The Research Question

1. The Research Question The potential role of NT-proBNP in screening for heart failure and in predicting prognosisRichard Hobbs, Care Taylor, Andrea Roalfe, Rachel Iles, University of Oxford. Taylor CJ, Roalfe AK, Iles R, Hobbs FDR. The potential role of NT-proBNP in screening for and predicting prognosis in heart failure: a survival analysis.BMJ Open 2014; 4:4 e004675 doi:10.1136/bmjopen-2013-004675 • The Question? To determine the potential role of N-terminal B type natriuretic peptide (NT-proBNP) in screening for and predicting prognosis in heart failure by examining diagnosis and ten year survival of patients with a raised NT-proBNP at screening. • Why this is important? - Heart failure in 2013 is • Common, very costly (to patients and healthcare systems), and has a large evidence base for management • BUT is often diagnosed in late stage or misdiagnosed and often under-managed

2. What the Researchers Did • Population/Subjects • 594 subjects with a baseline natiuretic peptide result in the ECHOES Study, which screened 6162 patients for HF or LVSD by screening patients from 16 practices in Central England between 1995–99 in 4 randomly sampled cohorts (general population, those with existing HF diagnosis, those at high risk of HF, those on diuretics). • Design • Prospective sub-study of subjects in the Echocardiographic Heart of England Screening study (ECHOES) in participants with a NT-proBNP level at baseline from all four cohorts and with validated diagnoses and long term follow up for mortality. • Basic Method/Intervention • Logistic regression to examine whether NT-proBNP is predictive of heart failure at screening after adjustment for age, sex and cohort. • Kaplan Meier curves and log rank tests to compare survival times of participants according to NT-proBNP level. • Cox regression to assess prognostic effect of NT-ProBNP, allowing for significant covariates. • Receiver operator curves to determine test reliability.

3. What the Researchers Found • Risk of heart failure increased almost 18-fold when NT-proBNP was 150pg/ml or above (adjusted OR =17.7 (95% CI 4.9 to 63.5). • Ten-year survival in the general population cohort was 61% (48% to 71%) for those with NT-proBNP>=150pg/ml and 89% (84% to 92%) for those below the cut-off at baseline. • After adjustment for age, sex and risk factors for heart failure, NT-proBNP level >= 150pg/ml was associated with a 58% increase in the risk of death within 10 years (adjusted HR =1.58 95% CI 1.09 to 2.30).

4. What This Means for Clinical Practice • Raised NT-proBNP levels, when screening the general population, are predictive of a diagnosis of heart failure. • A lower threshold than guidelines currently advocate for diagnosing symptomatic presenting patients is needed for screening. • Baseline NT-proBNP levels also predicted reduced survival at 10 years.