BNP Pathway

NHS Tayside BNP Pathway flowchart and notes

Initial Primary Care assessment

• Where heart failure is suspected perform clinical examination including ECG, chest x-ray, and FBC, U&E, LFT, glucose, TFT, +/- NTproBNP:  

• • If normal resting ECG without other clinical features suggestive of heart failure NTproBNP testing is not recommended. 

• • If LBBB or significant murmur is present request ECHO directly with ICE without need for BNP.  

• • If patient known to Cardiology department or echo within last 2 years please seek advice before requesting NT proBNP. 

• • NT pro BNP results should be treated with caution in the presence of co-morbidity, advanced age - see notes below re interpretation. 

• • Note that NTproBNP is now requested via ICE directly (no longer through transthoracic echo request algorithm). 

After NTproBNP consider need for ECHO referral:

• • f NTproBNP is less than 400ng/l - heart failure diagnosis unlikely - if normal ECG and no significant murmur ECHO not indicated.  
  • If NTproBNP 400-2000ng/L - consider heart failure as diagnosis, GP request ECHO via ICE, urgency dependent on clinical evaluation.  
  • If NTproBNP >2000ng/L - in absence of other causes heart failure likely, GP request URGENT ECHO via ICE if appropriate, based on clinical evaluation.  

Following ECHO:

Once patient has had ECHO, patient will be triaged directly by heart failure cardiologist to either clinic or advice depending on the result.  

Notes on interpreting NTproBNP

• NTproBNP levels lower in certain conditions:  
  • High BMI. 
  • In patients already established on heart failure medications.
• NTproBNP is higher in certain conditions:  
  • Aged over 70 years. 
  • Left ventricular hypertrophy, myocardial ischaemia, or tachycardia. 
  • Right ventricular overload/pulmonary hypertension/pulmonary embolism. 
  • Poor renal function (eGFR less than 60)
  • Infection. 
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes mellitus. 
  • Liver impairment.