{
  "abstract": "Introduction Inpatient demand for transthoracic echocardiography (TTE) for suspected heart failure (HF), triggered by elevated age-adjusted N-terminal pro-B-type natriuretic peptide (NT-proBNP), increasingly exceeds capacity at this district general hospital. The biomarker’s modest specificity results in low-yield referrals and delayed imaging for patients with heart failure with reduced ejection fraction (HFrEF), where guideline-directed medical therapy (GDMT) requires confirmation of ejection fraction (EF) <40%. ECG and chest radiography (CXR) are routinely available but not consistently captured at echocardiography referrals; incorporating them may improve scientist triage, protect capacity, and expedite imaging for patients most likely to benefit.Methods We conducted a retrospective service evaluation of adult inpatients with elevated age-adjusted NT-proBNP who underwent TTE between December 2024 and March 2025 (n = 50). ECG and CXR results closest to NT-proBNP sampling were retrospectively reviewed. ECG was abnormal if ≥1 predefined abnormality was reported; CXR if ≥2 HF-related radiographic features were reported. TTE served as the reference standard for diagnosis of HF, including HFrEF, HFmrEF, HFpEF, and cor pulmonale, with left ventricular EF classified per ESC guidelines. Four triage strategies, combining NT-proBNP with ECG and/or CXR, were assessed for sensitivity, specificity, and positive predictive value (PPV), as well as the number of TTEs required to confirm a diagnosis of HF.Results HF was confirmed in 31 patients (PPV 62%), including 20 with HFrEF. Using NT-proBNP alone, efficiency was limited: 1.61 TTEs per confirmed HF and 2.50 TTEs per confirmed HFrEF. Adding CXR markedly improved specificity (94.7%) and PPV (95.7%) and reduced activity to 1.05 TTEs per confirmed HF. Incorporating ECG increased sensitivity (93.6%) but reduced specificity (52.6%), increasing imaging demand (1.31 TTEs per confirmed HF). ECG-inclusive strategies maximised case capture but at the expense of increased false-positive triage. In the HFrEF subgroup, CXR-based strategies identified 80% of cases with good specificity (76.7%) and required 1.44 TTEs per confirmed HFrEF, whereas ECG-inclusive strategies achieved 95%–100% sensitivity but with reduced efficiency.Conclusion NT-proBNP alone is an inefficient criterion for prioritising inpatient TTE, particularly for identifying HFrEF. Integrating routinely available CXR - and selectively ECG -improves scientist triage and prioritisation under capacity constraints. The results informed the adoption of a structured, tiered inpatient TTE triage pathway, prioritising patients with abnormal CXR (± ECG) for expedited imaging while de-escalating low-yield referrals. This approach protects limited TTE capacity while supporting timely confirmation of HFrEF and initiation of GDMT within a HF risk-stratification and triage framework.Abstract 434 Table 2Diagnostic performance and echocardiography efficiency of triage strategies. Diagnostic accuracy and service efficiency of inpatient triage strategies combining age-adjusted NT-proBNP with electrocardiography (ECG) and chest radiography (CXR), using transthoracic echocardiography as the reference standard for heart failure (HF) and heart failure with reduced ejection fraction (HFrEF). Sensitivity (Sens), specificity (Spec), positive predictive value (PPV), and negative predictive value (NPV) are reported where calculable. Echoes per true HF and Echoes per true HFrEF represent the number of echocardiograms required to confirm one case of HF and HFrEF, respectively, reflecting imaging efficiency and relevance to timely initiation of guideline-directed medical therapy in capacity-limited inpatient services.Abstract 434 Table 1Cohort characteristics and heart failure yield. Baseline demographic and biochemical characteristics of the inpatient cohort with elevated age-adjusted NT-proBNP included in the service evaluation. Data are presented as mean ± standard deviation or number (percentage). Heart failure (HF) and heart failure with reduced ejection fraction (HFrEF) were confirmed by transthoracic echocardiography and used as the reference standard.Abstract 434 Figure 1Diagnostic performance of inpatient TTE triage strategies. Bars represent sensitivity, specificity, and positive predictive value (PPV) for each triage strategy, using transthoracic echocardiography as the reference standard. NT-proBNP alone is shown for comparison using PPV only, as sensitivity and specificity could not be calculated due to cohort inclusion criteria requiring elevated NT-proBNPAbstract 434 Figure 2Echocardiography efficiency of NT-proBNP-based triage strategies. Bars represent the number of echocardiograms required per confirmed diagnosis for service- feasible triage strategies incorporating ECG and/or chest radiograph findings. Lower values indicate greater diagnostic efficiency. The most operationally relevant triage strategies are represented",
  "authors": [
    {
      "affiliations": [
        "Warrington and Halton Hospitals NHS Foundation Trust, WARRINGTON, United Kingdom"
      ],
      "name": "Walter Genco"
    }
  ],
  "title": "434 Beyond NT-proBNP: Improving Diagnostic Yield in NT-proBNP-Triggered inpatient echocardiography with chest radiography and ECG. A service evaluation",
  "uid": "adc7e7f0-1a80-54a6-a815-69a1028e4e1c"
}