Observational studyThe British journal of general practice : the journal of the Royal College of General Practitioners2017
Primary care REFerral for EchocaRdiogram (REFER) in heart failure: a diagnostic accuracy study.
Observational study in The British journal of general practice : the journal of the Royal College of General Practitioners, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 24 papers, 5 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
24 citing papers in PubMed, 5 syntheses or guidelines pooled it, 40 citations in OpenAlex.
- Economic burden of heart failure in Europe: A systematic review of costs and cost-effectiveness.ESC heart failure · 2025Pooled it
- Diagnosing heart failure in primary care: individual patient data meta-analysis of two European prospective studies.ESC heart failure · 2021Pooled it
- A systematic review of clinical prediction rules for the diagnosis of chronic heart failure.ESC heart failure · 2019Pooled it
- Diagnostic accuracy of point-of-care natriuretic peptide testing for chronic heart failure in ambulatory care: systematic review and meta-analysis.BMJ (Clinical research ed.) · 2018Pooled it
- Practical guidance on heart failure diagnosis and management in primary care: recent EPCCS recommendations.The British journal of general practice : the journal of the Royal College of General Practitioners · 2017Guideline
- What services are currently provided to people with heart failure with preserved ejection fraction in the UK and what are their components? A systematic scoping review.European journal of cardiovascular nursing · 2026Article
- Age-adjusted natriuretic peptide thresholds for a diagnosis of heart failure in the community: Diagnostic accuracy study.ESC heart failure · 2025Article
- NT-proBNP testing for heart failure diagnosis in people with atrial fibrillation: A diagnostic accuracy study.PLoS medicine · 2025Article
- What services are currently provided to people with heart failure with preserved ejection fraction in the UK, and what are their components? A protocol for a scoping literature review.European journal of cardiovascular nursing · 2025Article
- To support the use of NT-proBNP to better detect heart failure in patients with type 2 diabetes.Endocrine · 2023Article
- Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study.The British journal of general practice : the journal of the Royal College of General Practitioners · 2023Article
- Reference Ranges for NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) and Risk Factors for Higher NT-proBNP Concentrations in a Large General Population Cohort.Circulation. Heart failure · 2022Article
- Feasibility of the cardiac output response to stress test in suspected heart failure patients.Family practice · 2022Observational
- Assessment of the impact of different N terminal pro brain natriuretic peptide thresholds on echocardiography services.ESC heart failure · 2022Article
- Saudi Heart Association Position Statement on the Use of Biomarkers for the Management of Heart Failure and Acute Coronary Syndrome.Journal of the Saudi Heart Association · 2022Article
- FASTer diagnosis: Time to BEAT heart failure.BJGP open · 2021Article
- Characterisation of the patients with suspected heart failure: experience from the SHEAF registry.Open heart · 2021Article
- Point-of-care testing of (N-terminal pro) B-type natriuretic peptide for heart disease patients in home care and ambulatory care settings.Practical laboratory medicine · 2020Review
- Time trends in the use and appropriateness of natriuretic peptide testing in primary care: an observational study.BJGP open · 2020Article
- Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care.European heart journal. Quality of care & clinical outcomes · 2019Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
14 authors at 6 institutions in 2 countries.
Funding
Abstract
backgroundSymptoms of breathlessness, fatigue, and ankle swelling are common in general practice but deciding which patients are likely to have heart failure is challenging.
aimTo evaluate the performance of a clinical decision rule (CDR), with or without N-Terminal pro-B type natriuretic peptide (NT-proBNP) assay, for identifying heart failure. DESIGN AND
settingProspective, observational, diagnostic validation study of patients aged >55 years, presenting with shortness of breath, lethargy, or ankle oedema, from 28 general practices in England.
methodThe outcome was test performance of the CDR and natriuretic peptide test in determining a diagnosis of heart failure. The reference standard was an expert consensus panel of three cardiologists.
resultsThree hundred and four participants were recruited, with 104 (34.2%; 95% confidence interval [CI] = 28.9 to 39.8) having a confirmed diagnosis of heart failure. The CDR+NT-proBNP had a sensitivity of 90.4% (95% CI = 83.0 to 95.3) and specificity 45.5% (95% CI = 38.5 to 52.7). NT-proBNP level alone with a cut-off <400 pg/ml had sensitivity 76.9% (95% CI = 67.6 to 84.6) and specificity 91.5% (95% CI = 86.7 to 95.0). At the lower cut-off of NT-proBNP <125 pg/ml, sensitivity was 94.2% (95% CI = 87.9 to 97.9) and specificity 49.0% (95% CI = 41.9 to 56.1).
conclusionAt the low threshold of NT-proBNP <125 pg/ml, natriuretic peptide testing alone was better than a validated CDR+NT-proBNP in determining which patients presenting with symptoms went on to have a diagnosis of heart failure. The higher NT-proBNP threshold of 400 pg/ml may mean more than one in five patients with heart failure are not appropriately referred. Guideline natriuretic peptide thresholds may need to be revised.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.