Authors' objectives: The appraisal aimed to identify and summarise evidence that addresses the following question: what is the clinical and cost effectiveness of N-terminal pro B-type natriuretic peptide (NT-proBNP) or B-type natriuretic peptide (BNP) as a diagnostic test to rule-in and rule-out acute heart failure in adults in the emergency department setting, compared with NT-proBNP, BNP, or standard care to rule-out acute heart failure?

Authors' results and conclusions: Based on evidence from two meta-analyses and additional observational studies, NT-proBNP and BNP testing was shown to have a consistently higher sensitivity than specificity, with sensitivity decreasing and specificity increasing as the diagnostic threshold increases. Another meta-analysis found that natriuretic peptide testing can reduce the length of hospital stay by at least one day. Further evidence from randomised controlled trials showed that NT-proBNP testing reduced readmission rates and the duration of the initial emergency department visit while BNP testing reduced time spent in hospital over the following year. HTW adapted a manufacturer-submitted cost-utility analysis and the model undertaken for the National Institute for Health and Care Excellence (NICE) clinical guideline CG187 to estimate the cost-effectiveness of diagnostic strategies using BNP or NT-proBNP. When comparing all strategies against each other, the NT-proBNP rule-in and rule-out strategy was found to be the optimal strategy overall.

Authors' recommendations: The evidence supports the routine adoption of N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement to rule-in and rule-out acute heart failure in adults presenting to the emergency department in whom there is clinical suspicion of this diagnosis. The addition of NT-proBNP measurement to routine clinical assessment may reduce length of hospital stay and the rate of re-hospitalisations. Health economic modelling indicates that NT-proBNP to rule-in and rule-out acute heart failure is the most cost-effective strategy.

Authors' methods: The Evidence Appraisal Report is based on a literature search (strategy available on request) for published clinical and economic evidence on the health technology of interest. It is not a full systematic review but aims to identify the best available evidence on the health technology of interest. Researchers critically evaluate and synthesise this evidence. We include the following clinical evidence in order of priority: systematic reviews; randomised trials; non-randomised trials. We only include evidence for “lower priority” evidence where outcomes are not reported by a “higher priority” source. We also search for economic evaluations or original research that can form the basis of an assessment of costs/cost comparison. We carry out various levels of economic evaluation, according to the evidence that is available to inform this.

Authors' identified further research: The Appraisal Panel considered that the availability of real-world audit data would be very beneficial to verify the utility of NT-proBNP measurement to rule-in and rule-out acute heart failure in adults in the emergency department setting in NHS Wales.

Project Status: Completed

URL for project: https://healthtechnology.wales/reports-guidance/natriuretic-peptides-to-rule-in-and-rule-out-a-diagnosis-of-acute-heart-failure/

Year Published: 2021

URL for published report: https://healthtechnology.wales/wp-content/uploads/2021/11/EAR026-BNP-and-NTproBNP.pdf

URL for additional information: https://healthtechnology.wales/reports-guidance/natriuretic-peptides-to-rule-in-and-rule-out-a-diagnosis-of-acute-heart-failure/

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Wales, United Kingdom

Organisation Name: Health Technology Wales

Contact Address: c/o Digital Health Care Wales, 21 Cowbridge Road East Cardiff CF11 9AD

Contact Name: Susan Myles, PhD

Contact Email: healthtechnology@wales.nhs.uk

Copyright: Health Technology Wales