Heart Failure: Diagnosis

Key points

• NICE NG106: measure NT-proBNP in EVERYONE with suspected heart failure — the older pathway that sent people with a previous MI straight to echocardiography has been removed.
• NT-proBNP > 2000 ng/l → urgent referral for specialist assessment and transthoracic echocardiography within 2 WEEKS (higher levels carry a worse prognosis).
• NT-proBNP 400-2000 ng/l → referral for specialist assessment and echocardiography within 6 WEEKS.
• NT-proBNP < 400 ng/l in an untreated person makes heart failure unlikely — review alternative causes, and discuss with a heart failure specialist if concern persists.
• Natriuretic peptide level does NOT distinguish heart failure with reduced, mildly reduced or preserved ejection fraction — echocardiography is what classifies it · use cardiac MRI or radionuclide imaging if the echo is technically sub-optimal.
• NT-proBNP is RAISED by: LVH · ischaemia · tachycardia · right ventricular overload · hypoxaemia including PE · eGFR < 60 · sepsis · COPD · diabetes · age > 70 · cirrhosis. It is LOWERED by: obesity · diuretics · ACE inhibitors · beta-blockers · ARBs · MRAs — so a normal level in a treated patient does not exclude heart failure.

Decision points in this pathway

• NT-proBNP above 2000 ng/l?
• NT-proBNP 400-2000 ng/l?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.