Cost-effectiveness of N-terminal pro-B-type natriuretic peptide thresholds for echocardiography referral in primary care heart failure management.

“Cost-effectiveness of N-terminal pro-B-type natriuretic peptide thresholds for echocardiography referral in primary care heart failure management. Png ME(1), Tahsina T(1), Jones NR(1), Taylor CJ(1)(2), Petrou S(1), Hobbs R(3)(4). Author information: (1)Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. (2)Department of Applied Health Sciences, University of Birmingham, Birmingham, UK. (3)Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK richard.hobbs@phc.ox.ac.uk. (4)Oxford Institute of Digital Health, University of Oxford, Oxford, UK. 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 UK primary care: echocardiography for all, the European Society of Cardiology (ESC) strategy (NT-proBNP ≥125 pg/mL) and the National Institute for Health and Care Excellence (NICE) strategy (NT-proBNP ≥400 pg/mL). An updated decision-analytical 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 quality-adjusted 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. © Author(s) (or their employer(s)) 2026. No commercial re-use. See rights and permissions. Published by BMJ Group. Conflict of interest statement: Competing interests: CJT reports consultancy and speaker fees from AstraZeneca, Bayer, Edwards and Roche and research funding from Bayer outside the submitted work. All other authors have no competing interests to declare.”