Earlier diagnosis of heart failure
Use of natriuretic peptide testing will certainly help GPs make earlier diagnosis of heart failure, said Professor Ken McDonald (Dublin, Ireland). The problem with diagnosing heart failure is that symptoms are often nonspecific, and physical signs absent.
“The GP should always have a high index of suspicion about non-specific symptoms in someone who is at risk of heart failure, for example, from prior myocardial infarction or longstanding hypertension.”
ECG and BNP measurement are rule-out tests that can be used in the community to triage patients. If both are normal, the patient almost certainly does not have heart failure. An abnormal test result does not mean that the patient has heart failure – specificity is relatively low – but it means that a heart failure diagnosis needs to be
considered. The usual BNP cut-off in diagnosing heart failure is 100 pg/ml. A level above this requires follow up. GPs should be aware, however, that BNP levels can be decreased by certain factors, including increased BMI and diuretic use. Many patients with a potential new diagnosis of heart failure have background hypertension and
may be taking a diuretic.
“You should be careful in over interpreting an apparently normal BNP in such cases.”
It is not cost-effective to do echocardiography in all patients in whom heart failure is suspected. Using BNP is a more cost effective way of making a new diagnosis. Professor McDonald emphasized the need for shared care:
“GPs can’t look after heart failure patients on their own, and neither can specialists.”
Diastolic heart failure
Diastolic heart failure or, as it is now known, heart failure with normal ejection fraction (HFNEF) has become easier to diagnose but there is limited evidence on treatment, said Professor Martin Cowie (London, UK). In practice, the condition is treated very similarly to systolic heart failure. Many patients with coronary heart disease, diabetes, hypertension or obesity will have a stiff heart and be breathless on exertion but have a normal ejection fraction. These are typical patients with HFNEF.
“But please don’t label a patient as having diastolic heart failure just because you can’t explain breathlessness and the echocardiogram looks normal. You have to try and find some evidence that this is the problem.”
HFNEF is diagnosed on the basis of signs/symptoms and high BNP – neither of which distinguish between systolic and diastolic heart failure – followed by echocardiography to show good systolic function but evidence of abnormal diastolic function.
GPs must therefore have access to a good echo reporting service and to BNP testing. 
The ESC heart failure guideline recommends diuretics to treat symptoms, and then treatment of the co-morbidity (hypertension, diabetes, etc). There have been large trials of ACE inhibitors and angiotensin receptor blockers (ARBs) but these were not conclusive.
“We really don’t know how to change the natural history of diastolic heart failure. It is a serious condition and patients are very symptomatic but as yet we don’t know how to treat it very well.”
Most patients currently end up on a diuretic, ACE inhibitor (or ARB) and as much beta-blocker as they can tolerate to slow the heart, but the evidence base is not there. Treating patients with HFNEF can be difficult medicine and may require considerable specialist input.