Suspected heart failure and CKD One diagnostic accuracy study was included that evaluated the diagnostic accuracy of BNP at diagnosing heart failure in a population with CKD and respiratory distress. The reference standard used in the study was unclear and may not have fully matched the protocol, but the study was included in the review in the absence of any direct evidence. The evidence was graded very low quality due to very high risk of bias, serious indirectness and serious imprecision. Risk of bias was very high due to it being unclear how participants were selected, unclear whether the reference standard was applied blind to BNP results, and unclear whether any patients were lost to Chronic Heart Failure Diagnosing heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 follow up or missing from the analysis. Only the results of the subgroup of patients with CKD stages G3 to G4 were reported in accordance with the protocol. Suspected heart failure and AF No diagnostic accuracy studies meeting the protocol were identified. Six studies in an acute population or setting, and another study with a target condition of major structural heart disease , were identified. After discussion, the committee agreed that these studies should not be included in the review, despite the absence of any direct evidence, as they would not provide reliable evidence in the population of interest. Trade-off between clinical benefits and harms For the reasons outlined above, the committee s discussion of the clinical evidence focussed on NT-proBNP rather than BNP. General suspected heart failure population BNP and NT-proBNP are used as a triage test, with people whose results are above a certain threshold being referred for echocardiography and specialist clinical assessment, following which a definitive diagnosis can be made. 