Dorset Improving Diagnosis of

Heart Failure

Implementation of BNP Measuring in

General Practice

Ist Project Steering Group 13th Sept 2011

Introduction to the BNP Project Introduction to the BNP Project

Dr Christopher Boos Dr Christopher Boos

Consultant CardiologistConsultant Cardiologist

Why Change the Current HF Diagnostic Pathway

HF huge clinical burden – length of stay, admission diagnosis, yet sig proportion not

getting access to specialist input

Prognosis is improving but several aspects of care need to be improved

HCC audit in 2007 reported that the delivery of HF diagnostic services is poor or only

average in 50% of the UK

Health Technology Assessment (HTA) in England - measuring NPs is the single most

useful test to add to the diagnostic process in primary care - Mant J et al 2009

– ‘rule-out’ test in patients with suitable clinical presentation and suspected heart

failure

NICE HF Guidelines 2003 <40% uptake Nationally by 2010

Suggested ESC Diagnostic

Algorithm 2009

This related to untreated patients.

NICE Update 2010

ESC HF Guidelines 2009

Heart failure is a clinical syndrome in which patients have the

following features:

† Symptoms typical of heart failure

(breathlessness at rest or on exercise, fatigue, tiredness, ankle

swelling)

and

† Signs typical of heart failure

(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised

jugular venous pressure, peripheral oedema, hepatomegaly)

and

† Objective evidence of a structural or functional

abnormality of the heart at rest

(cardiomegaly, third heart sound, cardiac murmurs, abnormality on

the echocardiogram, raised natriuretic peptide concentration

Why Change the Current HF Diagnostic Pathway

Discovery interviews (Dec 2010) – integrated care pathway for HF and

improve diagnosis – adopt BNP use into the diagnostic pathway

Recent process mapping of HF patient pathways - huge variation in service

provision and time to HF diagnosis across Dorset. GP ? HF patient might be

referred for

– blood tests then wait results then refer

– One stop echo, breathlessness clinic

– Cardiology Outpatients (Cardiologist may do echo upstream or

downstream)

Why Change the Current HF Diagnostic Pathway

BNP only in RBCH breathless clinic

Previously DCH - useful but stopped (funding, economies of scale)

Huge variation in Echo waits across Dorset

– median of 5 -7 weeks wait for echo

Difficulty in HF diagnosis (HFNEF/HFPEF)

Under diagnosis

Echo Pathway Audit Data – need for improved efficiency

Audit Sept 2011Audited last 66 one stop echo clinic referrals to AAM

40 with ? Heart failure

52.5% male, mean age 72.2 years

LV systolic dysfunction (EF<55%)

– 3 / 40 (7.5%)

HFNEF

– 3 / 40 (7.5%) – one with HCM and sig diastolic dysfunction

Any HF

– 6/40 (15%) had diagnosis compatible with HF

Other tests

FBC Renal LFTS TFTS Glucose CXR

35/39 35/39 34/39 20/39 32/39 25/39

Advantages of BNP

V Good rule out test

Raised level does not diagnose HF

Absolute levels carry prognostic importance

– Very high levels carry a poor prognosis

HFNEF vs HF reduced EF

– the level does not differentiate but can be helpful

Disadvantages of BNPCertain conditions can Reduce BNP

– Obesity

– Drugs - diuretics, ACE inhibitors, beta-blockers, ARBs and aldosterone antagonists

Certain Conditions increase BNP

– LVH

– Ischaemia

– Right ventricular overload and hypoxaemia (including PE)

– GFR < 60 ml/minute

– Sepsis

– COPD, Diabetes and liver cirrhosis

– Increasing age particularly > 70

Proposed Clinical Pathway

Discussion and Action Planning

Proposed Diagnostic Pathway

Routine bloods, including BNP (ECG +/- CXR)

Action Planning Form Dorset Specific HF pathway - BNP central to this

– BNP in Primary care only, secondary care ambition

– Education ++ Gps, secondary care

– Identify and agree central laboratory / Assay (NT-proBNP)

Diagnostic Cut offs?

– <70 100pg/mL and >70 300pg/mL

– Sample processing and information passage etc

– 24 PARADIGM pts mean 539 pg/mL; median 289 pg/mL 4/24 <100 (16%)

Secondary care trusts planning for delivery of time lines

– 2 week and 6 week time points

– Specialist assessment