See also the study selection flow chart in Appendix C, sensitivity/specificity forest plots in Appendix E, study evidence tables in Appendix F and excluded studies list in Appendix I. Table 24: Summary of studies included in the review Study Population Target condition Index test Reference standard Comments Patients with CKD who visited Heart failure BNP HF diagnosed based on history, radiological findings, and Very high risk of bias Serious indirectness Chronic Heart Failure Diagnosing heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Study Population Target condition Index test Reference standard Comments Nephrology Department with respiratory distress. echocardiographic findings, which included clinical symptoms fulfilling Framingham s criteria, LVEF < 50% on echocardiography, and LV diameter at end-diastole greater than 5.5 cm. No mention of whether or not a cardiologist carried out this assessment. Only the results of the subgroup of patients with CKD 3-4 have been extracted and reported in accordance with the protocol. Diagnosing heart failure Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Table 25: Clinical evidence summary: diagnostic test accuracy for index test(s) BNP and NT-proBNP Index Test (Population, Target condition, Threshold) No of studies n Quality Sensitivity % (95% CI) Specificity % (95% CI) Positive Predictive Value (PPV) % Negative Predictive Value (NPV) % AUC Plasma BNP BNP CKD stages 3 &4; HF VERY LOWa,b,c due to very serious risk of bias, serious indirectness, serious imprecision The assessment was conducted with an emphasis on test sensitivity as this was identified by the GC as the primary measure in guiding decision making. The GC set the sensitivity threshold of 95% as an acceptable level to recommend a test. (a) Risk of bias was assessed using the QUADAS-2 checklist. 