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Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf): none. The guideline authors’ full statements can be viewed at https://www.nice.org.uk/guidance/ng241/history.

Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf):

Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/about/who-we-are/policies-and-procedures).

Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (available at link [https://www.nice.org.uk/Media/Default/Get-involved/Fellows%20and%20scholars%20unsecure/Conflicts-of-interest-policy.pdf]). Provenance and peer review: commissioned; not externally peer reviewed.

Competing Interests: Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf). PE: provides medico-legal reports (which may include giving an opinion on life expectancy with children with cerebral palsy); trustee of Castang Foundation, a charity that supports research and management of cerebral palsy; has published a paper on long term and social impact of hypoxic-ischaemic encephalopathy; and completed an unpaid interview with an American pharmaceutical company about improvements in outcomes for 0-6 year olds. CF: was the chair for the NICE clinical guideline “Cerebral palsy in under 25s: assessment and management”; trustee of Whizz Kidz, a charity that funds powered mobility aids for children.

Competing Interests: Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (available at www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf): RP received payments to present a BMJ Mastercourses webinar on common problems in newborns and infants and a webinar on feeding problems in infants, and to conduct teaching with BMJ Learning.

Competing Interests: Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (available at http://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf): MD and CO have private practice that may include treating women with endometriosis. These authors’ full statements can be viewed at www.bmj.com/content/bmj/358/bmj.j3935/related#datasupp.

Objectives: To determine and compare the diagnostic accuracy of serum natriuretic peptide levels (B type natriuretic peptide, N terminal probrain natriuretic peptide (NTproBNP), and mid-regional proatrial natriuretic peptide (MRproANP)) in people presenting with acute heart failure to acute care settings using thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure., Design: Systematic review and diagnostic meta-analysis., Data Sources: Medline, Embase, Cochrane central register of controlled trials, Cochrane database of systematic reviews, database of abstracts of reviews of effects, NHS economic evaluation database, and Health Technology Assessment up to 28 January 2014, using combinations of subject headings and terms relating to heart failure and natriuretic peptides., Eligibility Criteria for Selecting Studies: Eligible studies evaluated one or more natriuretic peptides (B type natriuretic peptide, NTproBNP, or MRproANP) in the diagnosis of acute heart failure against an acceptable reference standard in consecutive or randomly selected adults in an acute care setting. Studies were excluded if they did not present sufficient data to extract or calculate true positives, false positives, false negatives, and true negatives, or report age independent natriuretic peptide thresholds. Studies not available in English were also excluded., Results: 37 unique study cohorts described in 42 study reports were included, with a total of 48 test evaluations reporting 15 263 test results. At the lower recommended thresholds of 100 ng/L for B type natriuretic peptide and 300 ng/L for NTproBNP, the natriuretic peptides have sensitivities of 0.95 (95% confidence interval 0.93 to 0.96) and 0.99 (0.97 to 1.00) and negative predictive values of 0.94 (0.90 to 0.96) and 0.98 (0.89 to 1.0), respectively, for a diagnosis of acute heart failure. At the lower recommended threshold of 120 pmol/L, MRproANP has a sensitivity ranging from 0.95 (range 0.90-0.98) to 0.97 (0.95-0.98) and a negative predictive value ranging from 0.90 (0.80-0.96) to 0.97 (0.96-0.98). At higher thresholds the sensitivity declined progressively and specificity remained variable across the range of values. There was no statistically significant difference in diagnostic accuracy between plasma B type natriuretic peptide and NTproBNP., Conclusions: At the rule-out thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure, plasma B type natriuretic peptide, NTproBNP, and MRproANP have excellent ability to exclude acute heart failure. Specificity is variable, and so imaging to confirm a diagnosis of heart failure is required. There is no statistical difference between the diagnostic accuracy of plasma B type natriuretic peptide and NTproBNP. Introduction of natriuretic peptide measurement in the investigation of patients with suspected acute heart failure has the potential to allow rapid and accurate exclusion of the diagnosis., (© Roberts et al 2015.)