Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4130 (Published 25 August 2010) Cite this as: BMJ 2010;341:c4130
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The last NICE recomendations recommended cut-off point of
400pg/ml of NT pro BNP as rule out test for heart failure (HF) diagnostic.
We recruited 220 consecutive patients referred by their GPs for
echocardiography for suspected heart failure and we measured the NT pro BNP
in all of them. Heart failure was diagnosed by one cardiologist if there
was heart failure symptoms and objective evidence of cardiac dysfunction at
rest. The cardiologist was blind to the Nt pro BNP results.
The diagnosis
of HF was confirmed in 52 patients ( 23,6%). The area under curve ROC was
0.96. For a cut-off point of 300pg/ml the sensitivity (se) was 1, the
specifity (sp) 0.88, the positive and negative predictive values (ppv and
npv) were 0.72 and 1. For a cut-off point of 400pg/ml se was 0.88, sp 0.9,
ppv0.73 and nvp 0.96 In the group with diagnosis of HF , 6 patients (11,53%) had NT pro BNP values < 400 pg/ ml while there were not patient
with diagnosis of HF and NT pro BNP values < 300 pg/ ml.
We think that
the cut-off point of Nt proBNP as rule out test in patients referred for echocardiography
for suspected heart failure should be 300 pg/ml instead of 400.
Competing interests: Roche diagnosis paid 35% of assays
I thank Dr Al-Mohamed and Prof Mant for their response (dated 18th
September) to my comments regarding the use of parameters such as jugular
venous pressure(JVP) and radiographic stigmata for validating the
diagnosis of either acute heart failure or chronic heart failure.
To start
with, the distinction between acute and chronic heart failure is, from the
clinician's point of view, an artificial one because during the course of
heart failure, many patients fluctuate between acute and chronic heart
failure. Accordingly, although the statistical evaluation of the validity
of JVP elevation and chest radiography was made in the context of acute
heart failure(1), the evaluation remains relevant also for chronic heart
failure.
Secondly, any verdict on validity of physical signs(whose
prevalence varies with disease prevalence) might be fundamentally unsound
if based solely on sensitivity and specificity because those parameters
lack the dynamic quality possessed by parameters such as positive
predictive value(PPV) and negative predictive value(NPV), the latter two
statistics being based on a recognition that their magnitude will vary
depending on disease prevalence(2).
With those caveats in mind, it is
reasonable to predict that, where the prevalence of heart failure in
high(be it acute or chronic) the positive predictive value(PPV) of
elevated JVP might be even higher than the statistic I quoted and,
conversely, where heart failure prevalence is low, PPV will be
correspondingly lower. The same is true for the radiographic stigmata that
I cited. Likelihood ratios also add value to interpretation of clinical
stigmata but no such flexibility exists for the interpretation of
sensitivity and specificity. My "rant" about suboptimal technique in
evaluation of JVP is corroborated by the comment that "When performed
properly by experienced physicians, JVP estimation is fairly accurate"(1),
but, unfortunately, evaluation of this parameter has been so thoroughly
devalues(almost to the point of parody) that in countries where the
comment "JVP raised 2cm" has become part of conventional medical
nomenclature, there will soon be no experienced physicians left to
interprete JVP sensibly, hence the comment that "its use in multicentre
studies is not reliable without adequate audit of clinical expertise in
each centre"(1)
Lack of audit of clinical expertise in each centre is the root cause of
the fact that research into management of heart failure with intact left
ventricular fraction(LVEF) has lagged so far behind research into
management of heart failure with reduced LVEF. In the absence of
validation by evaluation of LVEF the diagnosis of so-called diastolic
heart failure depends hugely on clinical expertise(including evaluation of
JVP and evalation of chest x-ray stigmata)and no mechanisms are in place
for auditing clinical expertise in each centre for the purpose of
launching multicentre clinical trials. The same is not true of heart
failure with reduced LVEF(a parameter which, in turn, also risked
devaluation when, in many publications it became the only one deemed to be
synonymous with left ventricular dysfunction), hence the exclusive focus
on this subtype of heart failure in all the major clinical trials
undertaken in the past few decades. It may well be that the
"establishment" in cardiology have been complicit in this devaluation of
clinical stigmata of heart failure, and in equating left ventricular
dysfunction solely with subnormal LVEF, hence the benign neglect of heart
failure with intact LVEF, and this is something that future generations
will not easily forgive.
References
(1) Gheorghiade M., Follath F., Ponikowski P et al
Assessing and grading congestion in acute heart failure: A scientific
statement from the Acute Heart failure Committee of the Heart failure
association of the European society of cardiology and endorsed by the
European Society of Intensive Care Medicine
European Journal of Heart failure 2010;12:423-33
(2)Henderson R
Assessing accuracy and its clinical consequences: a primer for receiver
operating charcteristic curve analysis
Ann Clin Biochem 1993;30:521039
Competing interests: No competing interests
Authors' Reply:
We are very grateful to Satchithananda, Dwivedi, and Hookey for their
comments on the guideline partial update.
1. Uncertainties were the key drivers behind the specific research
recommendations that we urge the readers including Satchithananda,
Dwivedi, and Hookey to seriously consider in the near future. This of
course is different to what Satchithananda, Dwivedi, and Hookey refer to
as uncertainties reflected by the rapid responses. The latter are
frequently related to the readers' unfamiliarity with the full guideline
(1) or with the process of how NICE scopes and develops clinical
guidelines.
2. The guideline stressed the importance of seeking the opinion of a
specialist in heart failure to guide the management of heart failure and
its related problems during admission to hospital. Having a heart failure
unit in a hospital is one possible way of facilitating this.
3. Palliative care had not been omitted. While our summary of the
heart failure guideline in the BMJ (2) did not refer to palliative care,
the recommendations on palliative care from 2003 still stand, and are
reproduced in the 2010 NICE guideline:
1.5.9.1 Issues of sudden death and living with uncertainty are
pertinent to all patients with heart failure. The opportunity to discuss
these issues should be available at all stages of care. [2003]
1.5.9.2 The palliative needs of patients and carers should be
identified, assessed and managed at the earliest opportunity. [2003]
1.5.9.3 Patients with heart failure and their carers should have
access to professionals with palliative care skills within the heart
failure team. [2003]
We have touched upon prognosis when considering the role of
natriuretic peptides in diagnosis and monitoring. We have also discussed
the impact of therapy on the prognosis of patients with chronic heart
failure. However, the topic of prognosis and its markers was not within
the scope of the partial update that we undertook. Satchithananda,
Dwivedi, and Hookey make an important point about the potential value of
clinical prognostic markers, which we feel is an important research topic.
4. Re-referral to the specialist as discussed in the guideline is in
the context of the management of the heart failure. We have discussed the
importance of addressing co-morbidity. However, there are other non-heart
failure reasons why a general practitioner may wish to refer the patient
to a specialist which are not unique to patients with heart failure.
Indeed, patients with syncope, resistance angina or those with
tachyarrhythmia would be expected to be referred to the appropriate
specialist irrespective of whether they have heart failure or not.
5. Obstructive sleep apnoea syndrome is one of many co-morbid
conditions of potential relevance to heart failure. The topic was outside
the scope of this partial update.
Dr A Al-Mohammad and Professor J Mant
References:
1 National Collaborating Centre for Acute and Chronic Conditions.
Chronic heart failure: Management of chronic heart failure in adults in
primary and secondary care. NICE Clinical Guideline 108, August 2010
http://www.nice.org.uk/guidance/CG108
2 Al-Mohammad A, Mant J, Laramee P and Swain S. Diagnosis and
management of adults with chronic heart failure: summary of updated NICE
guidance. BMJ 2010; 341:c4130 doi: 10.1136/bmj.c4130.
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply:
We are grateful to Dr Richardson for raising several excellent questions
and giving us the opportunity to address them:
1. The full guidance is a reference document that provides the
detailed evidence base and reasoning behind the recommendations.
Practitioners are advised to read the NICE version and the Quick Reference
Guide that has the algorithms and the recommendations, and if there is an
interest in a certain point, then one could look at the relevant 'from
evidence to recommendation' section where the reasons and justifications
for making a recommendation are discussed. Those who are interested in
dissecting the evidence and ensuring the right methodology and statistical
analyses were used will need to read the whole document. We hope this
point will make the task of Dr Richardson and his colleagues less onerous.
2. The non-heart failure causes of raised natriuretic peptides are a
reflection of an imperfect test with less than 100% specificity. This is
applicable to almost every test we do. The fact that certain conditions
may raise the natriuretic peptide level does not mean that patients with
these conditions should not have natriuretic peptide measurements. It
simply means that the rise in natriuretic peptide should not be readily
interpreted as heart failure without further investigation. Similarly, the
causes of reduced natriuretic peptides are not contra-indications to use
the test.
3. The role of the echocardiogram is as much to identify the
structural and functional abnormalities of the heart that are leading to
heart failure as it is to make a positive diagnosis of heart failure. The
Guideline Development Group recommended that the referral is for
echocardiography and specialist assessment rather than echocardiography
alone, in part to interpret the echocardiographic findings, in part to
establish the diagnosis. The echocardiogram by itself is insufficient to
make the diagnosis especially if left ventricular systolic dysfunction is
not present (as applies to about half of patients with heart failure). It
is more efficient use of scarce echo and specialist facilities to refer
patients with a higher probability of heart failure (i.e on the basis of a
natriuretic peptide test).
4. The referral to the specialist does not and should not stop the GP
commencing life-saving therapy with ACEI and BB. Should the specialist
diagnose that the patient does not have heart failure, then these
medications can be discontinued. The specialist's involvement is important
to make the diagnosis, assess the need for further investigations, and for
ensuring there are no other cardiac and non cardiac causes for the
complaint (irrespective of whether the patient happens to have mild LVSD).
Dr A Al-Mohammad and Professor J Mant
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply:
We are grateful to Dr Macaulay for responding to our article.
We have every sympathy with Dr. Macaulay's point about availability of
investigations. However, the purpose of the guideline is to make
recommendations on best practice in the light of the available evidence-
base. The availability of the tests is the responsibility of health
commissioning authorities, whose decisions will be informed by NICE
guidelines.
A final point, the health boards in Scotland may consider the guidance
from NICE as a supporting document, but we believe they will rely on the
SIGN guidelines. NICE guidelines are applicable to England, Wales and
Northern Ireland.
Dr A Al-Mohammad and Professor J Mant
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply:
We are grateful for the review of the diagnostic utility of raised jugular
venous pressure and chest X ray offered by Dr Jolobe's rapid response to
our article.
The raised jugular venous pressure is a useful sign of right sided heart
failure. In the context of diagnosis of heart failure, a systematic
review of diagnostic studies found it to be neither sensitive (50%) nor
specific (70%). (1) The raised JVP is not as sensitive as Dr Jolobe
believes when there is no rise in the right sided pressure and no
significant tricuspid valve regurgitation. Similarly, the chest X ray is
only moderately helpful at ruling in the diagnosis of chronic heart
failure (specificity 76%) and cannot exclude the diagnosis (sensitivity
67%).(1) Nevertheless, the chest X ray has an important role in excluding
alternate causes of the symptoms of heart failure. The NICE guidelines
are about the diagnosis of chronic heart failure, not about the diagnosis
of acute heart failure. The test performance that Dr. Jolobe cites on JVP
and chest X ray is from a guideline on acute heart failure.
Finally, we had no say in the choice of the cover of the Journal, although
we disagree with Dr Jolobe's impression, and believe that the editor of
the Journal was successful in the choice made.
Dr A Al-Mohammad and Professor J Mant
1 Mant J, Doust J, Roalfe A, Barton P, Cowie MR, Glasziou P, Mant D,
McManus RJ, Holder R, Deeks J, Fletcher K, Qume M, Sohanpal S, Sanders S,
Hobbs FDR. Systematic review and individual patient data meta-analysis of
diagnosis of heart failure, with modelling of implications of different
diagnostic strategies in primary care. Health Technol Assess 2009;13(32).
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply:
We share with Dr Samuel the passion to involve all aspects of care in the
community and within the hospital environment in the management of
patients with heart failure. Palliative care medicine is included within
the definition of the multi-disciplinary heart failure team.
Palliative care was a topic reviewed in the 2003 heart failure guidelines
and was not one of the topics reviewed as part of the current partial
update. The principles discussed in the chapter on palliative care from
2003 remain valid and applicable, and the recommendations from 2003 are
reproduced in the 2010 guideline (see response to letter from Talbot &
Tapley).(1)
There is considerably more to the management of heart failure than
treating with diuretics, and if the guideline is followed, then people
with heart failure will have the opportunity to live longer with fewer
admissions and better quality of life.
Dr A Al-Mohammad and Professor J Mant.
1 National Collaborating Centre for Acute and Chronic Conditions.
Chronic heart failure: Management of chronic heart failure in adults in
primary and secondary care. NICE Clinical Guideline 108, August 2010
http://www.nice.org.uk/guidance/CG108
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply:
We are grateful to Dr. Sharvill for raising several practical points.
1. Urea is not to be measured or interpreted alone. We are surprised
that your local laboratory has ceased to use urea. It is still helpful to
know if your patient is dehydrated as opposed to having primary renal
failure. If your patient had an upper gastrointestinal bleeding, it is
helpful to note a disproportionate rise of urea compared to the
creatinine. The uses of urea are many. Nevertheless, this is one of
several markers of renal function and electrolyte balance and constitutes
part of the monitoring of patients with heart failure.
2. Referral is indicated when heart failure is suspected. Heart
failure should not be suspected in all people with ankle oedema, which is
a non-specific symptom and sign of heart failure, especially in the
elderly. It could be the result of venous insufficiency, drugs (eg calcium
channel blockers and other vasodilators), or to hypo-albuminaemia, renal,
or hepatic disease. If the patient is suspected of having heart failure
with a history of myocardial infarction, then it is more cost-effective to
request an echocardiogram and clinical specialist assessment than checking
the natriuretic peptide prior to these assessments. The speed of diagnosis
is justified by the high hospitalization and mortality rates in the first
4 to 6 weeks of people with new onset of heart failure.
3. The research evidence shows us that BNP testing is highly
sensitive but not very specific. In other words, few people with heart
failure will have a low BNP, but there are other causes of a raised BNP
than heart failure. Prior therapy (e.g. with diuretics) can lower BNP
levels. A patient with symptoms and signs of heart failure, raised
natriuretic peptide, no left ventricular systolic dysfunction on echo and
congestion on the chest X ray are likely to have heart failure with
preserved ejection fraction.
Dr A Al-Mohammad and Professor Jonathan Mant.
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Authors' Reply;
We are grateful to Miss Talbot and Dr Tapley for their point about
palliative care. While our summary of the heart failure guideline in the
BMJ did not refer to palliative care, the recommendations on palliative
care from 2003 still stand, and are reproduced in the 2010 NICE guideline:
(1)
1.5.9.1 Issues of sudden death and living with uncertainty are
pertinent to all patients with heart failure. The opportunity to discuss
these issues should be available at all stages of care. [2003]
1.5.9.2 The palliative needs of patients and carers should be
identified, assessed and managed at the earliest opportunity. [2003]
1.5.9.3 Patients with heart failure and their carers should have
access to professionals with palliative care skills within the heart
failure team. [2003]
Dr A Al-Mohammad and Professor J Mant.
1 National Collaborating Centre for Acute and Chronic Conditions.
Chronic heart failure: Management of chronic heart failure in adults in
primary and secondary care. NICE Clinical Guideline 108, August 2010
http://www.nice.org.uk/guidance/CG108
Competing interests: Abdallah Al-Mohammad was the clinical adviser to the guideline development group of the CHF NICE guideline partial update, and corresponding author of the BMJ article: (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance). Jonathan Mant was the Chair of the guideline development group of the CHF NICE guideline partial update and co-author of the BMJ article (Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance)
Re:NTproBNP cut-point as rule out test for heart failure diagnostic
Considering recent recommendations of NICE guidelines, describing heart
failure diagnostic issues and work-up, it would be valuable to have some
reflections around BNP levels and diagnostic conditions.
From a neurological standpoint, pro-BMP ranges have been described
in cerebrovascular ischemic infarct samples. These series
detailed a possible relationship between heart failure pre or post
ischemic disease. The series of Shibazaki et al , employed the mean ( SD ), that is, 425.0 ( 550.4 ) as descriptive range in a ischemic stroke
subpopulation with 16% of AF. The BNP levels were not related to age,
hypertension, DM, hyperlipemia, smoking and disability scales nor D-
dimers.
That level was reduced to 307.7 when compared with control sample. These
authors pinpointed the role of BNP in heart failure and complicated heart
failure with brain ischemic disease.
Competing interests: No competing interests