Editor—Recent guidelines from the National Institute for Clinical Excellence (NICE) on heart failure recommend measuring natriuretic peptide concentration in patients with suspected heart failure, in addition to electrocardiography to exclude heart failure.1,2 However, normal results on electrocardiography and chest radiography make heart failure highly unlikely.
Low concentrations of natriuretic peptides also make the diagnosis of heart failure unlikely, and what is gained in addition to the information from a normal electrocardiogram, which has a negative predictive value ranging from 77% to 97% depending on the cut-off point and background risk, is unclear. Even if the natriuretic peptide increased negative predictive value from 97%3 to 100%, is a 3% increase worth the additional cost and would it improve management?
A study of referrals of patients with symptoms also casts doubt on the advantages of natriuretic peptide testing, as does a study after myocardial infarction.4 In people who have an abnormal electrocardiogram the need for echocardiography is reduced in those who have normal natriuretic peptide values.5 This is a rather different issue from that indicated in the NICE guideline.
Uncertainty remains about the best threshold values for natriuretic peptide testing, the best assay, the stability of samples in routine settings, and the effect of diuretics. Given the vast financial and resource implications of generating yet another testing industry to join the others of dubious value—the blood sugar industry and the prostatic specific antigen industry, to name but two—what substantive evidence justifies this recommendation? Why is a major national recommendation based on small studies with conflicting evidence of additional benefits?
Competing interests: None declared.
References
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