Transcript Slide 1

NTproBNP
for the Exclusion of
Heart Failure
Richard Blakey
BNP and NTproBNP
PROTEASE
Action of BNP
Release of CNP
From vascular
endothelium
Release of BNP
From ventricles
Release of ANP
from atria
Supression of
Renin-angiotensin
and endothelin
Decreased peripheral
vascular resistance
(decreased BP)
Increased
Natriuresis
NTproBNP predictor of mortality
1.00
Cumulative Survival
0.95
NT pro BNP
<5180
0.90
0.85
NTproBNP
>5180
0.80
0.75
0.70
0
10 20 30 40 50 60 70 80
Days from presentation
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Evidence
Reference:
(1) Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N
Eng J Med 2002; 347:161-7.
(2) Rev Cardiovasc Med 2001;2 Suppl 2:S13-8
(3) NICE (August 2010). chronic heart failure
(4) Mueller T et al. Diagnostic accuracy of B type natiuretic peptide and amino terminal proBNP in the emergency
diagnosis of heart failure. Heart 2005; 91: 606-12
(5) Moe GW et al. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with
suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF
study.Circulation. 2007 Jun 19;115(24):3103-10.
(6) Marz W et al. N-terminal pro-B-type natriuretic peptide predicts total and cardiovascular mortality in individuals
with or without stable coronary artery disease: the Ludwigshafen Risk and Cardiovascular Health Study.Clin Chem.
2007 Jun;53(6):1075-83.
(7) Doust JA et al. How well des B-type natriuretic peptide predict death and cardiac events in patients with heart
failure: systematic review. BMJ 2005;330:625
(8) Kragelund C et al. N-terminalpro-B-type natriuretic peptide and long-term mortality in stable coronary heart
disease. N Eng J Med 2005;352:666-75
(9) Steg PG et al. B-type natriuretic peptide and echocardiographic determination of ejection fraction in the
diagnosis of congestive heart failure in patients with acute dyspnea. Chest 2005;128:21-9.
(10) Knudsen CW et al. Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide
concentration in dyspneic patients: an analysis from the Breathing Not Properly Multinational Study. J Am Coll
Cardiol 2005;46:838-44.
(11) Commentary. Evidence Based Medicine 2006; 11:117.
(12) British Heart Foundation (November 2008). The roel of B-type natriuretic peptide (BNP) in the management of
heart failure.
(13) Daniels LB et al. Minimally elevated cardiac troponin T and elevated N-terminal pro-B-type natriuretic peptide
predict mortality in older adults: results from the Rancho Bernardo StudyJ Am Coll Cardiol. 2008 Aug 5;52(6):450-9.
Relevance to Primary Care
• Low levels of NP make heart failure unlikely
• Very high levels of NP are associated with
poor prognosis
• Heart Failure is not the only cause of raised NP
• Though affected by multiple factors – these
are unlikely to be of significance if the correct
cut off level is used.
Factors affecting NP levels
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Sex
Age
ACE I
BB
Renal Function
BMI
Suspected Heart Failure
• If patient has (new / changing) symptoms
suggestive of heart failure – SOB / peripheral
oedema
– Code as Suspected HF (1J60)
– If history of MI do not request NTproBNP but
refer urgently for echo and specialist assessment
– If no h/o MI - request NT pro BNP
Requesting NTproBNP
• Minimum 3ml
• Plain (Ochre) or Li Heparin (Green)
Cut-off Levels
• Heart failure is unlikely if the NTproBNP
level is...
• Men under 70y
• Women under 70y
• All 70y or over
<100pg/ml
<150pg/ml
<300pg/ml
• If so, consider an alternative diagnosis
• However if still think heart failure – ask
for specialist advice
Why not use NICE cut off level?
• NICE cut off level for NTproBNP is 400pg/ml
• This is based on European data for untreated
patients.
• Most patients at high risk and suspected of
heart failure
– MI / DM / hypertension / renal disease -
will be on treatment at time of referral
Raised NTproBNP
• If NTproBNP is above the cut off levels
but below 2000pg/ml – refer routinely
for echocardiography and specialist
opinion
• If > 2000pg/ml – refer urgently for
echocardiography and specialist opinion
What does urgent mean?
• The expectation of NICE is that those who
require urgent assessment
– h/o MI
– NTproBNP >2000pg/ml
• Should be scanned and assessed within
2 weeks of referral
What is a ‘specialist’
• “A physician with a special interest in heart
failure, who will usually be a cardiologist”
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Cardiologists
Care of elderly
General physicians
GPwSIs
With a special
interest in heart
failure
Why do they need a specialist
opinion?
• LVSD
– Consideration for revascularisation
– Consideration for device therapy
– Optimising drug therapy
• HFPEF
– Risks of treatment
– Complexity of treatment
• Cardiomyopathy/valves / arrhythmias / extra-cardiac
Pathway for Suspected
Heart Failure
*>100pg/ml men <70y,
>150pg/ml women <70y,
>300pg/ml all >70y
**> 2000pg/ml
Management
of
Heart
Failure
Heart failure - Interventions
NURSES
Time to first
event in
usual care
vs nurse
Intervention
groups
• Fewer people died or were re-admitted,
• Fewer days spent in hospital.
•Blue L et al BMJ 2001;323:715-718
16/07/2015
Dr Ivan Benett GPwSI Cardiology
Enhancing Quality Programme
• Heart Failure - Community & Primary Care
• 4 indicators of quality
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Diagnosis – BNP/echo/CXR/baseline bloods
Treatment LVSD – optimised ACE & BB
All HF patients – personalised care plans
End Stage HF – end of life plan
Enhancing Quality Programme
•Volunteers required
– Data on baseline drug doses for LVSD
– 1st wave practices for pilot of
community HF
Any Questions?