Cost-effectiveness of NT-proBNP thresholds for echocardiography referral in primary care heart failure management

Journal article

Background
N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a key test in primary care to inform which people with possible heart failure (HF) are referred for specialist assessment and echocardiography. However, the impact of alternative NT-proBNP diagnostic thresholds on healthcare use, costs, and patient outcomes remains uncertain. 
Methods
We conducted a cost-effectiveness analysis of three diagnostic strategies for suspected HF in the UK primary care: echocardiography for all, the European Society of Cardiology (ESC) strategy (NT-proBNP≥125pg/ml), and the National Institute for Health and Care Excellence (NICE) strategy (NT-proBNP≥400pg/ml). An updated decision-analytic model informed by the prospective REFerral for EchocaRdiogram (REFER) primary care cohort incorporated contemporary HF therapies and included patients with preserved ejection fraction. Analyses adopted a UK National Health Service perspective over a lifetime horizon. Costs and qualityadjusted life-years (QALYs) were discounted at 3.5% annually. Deterministic and scenario sensitivity analyses were undertaken to assess structural and parameter uncertainty.
Results
In the base-case, the NICE threshold (≥400 pg/ml) was associated with lower healthcare costs and similar QALYs compared with the ESC threshold (≥125 pg/ml). The lower threshold increased detection of HF but substantially increased investigations among patients without HF. Results were robust across most sensitivity analyses. Under a scenario assuming universal diuretic use among treated patients, ESC and echocardiography for all strategies generated additional QALYs at modest extra cost compared with NICE.
Conclusion
For patients with suspected HF in primary care, the NICE diagnostic threshold represents an efficient balance between case detection and healthcare resource use. Cost-effectiveness of lower thresholds is sensitive to assumptions regarding downstream treatment patterns, highlighting the importance of real-world prescribing when evaluating diagnostic strategies.

Authors: Png, ME; Tahsina, T; Jones, N; Taylor, C; Petrou, S

• Publication status: Accepted
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: Heart
• Acceptance date: 2026-06-06
• EISSN: 1468-201X
• ISSN: 1355-6037
• Language: English