Brain-type Natriuretic Peptide (BNP) - An Information Resource for Cardiac Networks.

Brain-type Natriuretic Peptide (BNP) - An Information Resource for Cardiac Networks.

• 1.
  NHS NHS Improvement Heart Improvement Programme Brain-type Natriuretic Peptide (BNP) An Information Resource for Cardiac Networks Sarah Armstrong-Klein, NHS Heart Improvement Programme NHS Improvement
• 2.
  This paper setsout a brief overview of information available around Brain-type Natriuretic Peptide (BNP) testing as a ‘rule-out’ measure for echocardiogram when suspecting a diagnosis of heart failure. It aims to draw together in one document: • the strands of evidence around BNP • to give a snapshot of cardiac networks and trusts where activity has been documented • to provide links to the relevant key documents • to provide links to research evidence. It is anticipated that the links will act as a resource in aiding those networks and trusts who wish to seek more detail in exploring the use of BNP in local practice. Brain-type Natriuretic Peptide (BNP)
• 3.
  www.heart.nhs.uk 2 Contents Foreword: Dr Mark Dancy 4 Section 1: Background 5 • Definition of heart failure • The scale of the problem in economic terms • The problem for healthcare services • Current advice on best practice Section 2: BNP 7 • What is BNP and NTproBNP? • The rationale for performing BNP as a first-line test for heart failure • Clinical issues • Algorithm for diagnosing heart failure NICE Clinical Guideline 2003 Section 3: BNP in Practice 8 • Setting up a BNP service - points to consider Section 4: BNP Theory into Practice 9 • Cardiac networks & trusts with business cases/proposals/pilots involving BNP including some economics and cost analysis work. Section 5: Links to Key Documents 12 Conclusion 13 References 14 Brain-type Natriuretic Peptide (BNP)
• 4.
  www.heart.nhs.uk 4 Foreword The 2003 NICE guidelines for With the impending 18 week heart failure gave BNP a clear wait target still challenging role in the investigation of many organisations, it is a breathless patients, good time for those who are emphasising that patients with not using BNP to reconsider a normal ECG and BNP are the impact it could have on very unlikely to have heart the thorny issue of waiting failure. Yet to date the uptake times for echocardiography of BNP has been limited. The which in many hospitals is still reasons for such limited the most persistent barrier to uptake include a reluctance on rapid patient throughput. the part of clinicians to rely on such a test and a concern by managers that its unfettered Dr Mark Dancy use could cause a rise in costs Consultant Cardiologist rather than a saving National Clinical Chair, consequent on a reduction in NHS Heart Improvement the use of echocardiography. Programme This paper revisits the issue of BNP used to rule out heart failure. It draws on the experience of those networks and organisations that have implemented BNP testing, providing examples of service models, audits and business cases. Brain-type Natriuretic Peptide (BNP)
• 5.
  www.heart.nhs.uk 5 Testing for heart failure: can using BNP as a first-line diagnostic test reduce the demand for echocardiography services? Section 1: Background Definition of Heart Failure initial hospital stay. In the next 25 years, hospital Heart failure (HF) is a complex syndrome that can result admissions due to heart failure are projected to rise by from any structural or functional cardiac disorder that 50%. The estimated total cost of heart failure to the impairs the ability of the heart to function as a pump to NHS is £716 million – 1.8% of the total budget. support a physiological circulation (NICE: Full Guideline p3, 2003). The syndrome of heart failure is characterised The problem for healthcare services by symptoms such as breathlessness and fatigue, and Echocardiogram is generally recognised as the gold signs such as fluid retention. Diagnosing heart failure is standard test for diagnosing HF. An echo test can not straightforward, however echocardiogram is widely quantify the degree of dysfunction within the acknowledged as the ‘Gold Standard’ test for myocardium and furthermore provide information on confirmation of the disease. cardiac structure that may explain the underlying cause of failure. However there are a number of issues around The scale of the problem in economic terms this diagnostic test that need to be taken into account: Heart failure is one of the most common conditions of industrialised society. Today in the UK around 900,000 • Many services in their current format cannot cope people have heart failure with a further similar number with the demand for echo tests who have yet to develop symptoms (Peterson et al, • The demand for echo tests will rise with the British Heart Foundation 2002, cited in NICE Full increasing ageing population Guideline, 2003). • There is an identified national shortage of trained Cardiac Physiologists who can perform echo tests The most common cause of heart failure in the UK is • Waiting for an echo test can delay diagnosis and coronary heart disease – with many patients having treatment and have a negative impact on morbidity suffered a myocardial infarction in the past. Heart failure and mortality for those patients with heart failure has a poor prognosis: just under 40% of patients • Waiting for an echo test can also delay a patient diagnosed with heart failure die within a year, getting onto the right care pathway where an echo depending on initial severity, although thereafter the test proves negative to heart failure mortality is less than 10% per year (Cowie, M, et al • Trusts must reduce non-invasive diagnostic waiting 2000, cited in NICE: Full Guideline p3, 2003). This times to a recommended maximum of 2 weeks by suggests that a prompt diagnosis and treatment would December 2008. be beneficial in reducing morbidity and mortality in those patients who do have heart disease. Current advice on best practice There is no single diagnostic test for heart failure, The cost of GP consultations is estimated at £45 million and diagnosis relies on clinical judgement based on per year, with an additional £35 million for GP referrals a combination of history, physical examination and to out-patient clinics. Community-based drug therapy appropriate investigations (NICE: Full Guideline costs the NHS around £129 million per year (Stewart & p3, 2003). Horowitz (2002) cited in NICE: Full Guideline p3, 2003). Heart failure accounts for a total of 1 million bed days – 2% of all NHS in-patient bed-days – and 5% of all emergency medical admissions to hospital. Readmission rates can be as high as 50% in the six months following Brain-type Natriuretic Peptide (BNP)
• 6.
  www.heart.nhs.uk 6 Whilst echocardiogram is considered Algorithm summarising recommendations for the to be the gold standard test for diagnosis of heart failure confirming a diagnosis of heart disease, there are tests that can be performed as a precursor to echo. These tests, if negative, can be considered (in the absence of any other clinical signs or symptoms) to exclude heart failure as a causative factor and therefore ‘rule out’ the need for an echo test. NICE: Full guideline (2003) recommends that patients in whom heart failure is suspected should have a 12-lead ECG and/or a natriuretic peptide (BNP or NTproBNP) blood test, and if either of these is abnormal, then to proceed to echocardiography, which will help consolidate the diagnosis and provide information on the underlying functional abnormality of the heart (J. Mant, 2007). See Algorithm (left) from NICE Clinical Guideline CG5, 2003. Other documents recommending this process include: Scottish Intercollegiate Guidelines Network (SIGN) Guideline 95, Management of Chronic Heart Failure, ISBN 1899893946 Feb 2007 NICE intentions on Heart Failure Guidance: NICE will shortly be publishing a commissioning tool to support implementation of the NICE Guidelines on Heart Failure. Brain-type Natriuretic Peptide (BNP)
• 7.
  www.heart.nhs.uk 7 Section 2: BNP What is BNP and NTproBNP? Clinical issues There are two main types of BNP that are available for Testing for amino-terminal pro-brain natriuretic peptide testing. The first is Brain-type Natriuretic Peptide (BNP) (NTproBNP) provides a useful adjunct to routine which is a hormone secreted in the ventricular assessment for differentiating acute Heart Failure from myocardium during periods of increased ventricular other aetiologies of dyspnoea (Lainchbury et al, 2003: stretch and wall tension (Levin et al, 1998, cited in Heart Maisel et al, 2002; Mueller et al, 2004 cited in Baggish Protection Study Group, 2007). BNP plays an important et al, 2006). However, other factors such as co morbid role in the regulation of blood pressure, blood volume illnesses, age, renal failure, and body mass may affect and sodium balance (Levin et al, op cit). Once secreted, NTproBNP levels in ways that can obscure the diagnosis the BNP precursor is split into the biologically active of Heart Failure, particularly when this marker is used in peptide and the second type of BNP – the more isolation (Raymond et al. 2003, cited in Baggish et al, stable amino-terminal prohormone fragment (N-BNP 2006). Therefore it is essential that BNP is used as a tool or NTproBNP). to aid diagnosis in addition to the patient’s history and clinical symptoms. Any doubt about the BNP result and It is already known that N-terminal pro-B-type natriuretic the patients diagnosis can still result in a patient being peptide (N-BNP) levels provide sensitive (and reasonably referred for echo testing if indicated. specific) tests for the diagnosis of heart failure and left ventricular dysfunction (Cowie et al, 1997; Talwar et al, 1999; Maisel et al, 2002; Moe 2005, cited in Heart Protection Study Group, 2007). Furthermore the BNP results provide good indicators of disease severity and prognosis in patients with heart failure (Jenberg et al, 2004, cited in Heart Protection Study Group, 2007). The rationale for performing BNP as a first-line test for heart failure: Performing a BNP test or an ECG as an initial test for patients with suspected heart failure can be recommended as these tests have high sensitivity for detecting heart failure. In other words heart failure is unlikely if these test results are considered to be normal. Patients who are found to have a normal BNP and ECG can proceed on to other disease care pathways so that their diagnoses can be reached without further unnecessary delay. Reducing the demand on the limited echo resource will be beneficial for earlier testing in those patients found to have positive BNP tests, and or symptoms requiring echo for confirmation of diagnosis. Brain-type Natriuretic Peptide (BNP)
• 8.
  www.heart.nhs.uk 8 Section 3: BNP in Practice Setting up a BNP service - points to consider Points to consider are: BNP testing can be done in a number of ways. The • the length of time for the results to be returned - following points should be considered when deciding on based on the examples in practice, this can vary from the set-up of such a service. less than 24 hours up to one week • the courier service to transport the samples to the BNP involves taking blood from a patient and testing it, provider which can be done in the following ways: • less convenient for patients • the importance of setting up a robust Service Level Primary Care Agreement (SLA) • In a general practice surgery: this will incur initial expenses including the purchase or hire of the Further considerations: analyser. There are also quality control issues to It should be noted that in some parts of the UK, the consider with regard to equipment, staff training and introduction of BNP has led to increased numbers of the purchase of limited shelf-life reagent strips. The echo tests being performed without an increase in true cost of each BNP test is likely to be higher in areas positives. This means that if the test is used where relatively small numbers of tests are required indiscriminately it may occur that the false positive and will reduce with volume. The benefits of this results outnumber the true positives. A local agreement service are the rapid results, convenience for patients, may be helpful in deciding who should order the test or early diagnosis and commencement of treatment. when access to ordering a BNP test is appropriate. Work carried out in Darlington found this to be an issue. • Centralised in one agreed location within a local area, for example a GP practice serving a number of For further information contact Dr Ahmet Fuat. surgeries: results can be made available within a few days or even on the same day, depending on the A further point to consider when calculating costs is that negotiated agreement. Benefits include: convenience there will be a percentage of positive BNP results where for the patient, cheaper than doing the test in an echocardiogram is also indicated. The cost of the individual surgeries, results may still be available within BNP test will need to be added to the cost of an an acceptable time span (depending on the echocardiogram. Many of the studies within this paper agreement). This type of service may involve the found that there were savings however, and in addition transportation of samples from or to the testing that there was an increase in the number of appropriate centre, therefore consideration of how this might be referrals once those testing negative had been set on done and any cost implication is important. alternative pathways of care. Secondary/Tertiary Care • At the local NHS Trust in a laboratory: this is often a more cost-effective option - most studies included in this paper found that there was a correlation between the number of tests and the cost per test. The more tests being done, the greater the cost-benefit. Quality control, equipment updates and staff training issues are routinely addressed within the remit of the local service provider. Brain-type Natriuretic Peptide (BNP)
• 9.
  www.heart.nhs.uk 9 Section 4: BNP Theory into Practice This section includes examples of activity around the Greater Manchester & Cheshire Cardiac Network country where BNP testing has been used as a means of ‘rule-out’ for echocardiography. • Stockport PCT – NTproBNP audit to demonstrate that the results are safe & effective in ruling out heart Hyperlinks are included to give you direct access to failure documents where detailed information and contacts can • Introducing BNP - poster be found. Some of the documents include economic • Audit of NTpro-BNP - poster information and cost analysis for the projects. • BNP GP Questionnaire Report • BNP Costing Report Bedfordshire & Hertfordshire Cardiac Network • BNP Letter to GPs • BNP Labels • BNP in Primary Care, Final Project Report 2006-7 - • BNP Factsheet includes cost analysis • Work in progress: ‘BNP Use in Secondary Care – For further information contact Jayne Scott, Clinical assess effect BNP screening of breathless patients has Scientist, East Cheshire NHS Trust; Julia Curtis, on their clinical pathway, length of stay, and the use of Commissioning Manager, Central and Eastern Cheshire other resources in primary care.’ PCT; or Janet Ratcliffe, Network Director. For further information contact Candy Jeffries, Service Lancashire & South Cumbria Cardiac Network Development Manager. • Audit of the introduction of the B-type natriuretic Cheshire & Merseyside Cardiac Network peptide (BNP) rule out test for HF which became available to GP’s across the Flyde Coast health • Cheshire & Merseyside Cardiac Network & CHD economy from 01 January 2006. Audit from Jan 06- Collaborative (2004) - Local trials on the use of BNP July 07 concluded that it was not appropriate to use BNP as a • B-type Natriuretic Peptide (BNP) for CHF audit – sole means for exclusion of HF across their network as November 2007 report referrals for echo were not reduced. Therefore they concluded there would be additional costs. For further information contact Sally Chisholm, Network Director; or Joanne Twissell, Admin Manager. For further information contact Margaret Leid, Network Director. Leicestershire Northampton and Rutland Cardiac Network Dorset & Somerset Cardiac Network • Kettering – Breathlessness pathway flow • Dorchester NTproBNP service pilot currently underway • Breathlessness screening pathway. October 2006 - March 2008. Audit report due at year end which will inform the future commissioning For further information contact Ben Knight, Deputy pathways Network Director; or Robert Wilson, Network Director. For further information and a copy of the final audit report contact Sally Bowker, Long Term Conditions Manager, Dorset PCT. Brain-type Natriuretic Peptide (BNP)
• 10.
  www.heart.nhs.uk 10 North of England Cardiovascular Network Fuat A. Improving diagnosis and management of heart failure across the primary-secondary care interface – a • North Tees Teaching PCT - Developing services for review of the evidence base and the Darlington service patients with heart failure. Commissioning framework delivery model. Clinical Focus Primary Care 2005; and outline business plan, 2004 1(2):43-48 For further information contact Tony Roberts, Clinical For further information contact Dr Ahmet Fuat. Effectiveness Specialist Advisor • North Tees Teaching PCT - A Service level agreement North West London Cardiac Network (SLA) for 6 months of provision of BNP testing 2004-5 • Ealing PCT: Ealing & Acton Commissioning group For further information contact John KS Frater, (EACG) - General practice based BNP testing- brief Consultant Chemical Pathologist, North Tees and evaluation of service in the first six months of Hartlepool NHS Foundation Trust provision. For further information contact Nalini Iyanger, Lead “Are we ready for widespread natriuretic Commissioning Manager. peptide use in clinical practice?” An editorial published in Circulation – Dr Ahmet Fuat. Peninsula Cardiac Managed Clinical Network (PCMCN) Fuat A, Murphy JJ, Hungin APS, Curry J, Mehrzad A, Hetherington A, Johnston JI, Smellie WSA, Duffy V, • BNP report – January 2008 Cawley P. The diagnostic accuracy and utility of • BNP pathway natriuretic peptides in a community population of • Plymouth Teaching Primary Care Trust - BNP pathway patients with suspected heart failure, using near patient information for GP’s using NTproBNP and laboratory assay methods. • NTproBNP data results April 07-Dec 08 (an excel British Journal of General Practice 2006; 56: 327-333 spreadsheet) Further papers published by Dr Fuat and others on For further information contact Chrissie Bennett, Service BNP can be found under the following references: Improvement Manager; Rosie Heath, Plymouth PCT Fuat A, Murhpy JJ, Brennan G, Mehrzad AA, Johnston JI, CHD Lead; or Elaine Fitzsimmons, Assistant Director of Smellie WSA. Suspected heart failure in primary care – Commissioning. the utility of N-terminal proB-Type natriuretic peptide (NTproBNP) as a pre-screening test for secondary care • Plymouth Teaching Primary Care Trust – Plymouth referral: A real life study. Heart 2005; 91 (Supplement I) heart failure service – an update A22 and European Heart Failure Journal 2005; 4 For further information contact Rosie Heath, Plymouth (Supplement 1): 128 PCT CHD Lead Fuat A, Murphy JJ, Brennan G, Mehrzad AA, Johnston JI, Smellie WSA. Screening for suspected heart failure with N-terminal proB-Type natriuretic peptide (NTproBNP) in primary care: Money Well Spent? Heart 2005; 91 (Supplement I) A56 and European Heart Failure Journal 2005; 4 (Supplement 1): 128 Brain-type Natriuretic Peptide (BNP)
• 11.
  www.heart.nhs.uk 11 South Central Vascular Network Trent Cardiac Network • East Berkshire – Pilot study for NTproBNP testing 2005 • Southern Derbyshire Acute Hospitals NHS Trust - BNP results from the first 6 months – March 2005 For further information on the pilot contact Study Lead • Derbyshire Royal Infirmary, Derby & Erewash PCT: The Dr Ian Walker, Consultant Medical Biochemistry impact of introducing an NTproBNP service into • BNP pilot summary Jan 2006 clinical practice • BNP audit evaluation Jan 2006 For further information contact Jenny Charles-Jones, • Invest to save BNP Cardiac Services Development Manager; For further information contact Michelle Stringer, or Martin Cassidy, Long Term Conditions Network Director. Programme. South East London Cardiac Network • BNP testing summary • Bromley BNP audit report • Greenwich audit of NTproBNP • Lambeth audit and evaluation of BNP • Lewisham BNP audit • Southwark BNP final evaluation • Bexley BNP audit report For further information contact Ellen Mcgowan, Service Improvement Manager; or Sara Nelson, Associate Network Director. South West London Cardiac Network • NTproBNP testing in primary care – consensus document • NTproBNP improvement story For further information contact Gillian Wilson, Cardiac Project Manager. Brain-type Natriuretic Peptide (BNP)
• 12.
  www.heart.nhs.uk 12 Section 5: Links to Key Documents Information in this section from Mant, J, Expert Links to economic evaluations: Summary: Diagnosis, Heart Failure National Knowledge Week, National Library for Health 2007, access from: NHS EED (2007) The cost effectiveness of B-type www.library.nhs.uk/cardiovascular click ‘evidence natriuretic peptide measurement in the primary care updates’, then ‘heart failure national knowledge week’ setting: a UK perspective NHS EED (2006) Community screening for left General links: ventricular systolic dysfunction using plasma and urinary NICE (2003) Chronic heart failure / Management of natriuretic peptides chronic heart failure in adults in primary and secondary care Randomised controlled trials NHS Clinical Knowledge Summaries (2006) Heart Failure Link to Randomised Controlled Trials published since July 2002 listed on PubMed on the topic of European Society of Cardiology (2005) Guidelines for Heart Failure and Diagnosis the diagnosis and treatment of chronic heart failure Other Links: European Society of Cardiology (2005) Guidelines on the diagnosis and treatment of acute heart failure Heart Improvement Programme – national priority projects British Heart Foundation (Accessed August 2007) Heart • 18 Weeks - Focus on Cardiac Diagnostics Failure Statistics • Making Best Use of Inpatient Beds • Atrial Fibrillation in Primary Care Department of Health (2003) Developing Services for • 18 Weeks Whole Pathway Project Heart Failure Heart Protection study Healthcare Commission (2007) Pushing the Boundaries: Improving services for patients with heart failure Royal College of Physicians: Managing Chronic Heart Healthcare Commission Service Review July 2007 Failure: Learning from Best Practice, p 36 www.healthcarecommission.org Links to guidance on diagnosis: European Society of Cardiology (2007) How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction NHS Quality Improvement Scotland (2005) The use of B-type natriuretic peptides (BNP and NT-proBNP) in the investigation of patients with suspected heart failure Brain-type Natriuretic Peptide (BNP)
• 13.
  www.heart.nhs.uk 13 Conclusion This overview document has brought together some of the theoretical evidence and practical application of using the BNP test as a precursor to echocardiography in England. Through the examples illustrated and the links supplied, this resource will facilitate further investigation and communication for those interested in pursuing more detailed information directly. It is hoped that this paper will inform decisions about adopting BNP as a ‘rule-out’ for echocardiogram based on real examples in current practice. Brain-type Natriuretic Peptide (BNP)
• 14.
  www.heart.nhs.uk 14 References Baggish AL, Siebert U, Lainchbury JG, Cameron R et al. (2006) A validated clinical and biochemical score for the diagnosis of acute heart failure: The ProBNP Investigation of Dyspnoea in the Emergency Department (PRIDE) Acute Heart Failure Score. American Heart Journal Vol. 151: 1:48-54 Cowie MR, Struthers AD, Wood DA et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet 1997; 350:1349-53 Cowie MR, Wood DA, Coates AJ, Thompson SG, Suresh V, Poole-Wilson PA, et al. Survival of patients with a new diagnosis of heart failure: a population bases study. Heart 2000; 83:505-10 Heart Protection Study Collaborative Group (2007) N-Terminal Pro-B-Type Natriuretic Peptide, Vascular Disease Risk, and Cholesterol Reduction Among 20,536 Patients in the MRC/BHF Heart Protection Study. Journal of the American College of Cardiology. Vol 49, No 3:311-9 Jernberg T, James S, Lindahl B et al. (2004) Natriuretic peptides in unstable coronary artery disease. Eur Heart J 2004; 25:1486-93 Lainchbury JG, Cambell E, Frampton CM, et al. Brain natriuretic peptide and N-terminal brain natriuretic peptide in the diagnosis of heart failure in patients with acute shortness of breath. J Am Coll Cardiol 2003: 42:728-35 Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med 1998; 339:321-8 Maisel AS, Krishnaswamy P, Nowak RM, et al. (2002) Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med: 347:161-7 Mant, J. (2007) Expert Summary: Diagnosis. Heart Failure National Knowledge Week, Cardiovascular Diseases Specialist Library, NHS National Library for Health at 07 www.library.nhs.uk/cardiovascular/Page.aspx?prv=y&pagename=HFKNWDIAG Accessed on 11/02/2008 Moe GW. BNP in the diagnosis and risk stratification of heart failure. Heart Fail Monit 2005; 4:116-22 Mueller C, Scholer A, Laule-Kilian K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnoea. N Engl J Med 2004; 350:647-54 National Institute for Health and Clinical Excellence (2003) Diagnosis and Management in Primary and Secondary Care: Full Guideline 5. London: National Institute for Health and Clinical Excellence http://www.nice.org.uk/nicemedia/pdf/Full_HF_Guideline.pdf National Collaborating Centre for Chronic Conditions (2003) National Institute for Clinical Excellence: Management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5 http://nice.org.uk/nicemedia/pdf/CG5NICEguideline.pdf Brain-type Natriuretic Peptide (BNP)
• 15.
  www.heart.nhs.uk 15 Peterson S, Raynor M, Wolstenholme J. (2002) Coronary Heart Disease Statistics: Heart Failure Supplement: London. British Heart Foundation Raymond I, Groenning BA, Hildebrandt PR, et al. The influence of age, sex and other variables on the plasma level of N-terminal pro-brain natriuretic peptide in a large sample of the general population. Heart 2003: 89:745-51 Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation. 2002;105:2861–6. Talwar S, Squire IB, Davies JE, Barnett DB, Ng LL. Plasma N-terminal pro-brain natriuretic peptide and the ECG in the assessment of left-ventricular systolic dysfunction in a high risk population. Eur Heart J 1999; 20:1736-44 Acknowledgments: Julie Harries Linda Binder Dr Mark Dancy Carolyn Heyes Sheelagh Machin Rhiannon Pepper Thanks to all the people who have kindly shared their work in this document. Brain-type Natriuretic Peptide (BNP)
• 16.
  NHS Improvement 3rd Floor NHS St John’s House East Street NHS Improvement Leicester LE1 6NB Telephone: 0116 222 5184 Fax: 0116 222 5101 www.improvement.nhs.uk