Clinical pathway for patients with suspected heart failure in primary care: Recommendations guided by NT-proBNP testing

Heart failure (HF) is a highly prevalent condition that contributes significantly to morbidity, mortality, and healthcare burden worldwide. In Portugal, the PORTHOS study estimated that 16.5% of adults aged 50 years and older have HF, underscoring the urgent need for earlier detection and optimized care pathways. N-terminal pro-B-type natriuretic peptide (NT-proBNP) has emerged as a key biomarker for HF screening, diagnosis, and prognosis. The recent reimbursement of NT-proBNP testing in Portuguese primary care represents a critical opportunity to enhance HF detection and management. This position paper provides evidence-based recommendations for clinical pathways following an elevated NT-proBNP result. We advocate for NT-proBNP measurement in individuals over 50 years old with diabetes, diuretic use, or symptoms such as fatigue, dyspnea, or congestion. Age-specific cut-off values are recommended: ≥125 pg/mL for ages 50-79 and ≥250 pg/mL for those aged 80 and older. Confirmatory testing using echocardiography and electrocardiography is essential for diagnosis and management planning. Ensuring smooth transitions between primary and secondary care is vital to improving outcomes. We highlight challenges in continuity of care and emphasize the importance of multidisciplinary collaboration, along with the adoption of digital tools to strengthen communication. Integrating NT-proBNP testing into routine practice will enable earlier diagnosis, timely intervention, and more efficient healthcare delivery. A coordinated approach that combines clinical best practices, public health strategies, and active patient engagement is essential to reducing HF-related morbidity and mortality.