A false negative result would either require re-testing, or could result in hospitalisation if an acute episode occurred prior to diagnosis. They therefore considered that taking into consideration the above that NT- proBNP and that the majority of labs now run NT-proBNP, some of them teaching hospitals which receive a high volume of tests, that only recommending NT-proBNP would not have a substantial resource impact for the NHS in England. One economic analysis was identified for this review assessing NT-proBNP thresholds. This study compared the MICE (Male, Infarction, Crepitations, (o)Edema) clinical decision rule using the upper NT-proBNP cut-off, the MICE clinical decision rule using the lower NT-proBNP cut-off, the 2010 NICE guideline recommended strategy (refer straight away for echocardiography if history of previous myocardial infarction (MI), otherwise refer for echocardiography if NT-proBNP>400pg/ml), NT-proBNP threshold of 125pg/ml, echocardiography for all, and do nothing. This analysis found that the 2010 NICE guideline strategy was the most cost effective approach for diagnosing heart failure in patients with suspected heart failure. This analysis was assessed as partially applicable with potentially serious limitations. The committee raised the following limitations of this economic evaluation. Firstly, this analysis used diagnostic accuracy data from the REFER study where the level of NT-proBNP had been used as a criterion in determining whether or not the patient had heart failure. The committee were concerned that this had introduced incorporation bias to the diagnostic accuracy results, Chronic Heart Failure Diagnosing heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 potentially biasing the overall results of the model. 