Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations

doi:10.1136/bmj.324.7352.1498

BMJ 2002;324:1498 ( 22 June )

Primary care

Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations

F D R Hobbs, head of department, ^a R C Davis, clinical research fellow, ^a A K Roalfe, statistician, ^a R Hare, research associate, ^a M K Davies, consultant cardiologist, ^b J E Kenkre, senior research fellow. ^a

^a Department of Primary Care and General Practice, Primary Care Clinical Sciences Building, University of Birmingham, Birmingham B15 2TT, ^b Department of Cardiology, Selly Oak Hospital, Birmingham B29 2PE

Correspondence to: F D R Hobbs f.d.r.hobbs{at}bham.ac.uk

Objective: To investigate the performance of a novelassay for N-terminal pro-brain natriuretic peptide (NT-proBNP)in diagnosing heart failure in various randomly selected generaland high risk communitypopulations.
Design: Community cohort study (substudy of the echocardiographicheart of England screeningstudy).
Setting: Four randomly selected general practices inthe West Midlands ofEngland.
Participants: 591 randomly sampled patients over the ageof 45, stratified for age and socioeconomic status and fallinginto four cohorts (general population, patients with an existingclinical label of heart failure, patients prescribed diuretics,and patients deemed at high risk of heartfailure).
Main outcome measure: Sensitivity, specificity, positive and negativepredictive values, likelihood ratios, and area under receiveroperating characteristic curve for NT-proBNP assay in the diagnosisof heartfailure.
Results: For NT-proBNP in the diagnosis of heart failurein the general population (population screen), a level of >36pmol/l had a sensitivity of 100%, a specificity of 70%, a positivepredictive value of 7%, a negative predictive value of 100%, andan area under the receiver operating characteristic curve of 0.92(95% confidence interval 0.82 to 1.0). Similar negative predictivevalues were found for patients from the three other populationsscreened.
Conclusions: This NT-proBNP assay seems to have value inthe diagnosis of heart failure in the community. High negativepredictive values indicate that the assay's chief use would beto rule out heart failure in patients with suspected heart failurewith normal concentrations of NT-proBNP. Positive results mayidentify patients who need cardiacimaging.

What is already known on this topic
Many primary care doctors rely on clinical diagnosis of heart failure, although the validity of such diagnosis is poor

Electrocardiography can be used to triage patients for echocardiography, but specialist interpretation may be needed

Assay of brain natriuretic peptide is a potential aid in the diagnosis of heart failure

What this study adds
Assay of N-terminal pro-brain natriuretic peptide (NT-proBNP) seems to be a reliable test for ruling out heart failure

Normal concentrations virtually exclude the diagnosis of heart failure, and very high levels effectively diagnose the condition; intermediate values require confirmation by echocardiography

Assay of NT-proBNP has potential as part of a diagnostic triage in patients presenting with symptoms suggestive of heart failure or in screening populations at high risk

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NT-proBNP assay can effectively rule out heart failure
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