Lack of Left Ventricular Ejection Fraction Measurement Following a High B-type Natriuretic Peptide Value

The objective of this study was to determine how often providers did not obtain a recommended measure of left ventricular ejection fraction (LVEF) following a high B-type natriuretic peptide (BNP) value when the LVEF was not known to be low (<40%). Such patients may benefit from life-prolonging treatment.

We identified consecutive patients (inpatient or outpatient) with a BNP value of at least 200 pg/mL within a single VA health care system (3 inpatient facilities and 8 community clinics) during a 10-month period (September 2008-June 2009). We performed chart review to determine results of any imaging study performed (inside or outside the health system) prior to or after the high BNP value.

Of the 296 patients with a high BNP, 212 were not known to have a low LVEF. Of these, 99 (47%) did not have the guideline recommended follow-up LVEF study. Among those that survived at least 6 months following BNP and a follow-up echocardiogram was indicated (no prior LVEF or prior LVEF was > 40%), mortality was 20% if an echocardiogram was performed within 6 months of the BNP and 27% if it was not performed within 6 months of BNP testing (P = 0.21).

Approximately half of patients with a high BNP and an LVEF not known to be low did not have a follow-up guideline recommended LVEF study and may have unrecognized heart failure. Our findings suggest that a trial is warranted of a clinical pathway where those patients with a high BNP and without appropriate follow-up are randomized to have their physician receive a notification of the high BNP value.