Are you a practice nurse seeing patients who have:
• Type 2 diabetes
• Respiratory conditions
• Renal dysfunction
Comorbidities can often mean heart failure goes unsuspected. Ask your patients whether they are experiencing any of the key symptoms.
At Roche Diagnostics, we understand the difficulties associated with remaining up to date with all the latest best practices across numerous therapy areas.
The challenges arising from backlogs and limited time during appointments mean heart failure can be easy to miss, especially alongside comorbidities which share similar symptoms. This is common in patients who develop heart failure alongside pre-existing conditions.
This website aims to help practice nurses nationwide to spot the symptoms of heart failure, how to test for suspected heart failure and explain the benefits of NT-proBNP testing for you, your patients and the wider healthcare system.
The importance of early diagnosis
Heart failure is a chronic condition, and the longer it is left undiagnosed and untreated, the worse it will become. Currently 40% of patients who were admitted to hospital had presented heart failure symptoms in primary care in the year prior to their admission, but they were missed or attributed to other conditions.1
Furthermore, some 1 in 3 patients over 45 get misdiagnosed.2 There are multiple reasons why heart failure may not be recognised, including misclassification as chronic obstructive pulmonary disease, ageing, lack of fitness or obesity due to a similarity in symptoms.3
People with heart failure are often living with several long-term conditions; a large study using UK data found that 79% of people with heart failure had three or more comorbidities.4
Early diagnosis changes lives.5
Heart failure symptoms are easy to miss. Look out for symptoms in patients with risk factors for heart failure and test your patients’ NT-proBNP levels with a simple blood test.
Test your patients’ NT-proBNP levels with a simple blood test.
Recognise the symptoms
Heart failure can affect all ages and genders. Keep an open mind if a patient presents with one or more of these key symptoms, especially alongside comorbidities. Pumping Marvellous, the UK’s patient lead heart failure charity, have developed the B.E.A.T methodology:6
Symptoms of heart failure and key questions
Symptom
Breathlessness (particularly on exertion or lying flat e.g. sleeping at night)
What to ask
Have you noticed yourself getting more out of breath recently?
Symptom
Fatigue and/or reduced tolerance for exercise
What to ask
Have you noticed yourself getting more exhausted with less effort?
Symptom
Swelling (particularly in the feet) as a result of fluid retention
What to ask
Are your shoes and socks feeling tighter or leaving marks?
Symptom
Palpitations
What to ask
Have you noticed a rapid, fluttering or pounding heartbeat?
Symptom
Weight gain (indication of fluid retention)
What to ask
Have you put on weight recently?
~
Symptom
Persistent cough
What to ask
Have you been coughing much?
Updates to the NICE heart failure quality standards
On 10th January 2023, NICE Guidelines updated the quality standards of chronic heart failure to include new recommendations for the detection, diagnosis and management of heart failure.18
NICE guidelines recommend that testing for NT-proBNP should be the priority test when patients present with any of the symptoms of heart failure.18
Yet currently less than 24% of patients have an NT-proBNP test in primary care prior to a heart failure diagnosis.20
Currenty <24% of patients diagnosed with heart failure have an NT-proBNP test in primary care21
<80% of patients are only diagnosed with heart failure after a hospital admission21
© NICE [2018] Chronic heart failure in adults: diagnosis and management. Available from www.nice.org.uk/guidance/ng106. All rights reserved. Subject to Notice of rights.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Type 2 diabetes patients are twice as likely to develop heart failure.7
49% of chronic kidney disease patients will develop heart failure in their lifetime.8
Atrial fibrillation and heart failure frequently coexist and influence the progression of the other.9
Anaemia is found in about one-third of all cases of congestive heart failure.10
People with heart failure are often living with several long-term conditions.4 Patients may assume their symptoms are related to these other conditions or to side effects of medications they are taking and may not know to bring these up with their healthcare professionals. In a survey of 110 primary care clinicians, 80% reported that multiple comorbidities were the biggest challenge in recognising potential heart failure in patients.11
The NT-proBNP blood test is a cost-effective and NICE recommended method of ruling out heart failure for patients presenting heart failure symptoms compared to an echocardiogram,12 which if not required, can amount to unnecessary expenses and prolonged wait times for those in need of echocardiograms.13
NT-proBNP can save you and the wider healthcare system time by setting patients on the correct heart failure diagnosis pathway as early as possible.14,15
Of those who were tested by their GP, 75% were men and 25% were women2
Women were almost twice as likely to be misdiagnosed than men2
Why test for NT-proBNP?
NP-proBNP has a very high diagnostic sensitivity for heart failure and testing in patients with symptoms delivers a fast route to ruling out heart failure as a diagnosis. High levels of NT-proBNP are associated with a poor prognosis. Patients with values >2,000 ng/l are at greater risk of death17. High levels therefore indicate the need for urgent referral.18
Triage patients at need of urgent specialist assessment18
Rule-out heart failure and reduce pressure on echocardiography services19
Costs less than £28 per patient (compared to £377 for an echocardiogram)12
Early and accurate diagnosis of heart failure has the potential to reduce rates of misdiagnosis and GP appointments14
If you've had trouble accessing NT-proBNP testing, contact Roche and we'll be happy to help.
Boost your CPD score with the new heart failure module
Take what you have learnt here and put your understanding to the test with the brand-new e-learning module from Practice Nurse. Contributing to your CPD score upon completion, this module can help you better understand heart failure, how to manage it and the importance of NT-proBNP testing to aid accurate and timely diagnosis.
Nick Hartshorne-Evans, CEO of the Pumping Marvellous Foundation and Dr Clare Taylor, academic GP, take a deep dive into the world of heart failure in this 18-minute podcast.
Discover the importance of early heart failure detection, how GPs can support this to ensure evidence-based treatments are delivered sooner, emergency hospitalisations are prevented, and the quality and longevity of patients' lives are improved.
The Pumping Marvellous Foundation (PMF) is the UK’s patient-led heart failure charity. Founder & CEO Nick Hartshorne-Evans, a heart failure patient whose experiences whilst rehabilitating, shaped the Foundation’s goals and principles to improve patient outcomes.
With patient resources available for download by healthcare professionals, Pumping Marvellous takes a patient-centric approach to heart failure diagnosis, ongoing management and care.
References
1. NHS England, 2019. NHS Long Term Plan. Ch3, Cardiovascular disease. Available on longtermplan.nhs.uk
2. Censuswide, Data from survey of 625 heart failure patients analysed for this report. Data file, accessed 11 August 2020
3. Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail. 2020 Aug;22(8):1342-1356. doi: 10.1002/ejhf.1858. Epub 2020 Jun 1. PMID: 32483830; PMCID: PMC7540043.
4. Conrad N, Judge A, Tran J, et al. Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals. Lancet2018;391:572-80. doi:10.1016/ S0140-6736(17)32520-5 pmid:29174292).
5. Wang Y, et al. Early detection of heart failure with varying prediction windows by structured and unstructured data in electronic health records. Annu Int Conf IEEE Eng Med Biol Soc. 2015;2015:2530-3. doi: 10.1109/EMBC.2015.7318907. PMID: 26736807; PMCID: PMC5233460.
6. FASTer diagnosis: Time to BEAT heart failure Clare J Taylor, Nick Hartshorne-Evans, Duwarakan Satchithananda and FD. Richard Hobbs BJGP Open 2021; 5 (3): BJGPO.2021.0006. DOI: https://doi.org/10.3399/BJGPO.2021.0006.
7. Kenny et al. (2019). Heart Failure in Type 2 Diabetes Mellitus. Impact of Glucose-Lowering Agents, Heart Failure Therapies, and Novel Therapeutic Strategies. Circulation Research. 2019;124:121–141.
8. Damman, K.; Valente, M.A.; Voors, A.A.; O’Connor, C.M.; Van Veldhuisen, D.J.; Hillege, H.L. Renal impairment, worsening renal function, and outcome in patients with heart failure: An updated meta-analysis. Eur. Heart J. 2014, 35, 455–469.
9. Bavishi A, Patel RB. Addressing Comorbidities in Heart Failure: Hypertension, Atrial Fibrillation, and Diabetes. Heart Fail Clin. 2020 Oct;16(4):441-456. doi: 10.1016/j.hfc.2020.06.005. Epub 2020 Jul 21. PMID: 32888639; PMCID: PMC7479642.
10. Silverberg DS, Wexler D, Iaina A. The role of anemia in the progression of congestive heart failure. Is there a place for erythropoietin and intravenous iron? J Nephrol. 2004 Nov-Dec;17(6):749-61. PMID: 15593047.
11. Buzzback online survey conducted on behalf of Roche Diagnostics. n=110 GPs and Nurses in Great Britain. Data on file (August 2022)
12. NHS England, National Cost Collection for the NHS, 2022. Available from: https://www.england.nhs.uk/costing-in-the-nhs/national-cost-collection/#ncc1819 [Last accessed: July 2023]
13. NHS England, 2022. Diagnostics Waiting Times & Activity. https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2022-23/. [Last accessed: July 2023]
14. National Institute for Health and Care Excellence [NG106], 2020. Reducing inappropriate use of NT pro BNP: A Quality Improvement project. Available from: https://www.nice.org.uk/sharedlearning/reducing-inappropriate-use-of-nt-pro-bnp-a-quality-improvement-project [Last accessed: July 2023]
15. Roalfe et al. (2022) Long term trends in natriuretic peptide testing for heart failure in UK primary care: a cohort study. European Heart Journal, Volume 43, Issue 9, 1 Pages 881–891
16. Mueller, C.et al. (2019), Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail, 21: 715-731. https:// doi.org/10.1002/ejhf.1494
17. Taylor et al. (2022) Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004–2018 Heart 2022;108:543-549
18. National Institute for Health and Care Excellence. Chronic heart failure in adults. Available from: https://www.nice.org.uk/guidance/qs9 [Last accessed: July 2023]
19. Taylor et al. (2017) The REFER (REFer for EchocaRdiogram) study: a prospective validation and health economic analysis of a clinical decision rule, NT-proBNP or their combination in the diagnosis of heart failure in primary care. Southampton (UK): NIHR Journals Library; 2017 Apr. PMID: 28445025.
20. IQVIA Medical Research Data, IQVIA Ltd, incorporating data from THIN, a Cegedim database, 2011 – 2021
21. Bottle A, Kim D, Aylin P, Cowie MR, Majeed A, Hayhoe B. Routes to diagnosis of heart failure: observational study using linked data in England. Heart. 2018 Apr;104(7):600-605. doi: 10.1136/heartjnl-2017-312183. Epub 2017 Oct 5. PMID: 28982720.
22. British Heart Foundation. UK CVD Factsheet. Page 14. Available from: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf [Last accessed: July 2023]
23. British Heart Foundation. The heart-kidney link. Available from: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/kidney-heart-link [Last accessed: July 2023] (edited)
