A management programme for suspected heart failure in primary care in cooperation with specialists in cardiology

Figures & data

Figure 1. The algorithm for diagnosing congestive heart failure. The algorithm for diagnosing CHF according to prevailing Swedish recommendations, and based on European guidelines (13,14). Symptoms suggestive of CHF include dyspnoea at rest or during effort, tiredness, nocturnal dyspnoea or cough, nocturia, loss of appetite, nausea, depression, abdominal pain, and difficulty concentrating. Signs suggestive of CHF include pulmonary rales, peripheral oedema, tachycardia, jugular vein distension, hepatomegaly, tachypnoea, S3 or S4 gallop rhythm, pleural effusion, and ascites. Patients with suspected CHF because of symptoms and signs, or signs suggestive of left ventricular dysfunction; together with an abnormal ECG and/or elevated value of NT-proBNP were eligible for inclusion.

Table 1. Values of NT-pro BNP to facilitate decision making in primary care according to prevailing Swedish recommendations on the management of CHF.

Age, years	NT-pro BNP, ng/l
< 50	< 300	300–450	> 450
50–75	< 300	300–900	> 900
> 75	< 300	300–1800	> 1800
Interpretation	Heart failure unlikely	Heart failure possible	Heart failure probable

Assessment of natriuretic peptides can add to the diagnostic accuracy of defining CHF but is not to be used alone to make a diagnosis. NT-pro BNP was measured by an electrochemiluminiscence immunoassay (Cobas 232, Roche Diagnostics, Mannheim, Germany) (17). The cut-off values of NT-pro BNP values in this study were according to Swedish recommendations at the time of the study, and were adapted from van Kimmenade et al. (13,15).

Table 2. Baseline demographics and findings of patients with suspected new onset CHF on referral, according to a confirmed diagnosis of CHF or not. Data are presented as mean values ± SD or proportions, as appropriate.

	CHF	Non-CHF	P
n	46	52	ns
Age, years	76.3 ± 9.5	75.0 ± 9.3	ns
Gender, % men	62	36	ns
Blood pressure, systolic, mm Hg	137 ± 33	137 ± 19	ns
Blood pressure, diastolic, mm Hg	81 ± 18	80 ± 10	ns
Heart rate, beats/min	73 ± 14	75 ± 15	ns
QRS width, ms	107 ± 25	93 ± 18	< 0.05
Hypertension, %	67	51	ns
Ischaemic heart disease, %	39	20	< 0.05
Atrial fibrillation, %	30	18	< 0.001
Diabetes mellitus, %	24	10	< 0.001
Respiratory diseases, %	16	35	< 0.001
Previous and current smokers, %	28	27	ns
Haemoglobin, g/l	139 ± 16	143 ± 48	ns
Serum creatinine, μmol/l	107 ± 42	82 ± 20	< 0.001
NT-pro-brain natriuretic peptide, ng/l	1491 ± 1446	521 ± 407	< 0.001
Quality of life by EQ5D	67 ± 18	67 ± 61	ns
ACE-inhibitors or angiotensin receptor blockers, %	42	24	ns
ß-blocking agents, %	67	54	ns
Diuretics, %	72	52	ns

ACE, angiotensin converting enzyme; CHF, congestive heart failure; ns, not significant; P, probability.

Figure 2. NT-proBNP values obtained at the primary care centre and the hospital outpatient clinic. The solid line represents the line of identity.

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