NT-proBNP Testing for Heart Failure Diagnosis

Medicare rebate

From 1st Nov 2024, BNP/NT-proBNP testing will be Medicare rebatable when ordered by GPs. These biomarkers have been used primarily by cardiologists and emergency clinicians but now GPs can request the test to assess patients for heart failure and the test will attract a Medicare rebate.

NT–proBNP and BNP tests are treated as equivalent by Medicare and our laboratories. Testing FrequencyBNP or NT-proBNP will attract a Medicare benefit only once per 12-month period.

When to request NT-proBNP for patients?

Request NT-proBNP when patients are presenting:

• Dyspnea: acute or chronic shortness of breath, especially where heart failure is suspected but not confirmed.
• Oedema: peripheral oedema, unexplained fatigue, or elevated JVP.
• Comorbidity: a history of lung disease where you are assessing for coexisting heart failure.
• Risk Factors: patients who are at risk of CHF due to age, hypertension, or diabetes but do not yet show clear signs of the condition.

Assess whether a patient presenting with one of the above factors is requiring echocardiography.

Benefits over traditional diagnostic methods

• Accessible: easier to access compared to echocardiography, especially in non-urban settings.
• Time-sensitive: faster results compared to waiting for imaging.
• Specificity: high negative predictive value – a low NT-proBNP level virtually excludes CHF, allowing you to focus on alternative diagnoses.

Likelihood of heart failure

New MBS item for diagnosis of heart failure

The introduction of bulk-billed b-type natriuretic peptide (BNP) for use in the screening of heart failure by general practitioners is a welcome addition to the Medicare Benefit schedule from November 2024.

Heart failure is a significant clinical problem on a worldwide basis and the early diagnosis can help patients and doctors manage the condition more effectively. Giving access to GPs for BNP testing is an evidence based and key step in the care pathway. In 2013 an Agency for Healthcare Research and Quality sponsored comparative effectiveness review demonstrated that there is a high quality of evidence to support the use of BNP or NT-proBNP as a rule-out test in chronic and acute heart failure both in the emergency room and in the community.

The role of BNP/NT-proBNP in the diagnosis of heart failure

The National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand, guidelines published in 2018 for the prevention, detection and management of Heart Failure made a Strong Recommendation for the use of BNP or NT-proBNP for diagnosis when the diagnosis is uncertain. This guideline recommended a rule-out for heart failure with NT-proBNP of less 300 ng/L. This recommendation is based on primary papers rather than the published systematic review evidence. A more recent guideline published by the European Society of Cardiology has a few different cut-points that are relevant to ruling out the diagnosis of heart failure. In chronic heart failure a NT-proBNP of < 125 ng/L or BNP < 35 ng/L can rule out chronic heart failure in all ages. This is based on people with symptoms suggestive of heart failure or symptoms that could include heart failure as a possible differential diagnosis. Above these levels it is recommended that echocardiography is performed.  For people who present with symptoms suggestive of acute heart failure the cut-point for NT-proBNP is < 300 ng/L or BNP < 100 ng/L.

The cut-points presented are based on a rule-out of heart failure either chronic or acute. Due to the number of other common conditions (e.g. advanced age, renal dysfunction, COPD, anaemia etc.) that can cause an increase in BNP/NT-proBNP the rule-in data is less robust but is still an effective biomarker, particularly as the results get into the higher ranges (> 900 ng/L for NT-proBNP). In the systematic reviews conducted for the 2014 report the GRADE rating was high (4 hashed circles) for rule-out and moderate (three hashed, one open) for rule-in. Thus, the Medicare benefit talks about using BNP/NT-proBNP as a screening test to help identify who would benefit from echocardiogram, as echocardiogram remains the diagnostic test of choice.

In the context of the new benefit, for use in the community, the exclusion of heart failure with NT-proBNP of < 125 ng/L or BNP < 35 ng/L can rule out heart failure in all ages. People with values above these levels will benefit from echocardiography to make the diagnosis.

The Medicare benefit does not distinguish between BNP/NT-proBNP as the evidence for use is equivalent for both. However, there is an important caveat for the choice of BNP in the community setting. NT-proBNP is more stable (days) than BNP (hours) in collected serum samples. BNP requires special handling by the laboratory to maintain stability, if it is not analysed in reasonably quick timeframe. This factor has been taken into consideration in the UK based NICE recommendations and the Canada based Ontario Health Technology assessment.  Thus, most GPs will become familiar with NT-proBNP where hospital-based Doctors may see both BNP and NT-proBNP results.

BNP/NT-proBNP items on the medicare benefits schedule

BNP/NT-proBNP has been available with restricted criteria for certain conditions. These benefits remain in place.  Items 66585 refers to testing in patients with scleroderma and risk of pulmonary arterial hypertension, 66586 for people with diagnosed pulmonary artery hypertension to monitor disease progression, and 66830 refers to the use in people presenting with dyspnoea at hospital emergency departments. The new item, 66829, refers to the use in suspected heart failure in the community setting, to aid in the clinical decision for the necessity of an echocardiogram.

The new benefit is restricted to once per year and as an assistance in identifying people with possible heart failure. For all MBS items it is important to provide the appropriate clinical detail in the clinical note on the requestion, so that the billing item can be correctly identified.

BNP/NT-proBNP items not on the medicare denefits schedule

There are other clinical areas where the use NT-proBNP or BNP can be helpful in establishing prognosis and supporting management of heart failure. These use cases are not covered by the MBS and in these instances, patients will need to pay for the test.

References:

^{Balion C, Don-Wauchope A, Hill S, Santaguida PL, Booth R, Brown JA, et al. Use of Natriuretic Peptide Measurement in the Management of Heart Failure. Agency for Healthcare Research and Quality (US); 2013.}

^{Booth RA, Hill SA, Don-Wauchope A, Santaguida PL, Oremus M, McKelvie R, et al. Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review. Heart failure reviews. 2014;19:439–51.}

^{Hill SA, Booth RA, Santaguida PL, Don-Wauchope A, Brown JA, Oremus M, et al. Use of BNP and NT-proBNP for the diagnosis of heart failure in the emergency department: a systematic review of the evidence. Heart failure reviews. 2014;19:421–38.}

^{Atherton JJ, Sindone A, Pasquale CGD, Driscoll A, MacDonald PS, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart, Lung Circ. 2018;27:1123–208.}

^{McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail. 2022;24:4–131.}

^{https://www.nice.org.uk/guidance/ng106}

^{(Quality) OH. Use of B-Type Natriuretic Peptide (BNP) and N-Terminal proBNP (NT-proBNP) as Diagnostic Tests in Adults With Suspected Heart Failure: A Health Technology Assessment. Ont Heal Technol Assess Ser. 2021;21:1–125.}