic peptide
- OR, odds ratio
- POCT, point-of-care testing
- Point-of-care testing
- Primary care
- RCT, randomized controlled trials
- Sn, sensitivity
- Sp, specificity
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Affiliation(s)
- Nayuta Shimizu
- Division of Community and Family Medicine, Center of Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Center of Community Medicine, Jichi Medical University, Tochigi, Japan
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CONANGLA LAURA, DOMINGO MAR, LUPÓN JOSEP, WILKE ASUNCIÓN, JUNCÀ GLADYS, TEJEDOR XAVIER, VOLPICELLI GIOVANNI, EVANGELISTA LIDIA, PERA GUILLEM, TORAN PERE, MAS ARIADNA, CEDIEL GERMÁN, VERDÚ JOSÉMARÍA, BAYES-GENIS ANTONI. Lung Ultrasound for Heart Failure Diagnosis in Primary Care. J Card Fail 2020; 26:824-831. [DOI: 10.1016/j.cardfail.2020.04.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 01/07/2023]
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Time trends in the use and appropriateness of natriuretic peptide testing in primary care: an observational study. BJGP Open 2020; 4:bjgpopen20X101074. [PMID: 32788172 PMCID: PMC7606146 DOI: 10.3399/bjgpopen20x101074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/06/2020] [Indexed: 12/21/2022] Open
Abstract
Background Diagnosing heart failure (HF) is difficult, relying on medical history, symptoms, and signs only. Clinical guidelines recommend natriuretic peptides (NPs) as an additional diagnostic test, notably to exclude HF in suspected patients. NP testing has been available since 2003 for primary care in the Netherlands, but little is known about its uptake. Aim To evaluate the trend in ordering and appropriateness of NP testing in primary care. Design & setting An observational study was performed between January 2005 and December 2013. Nine Dutch general practices participated, with 21 000 registered people (approximately 4300 aged ≥65 years). Method The total number of patients undergoing NP testing each year was calculated per 1000 patient years (PY) based on the total practice population. NP levels were used to assess whether NP testing was applied to exclude or confirm HF. Results The number of NP testing increased from 2.5 per 1000 PY in 2005 to 14.0 per 1000 PY in 2013, with a peak in 2009 of 15.6 per 1000 PY. The proportion of participants with N-terminal B-type natriuretic peptide (NTproBNP) below 125 pg/ml (the exclusionary threshold recommended by the European Society of Cardiology [ESC] guidelines on HF) was on average 30%, and highest in the first year (47%). Conclusion After a rapid uptake of NP testing in primary care from 2005 onwards, the use of it seemed to stabilise after 2009, thus leaving patients who are prone to HF without an optimal diagnostic work-up.
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Margel D, Ber Y, Peer A, Shavit-Grievink L, Pinthus JH, Witberg G, Baniel J, Kedar D, Rosenbaum E. Cardiac biomarkers in patients with prostate cancer and cardiovascular disease receiving gonadotrophin releasing hormone agonist vs antagonist. Prostate Cancer Prostatic Dis 2020; 24:177-185. [PMID: 32737420 DOI: 10.1038/s41391-020-0264-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gonadotrophin releasing hormone (GnRH) agonists and antagonists reduce testosterone levels for the treatment of advanced and metastatic prostate cancer. Androgen deprivation therapy (ADT) is associated with increased risk of cardiovascular (CV) events and CV disease (CVD), especially in patients with preexisting CVD treated with GnRH agonists. Here, we investigated the potential relationship between serum levels of the cardiac biomarkers N-terminal pro-B-type natriuretic peptide (NTproBNP), D-dimer, C-reactive protein (CRP), and high-sensitivity troponin (hsTn) and the risk of new CV events in prostate cancer patients with a history of CVD receiving a GnRH agonist or antagonist. METHODS Post-hoc analyses were performed of a phase II randomized study that prospectively assessed CV events in patients with prostate cancer and preexisting CVD, receiving GnRH agonist or antagonist. Cox proportional hazards models were used to determine whether the selected biomarkers had any predictive effect on CV events at baseline and across a 12-month treatment period. RESULTS Baseline and disease characteristics of the 80 patients who took part in the study were well balanced between treatment arms. Ischemic heart disease (66%) and myocardial infarction (37%) were the most common prior CVD and the majority (92%) of patients received CV medication. We found that high levels of NTproBNP (p = 0.008), and hsTn (p = 0.004) at baseline were associated with the development of new CV events in the GnRH agonist group but not in the antagonist. In addition, a nonsignificant trend was observed between higher levels of NTproBNP over time and the development of new CV events in the GnRH agonist group. CONCLUSIONS The use of cardiac biomarkers may be worthy of further study as tools in the prediction of CV risk in prostate cancer patients receiving ADT. Analysis was limited by the small sample size; larger studies are required to validate biomarker use to predict CV events among patients receiving ADT.
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Affiliation(s)
- David Margel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yaara Ber
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Avivit Peer
- Department of Oncology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Liat Shavit-Grievink
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel.,Davidoff Cancer Centre, Rabin Medical Center, Petach Tikva, Israel
| | - Jehonathan H Pinthus
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Guy Witberg
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Jack Baniel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Kedar
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Eli Rosenbaum
- Davidoff Cancer Centre, Rabin Medical Center, Petach Tikva, Israel
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Gierula J, Cubbon RM, Paton MF, Byrom R, Lowry JE, Winsor SF, McGinlay M, Sunley E, Pickles E, Kearney LC, Koshy A, Slater TA, Chumun HK, Jamil HA, Bailey KM, Barth JH, Kearney MT, Witte KK. Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:218-224. [PMID: 30452611 DOI: 10.1093/ehjqcco/qcy053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 11/13/2022]
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.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Sarah F Winsor
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Melanie McGinlay
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Emma Sunley
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Emma Pickles
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Lorraine C Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Aaron Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Hemant K Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Kristian M Bailey
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Julian H Barth
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
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26
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Charman S, Okwose N, Maniatopoulos G, Graziadio S, Metzler T, Banks H, Vale L, MacGowan GA, Seferović PM, Fuat A, Deaton C, Mant J, Hobbs RFD, Jakovljevic DG. Opportunities and challenges of a novel cardiac output response to stress (CORS) test to enhance diagnosis of heart failure in primary care: qualitative study. BMJ Open 2019; 9:e028122. [PMID: 30987993 PMCID: PMC6500186 DOI: 10.1136/bmjopen-2018-028122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To explore the role of the novel cardiac output response to stress (CORS), test in the current diagnostic pathway for heart failure and the opportunities and challenges to potential implementation in primary care. DESIGN Qualitative study using semistructured in-depth interviews which were audio recorded and transcribed verbatim. Data from the interviews were analysed thematically using an inductive approach. SETTING Newcastle upon Tyne, UK. PARTICIPANTS Fourteen healthcare professionals (six males, eight females) from primary (general practitioners (GPs), nurses, healthcare assistant, practice managers) and secondary care (consultant cardiologists). RESULTS Four themes relating to opportunities and challenges surrounding the implementation of the new diagnostic technology were identified. These reflected that the adoption of CORS test would be an advantage to primary care but the test had barriers to implementation which include: establishment of clinical utility, suitability for immobile patients and cost implication to GP practices. CONCLUSION The development of a simple non-invasive clinical test to accelerate the diagnosis of heart failure in primary care maybe helpful to reduce unnecessary referrals to secondary care. The CORS test has the potential to serve this purpose; however, factors such as cost effectiveness, diagnostic accuracy and seamless implementation in primary care have to be fully explored.
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Affiliation(s)
- Sarah Charman
- Cardiovascular Research Centre, Newcastle University, Newcastle, UK
| | - Nduka Okwose
- Cardiovascular Research Centre, Newcastle University, Newcastle, UK
| | | | - Sara Graziadio
- NIHR In Vitro Diagnostics Co-operative, Newcastle University, Newcastle, UK
| | - Tamara Metzler
- Cardiovascular Research Centre, Newcastle University, Newcastle, UK
| | - Helen Banks
- Cardiovascular Research Centre, Newcastle University, Newcastle, UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Guy A MacGowan
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Petar M Seferović
- Cardiology, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Ahmet Fuat
- Primary Care, Carmel Medical Practice, Darlington, UK
| | - Christi Deaton
- Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- General Practice and Primary Care Research Unit, University of Cambridge, Cambridge, UK
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Gallagher J, McCormack D, Zhou S, Ryan F, Watson C, McDonald K, Ledwidge MT. A systematic review of clinical prediction rules for the diagnosis of chronic heart failure. ESC Heart Fail 2019; 6:499-508. [PMID: 30854781 PMCID: PMC6487728 DOI: 10.1002/ehf2.12426] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 02/08/2019] [Indexed: 11/16/2022] Open
Abstract
Aims This study sought to review the literature for clinical prediction models for the diagnosis of patients with chronic heart failure in the community and to validate the models in a novel cohort of patients with a suspected diagnosis of chronic heart failure. Methods and results MEDLINE and Embase were searched from 1946 to Q4 2017. Studies were eligible if they contained at least one multivariable model for the diagnosis of chronic heart failure applicable to the primary care setting. The CHARMS checklist was used to evaluate models. We also validated models, where possible, in a novel cohort of patients with a suspected diagnosis of heart failure referred to a rapid access diagnostic clinic. In total, 5310 articles were identified with nine articles subsequently meeting the eligibility criteria. Three models had undergone internal validation, and four had undergone external validation. No clinical impact studies have been completed to date. Area under the curve (AUC) varied from 0.74 to 0.93 and from 0.60 to 0.65 in the novel cohort for clinical models alone with AUC up to 0.89 in combination with electrocardiogram and B‐type natriuretic peptide (BNP). The AUC for BNP was 0.86 (95% confidence interval 83.3–88.6%). Conclusions This review demonstrates that there are a number of clinical prediction rules relevant to the diagnosis of chronic heart failure in the literature. Clinical impact studies are required to compare the use of clinical prediction rules and biomarker strategies in this setting.
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Affiliation(s)
- Joe Gallagher
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland.,Irish College of General Practitioners, Lincoln Place, Dublin, Ireland
| | - Darren McCormack
- gHealth Research Group, University College Dublin, Belfield, Dublin, 4, Ireland
| | - Shuaiwei Zhou
- Heartbeat Trust, Crofton Terrace, Dun Laoghaire, Co Dublin, Ireland
| | - Fiona Ryan
- Heartbeat Trust, Crofton Terrace, Dun Laoghaire, Co Dublin, Ireland
| | - Chris Watson
- Centre for Experimental Medicine, Queens University, Belfast, Ireland
| | - Kenneth McDonald
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland
| | - Mark T Ledwidge
- School of Medicine & Medical Sciences, University College Dublin, Belfield, Dublin, 4, Ireland
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28
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Charman SJ, Okwose NC, Stefanetti RJ, Bailey K, Skinner J, Ristic A, Seferovic PM, Scott M, Turley S, Fuat A, Mant J, Hobbs RF, MacGowan GA, Jakovljevic DG. A novel cardiac output response to stress test developed to improve diagnosis and monitoring of heart failure in primary care. ESC Heart Fail 2018; 5:703-712. [PMID: 29943902 PMCID: PMC6073030 DOI: 10.1002/ehf2.12302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/15/2018] [Accepted: 04/16/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Primary care physicians lack access to an objective cardiac function test. This study for the first time describes a novel cardiac output response to stress (CORS) test developed to improve diagnosis and monitoring of heart failure in primary care and investigates its reproducibility. METHODS AND RESULTS Prospective observational study recruited 32 consecutive primary care patients (age, 63 ± 9 years; female, n = 18). Cardiac output was measured continuously using the bioreactance method in supine and standing positions and during two 3 min stages of a step-exercise protocol (10 and 15 steps per minute) using a 15 cm height bench. The CORS test was performed on two occasions, i.e. Test 1 and Test 2. There was no significant difference between repeated measures of cardiac output and stroke volume at supine standing and Stage 1 and Stage 2 step exercises (all P > 0.3). There was a significant positive relationship between Test 1 and Test 2 cardiac outputs (r = 0.92, P = 0.01 with coefficient of variation of 7.1%). The mean difference in cardiac output (with upper and lower limits of agreement) between Test 1 and Test 2 was 0.1 (-1.9 to 2.1) L/min, combining supine, standing, and step-exercise data. CONCLUSIONS The CORS, as a novel test for objective evaluation of cardiac function, demonstrates acceptable reproducibility and can potentially be implemented in primary care.
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Affiliation(s)
- Sarah J. Charman
- Cardiovascular Research Centre, Institutes of Cellular and Genetic Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Nduka C. Okwose
- Cardiovascular Research Centre, Institutes of Cellular and Genetic Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Renae J. Stefanetti
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Medical SchoolNewcastle UniversityNewcastle upon TyneUK
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Kristian Bailey
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Jane Skinner
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Arsen Ristic
- Cardiology Department, Clinical Centre Serbia, School of MedicineUniversity of BelgradeBelgradeSerbia
| | - Petar M. Seferovic
- Cardiology Department, Clinical Centre Serbia, School of MedicineUniversity of BelgradeBelgradeSerbia
| | | | | | - Ahmet Fuat
- Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust and School of Medicine, Pharmacy and HealthDurham UniversityDurhamUK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Richard F.D. Hobbs
- Nuffield Department of Primary Health Care SciencesUniversity of OxfordOxfordUK
| | - Guy A. MacGowan
- Cardiovascular Research Centre, Institutes of Cellular and Genetic Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Djordje G. Jakovljevic
- Cardiovascular Research Centre, Institutes of Cellular and Genetic Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
- RCUK Centre for Ageing and VitalityNewcastle UniversityNewcastle upon TyneUK
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29
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Practical guidance on heart failure diagnosis and management in primary care: recent EPCCS recommendations. Br J Gen Pract 2018; 67:326-327. [PMID: 28663432 DOI: 10.3399/bjgp17x691553] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/21/2016] [Indexed: 12/11/2022] Open
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Abstract
PURPOSE OF REVIEW Breathlessness is a high-volume problem with 10% of adults experiencing the symptom daily placing a heavy burden on the health and wider economy. As it worsens, they enter the specialist and hospital-based symptom services where costs quickly escalate and people may find themselves in a place not of their choosing. For many, their care will be delivered by a disease or organ specialist and can find themselves passing between physicians without coordination for symptom support. General practitioners (GPs) will be familiar with this scenario and can often feel out of their depth. Recent advances in our thinking about breathlessness symptom management can offer opportunities and a sense of hope when the GP is faced with this situation. RECENT FINDINGS Original research, reviews and other findings over the last 12-18 months that pertain to the value that general practice and the wider primary care system can add, include opportunities to help people recognize they have a problem that can be treated. We present systems that support decisions made by primary healthcare professionals and an increasingly strong case that a solution is required in primary care for an ageing and frail population where breathlessness will be common. SUMMARY Primary care practitioners and leaders must start to realize the importance of recognizing and acting early in the life course of the person with breathlessness because its impact is enormous. They will need to work closely with public health colleagues and learn from specialists who have been doing this work usually with people near to the end of life translating the skills and knowledge further upstream to allow people to live well and remain near home and in their communities.
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31
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Taylor KS, Verbakel JY, Feakins BG, Price CP, Perera R, Bankhead C, Plüddemann A. Diagnostic accuracy of point-of-care natriuretic peptide testing for chronic heart failure in ambulatory care: systematic review and meta-analysis. BMJ 2018; 361:k1450. [PMID: 29785952 PMCID: PMC5960954 DOI: 10.1136/bmj.k1450] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of point-of-care natriuretic peptide tests in patients with chronic heart failure, with a focus on the ambulatory care setting. DESIGN Systematic review and meta-analysis. DATA SOURCES Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, Health Technology Assessment Database, Science Citation Index, and Conference Proceedings Citation Index until 31 March 2017. STUDY SELECTION Eligible studies evaluated point-of-care natriuretic peptide testing (B-type natriuretic peptide (BNP) or N terminal fragment pro B-type natriuretic peptide (NTproBNP)) against any relevant reference standard, including echocardiography, clinical examination, or combinations of these, in humans. Studies were excluded if reported data were insufficient to construct 2×2 tables. No language restrictions were applied. RESULTS 42 publications of 39 individual studies met the inclusion criteria and 40 publications of 37 studies were included in the analysis. Of the 37 studies, 30 evaluated BNP point-of-care testing and seven evaluated NTproBNP testing. 15 studies were done in ambulatory care settings in populations with a low prevalence of chronic heart failure. Five studies were done in primary care. At thresholds >100 pg/mL, the sensitivity of BNP, measured with the point-of-care index device Triage, was generally high and was 0.95 (95% confidence interval 0.90 to 0.98) at 100 pg/mL. At thresholds <100 pg/mL, sensitivity ranged from 0.46 to 0.97 and specificity from 0.31 to 0.98. Primary care studies that used NTproBNP testing reported a sensitivity of 0.99 (0.57 to 1.00) and specificity of 0.60 (0.44 to 0.74) at 135 pg/mL. No statistically significant difference in diagnostic accuracy was found between point-of-care BNP and NTproBNP tests. CONCLUSIONS Given the lack of studies in primary care, the paucity of NTproBNP data, and potential methodological limitations in these studies, large scale trials in primary care are needed to assess the role of point-of-care natriuretic peptide testing and clarify appropriate thresholds to improve care of patients with suspected or chronic heart failure.
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Affiliation(s)
- Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Benjamin G Feakins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Christopher P Price
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Annette Plüddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
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32
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van Doorn S, Geersing GJ, Kievit RF, van Mourik Y, Bertens LC, van Riet EES, Boonman-de Winter LJ, Moons KGM, Hoes AW, Rutten FH. Opportunistic screening for heart failure with natriuretic peptides in patients with atrial fibrillation: a meta-analysis of individual participant data of four screening studies. Heart 2018; 104:1236-1237. [DOI: 10.1136/heartjnl-2017-312781] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/18/2018] [Accepted: 02/22/2018] [Indexed: 02/06/2023] Open
Abstract
ObjectiveHeart failure (HF) often coexists in atrial fibrillation (AF) but is frequently unrecognised due to overlapping symptomatology. Furthermore, AF can cause elevated natriuretic peptide levels, impairing its diagnostic value for HF detection. We aimed to assess the prevalence of previously unknown HF in community-dwelling patients with AF, and to determine the diagnostic value of the amino-terminal pro B-type natriuretic peptide (NTproBNP) for HF screening in patients with AF.MethodsIndividual participant data from four HF-screening studies in older community-dwelling persons were combined. Presence or absence of HF was in each study established by an expert panel following the criteria of the European Society of Cardiology. We performed a two-stage patient-level meta-analysis to calculate traditional diagnostic indices.ResultsOf the 1941 individuals included in the four studies, 196 (10.1%) had AF at baseline. HF was uncovered in 83 (43%) of these 196 patients with AF, versus 381 (19.7%) in those without AF at baseline. Median NTproBNP levels of patients with AF with and without HF were 744 pg/mL and 211 pg/mL, respectively. At the cut-point of 125 pg/mL, sensitivity was 93%, specificity 35%, and positive and negative predictive values 51% and 86%, respectively. Only 23% of all patients with AF had an NTproBNP level below the 125 pg/mL cut-point, with still a 13% prevalence of HF in this group.ConclusionsWith a prevalence of nearly 50%, unrecognised HF is common among community-dwelling patients with AF. Given the high prior change, natriuretic peptides are diagnostically not helpful, and straightforward echocardiography seems to be the preferred strategy for HF screening in patients with AF.
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33
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Monahan M, Barton P, Taylor CJ, Roalfe AK, Hobbs FDR, Cowie M, Davis R, Deeks J, Mant J, McCahon D, McDonagh T, Sutton G, Tait L. MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care. Int J Cardiol 2017; 241:255-261. [PMID: 28366472 PMCID: PMC5483229 DOI: 10.1016/j.ijcard.2017.02.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Detection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital. DESIGN A decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. METHODS Data from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective. RESULTS The current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a "do nothing" strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses. CONCLUSIONS This represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.
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Affiliation(s)
- Mark Monahan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Pelham Barton
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom
| | - Andrea K Roalfe
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom.
| | - Martin Cowie
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals, Lyndon, West Bromwich, West Midlands B71 4HJ, United Kingdom
| | - Jon Deeks
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Jonathan Mant
- Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge CB1 8RN, United Kingdom
| | - Deborah McCahon
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - George Sutton
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Lynda Tait
- School of Health Sciences, University of Nottingham, B Floor, South Block Link, Queen's Medical Centre, Nottingham NG7 2HA, United Kingdom
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