One NT-proBNP test reimbursed per patient per year to help exclude heart failure in GP.

Added to the MBS in November 2024, NT-proBNP testing is highly accurate for excluding heart failure, and can help doctors appropriately triage, investigate and refer symptomatic patients when diagnosis is uncertain, says cardiologist Professor Andrew Sindone*, Director of the Heart Failure Unit and Department of Cardiac Rehabilitation at Concord Hospital and Head of Department of Cardiology, Ryde Hospital. 

He explains how the test works and how to use it in general practice. 

What does the test measure?

The test measures a blood biomarker called N‑terminal pro‑Brain natriuretic peptide (NTproBNP).

The heart muscle wall contains packages of a hormone called Pro B-type natriuretic peptide, Professor Sindone explains. 

“When the heart is under stretch or stress, these little packages get secreted into the circulation, where it gets cleaved into two parts.” 

The active fragment, BNP, causes natriuresis and diuresis to help eliminate excess fluid from the body. “So it’s a compensatory mechanism,” Professor Sindone says.

BNP is not a great biomarker in non-hospital settings, however, because it goes off very quickly when sitting on a bench in a test tube, “levels in the body go up and down all the time,” and are increased in patients taking heart failure medication sacubitril/valsartan (Entresto).

In contrast, the inactive fragment NT-proBNP is “stable in a test tube, and the levels also stay pretty stable in the body.” Nor are levels affected by Entresto.

How to use it in GP

MBS reimbursement is available for one blood test per year in patients with signs and symptoms suggestive of heart failure if diagnosis is uncertain, in line with National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines. 

It is most useful for ruling out heart failure, with a cut-off value of 125 pg/mL, Professor Sindone explains. 

“In an ambulatory patient, if the test is less than 125, it’s got a more than 95% negative predictive value. So it’s very unlikely to be heart failure,” he says.
“So that can avoid unnecessary testing, an echocardiogram, avoid chest X-rays, avoid a referral to a cardiologist. I might be sending them to see a lung specialist or maybe be reassured that it’s not heart failure. Maybe they’re depressed or obese or have varicose veins in the legs causing swelling.”

“If it’s more than 125, then you should think it might be heart failure,” he adds, in which case you could consider referral to a cardiologist for further investigation. 

Any caveats? NT-proBNP levels can go up in kidney failure, septicaemia, pulmonary embolism, and after a heart attack. “Those are the main confounders,” Professor Sindone says.

Especially useful in patients with HFpEF

NT-proBNP is a “game-changer” for Australian patients with heart failure with preserved ejection fraction, who now outnumber those with reduced ejection fraction, Professor Sindone says.

While HFpEF is “really hard to diagnose and greatly under-recognised,” NT-proBNP is equally as effective for excluding this type of heart failure.

“So we’re going to be able to diagnose more and more people with heart failure with preserved ejection fraction. And that’ll mean we can help more people who just thought they’re getting old, they’re getting short of breath and fatigue, and they could not do what they did before because their heart’s getting older and stiffer.”

Start treatment ASAP

This is important because we now have effective heart failure treatment across the board, Professor Sindone stresses, recommending GPs take a “shoot first, ask questions later” approach if NT-proBNP is high.

“We’ve got a treatment that works across the spectrum of ejection fraction, whether it’s reduced or preserved. You can start an SGL2 inhibitor, whether it be empagliflozin (Jardiance) or dapagliflozin (Farxiga). That will improve the symptoms, reduce the risk of hospitalisation, and reduce risk of death. And then you can get them to see the cardiologist who can do the echo, triage to reduced or preserved ejection fraction, and do other tests like angiograms, if appropriate.”

If patients are not responding as expected or their NT-proBNP result is very high, he suggests ringing the cardiologist to ask for an urgent appointment.

Results linked with prognosis

Test results have also been shown to correlate with survival, Professor Sindone says. “The higher your level, the higher your chance of dying if you’ve got heart failure. So it’s a good prognostic marker.” 

“It also correlates with response to treatment. If it’s high and then you treat someone and it comes down, that means they’re responding to treatment.”
“If you do serial testing and it’s coming down, great. If it’s going up, you’ve got to try harder. So you can actually use it to guide your treatment, but it’s not reimbursed for that in Australia yet.”

Key takeaways:

• NT-proBNP tests are now reimbursed for the exclusion of heart failure in non-hospitalised patients with heart failure signs and symptoms if the diagnosis is uncertain​. 

• One test can be reimbursed per patient per year. 

• It has a 95% negative predictive value and heart failure is unlikely at levels below 125 pg/mL. 

• If level is over 125 pg/mL, consider cardiology referral and/or further investigations. 

• It is particularly helpful in hard-to-diagnose HFpEF, cases of which now outnumber those of HFrEF. 

• Results are also linked with prognosis and response to treatment but reimbursement is not yet available for this use.  

* Professor Sindone has received honoraria, speaker fees, consultancy fees, travel support, is a member of advisory boards or has appeared on expert panels for:​ Abbott, Alphapharm, Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL, Edwards, Eli Lilly, Glaxo Smith Kline, HealthEd, Inside Practice, Menarini, Merck Sharp and Dohm, Moderna, Mylan, Novartis, Novo Nordisk, Orion, Otsuka, Pfizer, Pharmacosmos, Roche, Sanofi, Servier, Viatris, Vifor​. 

# Roche Diagnostics is a Healthed sponsor.