Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004–2018

Abstract

ObjectiveHeart failure (HF) is a malignant condition requiring urgent treatment. Guidelines recommend natriuretic peptide (NP) testing in primary care to prioritise referral for specialist diagnostic assessment. We aimed to assess association of baseline NP with hospitalisation and mortality in people with newly diagnosed HF.MethodsPopulation-based cohort study of 40 007 patients in the Clinical Practice Research Datalink in England with a new HF diagnosis (48% men, mean age 78.5 years). We used linked primary and secondary care data between 1 January 2004 and 31 December 2018 to report one-year hospitalisation and 1-year, 5-year and 10-year mortality by NP level.Results22 085 (55%) participants were hospitalised in the year following diagnosis. Adjusted odds of HF-related hospitalisation in those with a high NP (NT-proBNP >2000 pg/mL) were twofold greater (OR 2.26 95% CI 1.98 to 2.59) than a moderate NP (NT-proBNP 400–2000 pg/mL). All-cause mortality rates in the high NP group were 27%, 62% and 82% at 1, 5 and 10 years, compared with 19%, 50% and 77%, respectively, in the moderate NP group and, in a competing risks model, risk of HF-related death was 50% higher at each timepoint. Median time between NP test and HF diagnosis was 101 days (IQR 19–581).ConclusionsHigh baseline NP is associated with increased HF-related hospitalisation and poor survival. While healthcare systems remain under pressure from the impact of COVID-19, research to test novel strategies to prevent hospitalisation and improve outcomes—such as a mandatory two-week HF diagnosis pathway—is urgently needed.

Long term trends in natriuretic peptide testing for heart failure in UK primary care: a cohort study

“… 36 In alignment with this, recent studies have found poor adherence to NICE recommended timeframes. 13 , 16 , 37 One CPRD study that analysed routes to HF diagnosis with data from 2010 to 2013, found that only 1.2% of patients who had a previous myocardial infarction completed the referral pathway within 2 weeks (as per 2010 NICE guideline) and only 3.9% of patients completed the pathway within 6 weeks. 13 …”

“…There is already evidence to demonstrate that patients with suspected HF have high mortality and hospitalization rates and that timely HF specialist involvement is associated with better outcomes. 16 , 38 However, the pathway to HF diagnosis is complex with patient, clinician, and disease factors determining both the mode of presentation and speed of diagnostic labelling. Our previous qualitative work found patients with a recent HF diagnosis often normalized their symptoms until they were severe enough to have a substantial impact on daily activities 39 and, in some cases, emergency admission from home via ambulance was facilitated by their family.…”

“…4 However, there is evidence that this guidance is not followed in practice and outcomes for people with HF remain poor, particularly if baseline NP level is high. 8 , 13 , 16 The British Heart Foundation recently published a report highlighting the importance of earlier diagnosis of HF in primary care to improve morbidity and mortality. 17 Our main aim was to report trends in NP testing in UK primary care over time, and by individual patient factors, and HF diagnosis rate.…”

Survival rate and predictors of 36-month mortality in patients with heart failure in Sub Saharan Africa: insights from the Douala Heart Failure Registry (Do-HF)

“…Firstly, participants were recruited from specialized cardiology units, impacting the extrapolation of results to the general HF population. Secondly, biological parameters like NT-pro-BNP plasma levels were available only in a subset of patients, which might have precluded an accurate assessment of the predictive role of plasma levels of BNP as described elsewhere ( 36 , 37 ). Our strengths include being one of the first studies that assessed the long-term outcome of HF in SSA patients and with a low rate of loss to follow-up.…”

How can we improve the diagnosis of heart failure?

“…Often NP testing is not considered, due to the common HF symptoms, such as breathlessness and fatigue, being associated with old age, de-conditioning (particularly during the impact of COVID-19) and presence of other respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD). High NP levels at diagnosis (>2000 pg/mL) are associated with a two-fold increase in HF-hospitalisation in the first year and a higher mortality (Taylor et al., 2022). Much like a 2-week wait referral for suspected malignancy, it is imperative that the diagnostic pathway for HF is also followed through.…”