ISBN: 978-1-4731-3093-7 committee noted that according to these recommendations, and the removal of the different diagnostic pathway for those with previous MI, all patients should receive an NT-proBNP level and therefore this recommendation was no longer necessary. The committee also reiterated the importance that patients with very high NT-proBNP levels (>2,000pg/ml) receive an echocardiography promptly (within 2 weeks) due to the association of NT-proBNP levels and prognosis. The committee noted that while an NT-proBNP threshold of 400 pg/mL was most cost-effective, some patients with test results below this threshold and even below 125pg/mL went on to be diagnosed with heart failure in the REFER trial. Therefore, it was important that healthcare professionals were aware that even in people with low NT-proBNP results, heart failure cannot definitively be ruled out. The committee noted that NT-proBNP levels were lower in populations of West African/Afro-Caribbeandescent and also in patients with morbid obesity. The committee agreed that in these patients, alternative causes for their symptoms should be reviewed, and if there is still concern that symptoms may be due to heart failure, this should be discussed with a heart failure specialist. The committee considered that the changes to the recommendations would have limited impact on current practice in terms of the diagnostic pathway. However, laboratories that currently only do BNP testing would have to move to NT-proBNP testing and this may have an initial resource impact with regards to implementation. Suspected heart failure and CKD The committee agreed that studies in patients with CKD stage G5 or receiving dialysis were outside the scope of the review. This was on the basis that these patients would already be receiving specialist clinical review and assessment and were not relevant to a diagnostic pathway focussed primarily on patients presenting to primary care with heart failure symptoms. 