Heart Failure

Introduction

Heart failure (HF) is the impaired ability of the heart to maintain the circulation of blood due to a structural or functional impairment of ventricular filling or ejection.
50% per cent of patients with heart failure die within 5 years of diagnosis, and 40% of patients admitted with heart failure will die or be readmitted within 1 year.
A normal LVEF is considered as greater than or equal to 50%, but patients may still have a heart failure syndrome with a ‘normal’ LVEF (they will usually have other structural changes on echocardiogram either at rest or on exertion).

In scope

Patients with confirmed or suspected HF and NT-proBNP >400pg/ml
Patients with an incidental diagnosis of HF on an echocardiogram showing left ventricular ejection fraction (LVEF) <50% within the last 12 months.

Not in scope

Patients who are currently under a named cardiologist or the community cardiac teams who are actively involved in managing their care. Please contact the consultant or community team (they will liaise with consultant in complex cases) directly.
Patients <16 years of age. Please refer to Paediatrics.

Red Flag Features

Signs and symptoms of acute decompensated heart failure

Investigations required prior to referral

Recent ECG

Blood tests (within 1 month) “Heart Failure (Adults)” on ICE advised: which includes base line tests:

NT-ProBNP (unless echocardiogram within 12 months shows LVEF <50%)
FBC, UE, Albumin ,TSH (FT4)
Second line tests are only reported if BNP >400 (existing results may be re-reported if within 3 months): Iron Saturation, Ferritin and Hba1c
CXR and spirometry if NT-proBNP lower than 400pg/ml advised.
Community echocardiograms should not be requested to diagnose HF. This is due to the particular challenges surrounding HFpEF diagnoses and, as per NICE recommendations, patients with raised NT-proBNP should not be offered an open-access echocardiogram from primary care unless the provider is fully integrated with the local acute heart failure service. Therefore, please refer all suspected cases of heart failure with raised NT-proBNP via the single point of access service.

Management optimisation

Please see NICE CKS for management of:

Implantable Cardioverter defibrillators (ICDs) and Cardiac Resynchronisation therapy (CRT)

Recommended for treating people with previous serious ventricular arrhythmia, without a treatable cause eg:

have survived a cardiac arrest caused by VT or VF or
have spontaneous sustained VT causing syncope or significant haemodynamic compromise or
have sustained VT without syncope or cardiac arrest, and also have an associated reduction in LVEF of 35% or less but their symptoms are no worse than class 3 of the NYHA functional classification of heart failure.

those who have a familial cardiac condition with a high risk of sudden death, such as long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or arrhythmogenic right ventricular dysplasia or have undergone surgical repair of congenital heart disease.
ICD,CRT, CRT with defibrillator (CRT-D) or CRT with pacing (CRT-P) are recommended as treatment options for people with heart failure who have left ventricular dysfunction with a LVEF of 35% or less.

End-stage heart failure

People can be regarded as being in end-stage heart failure if they are at high risk of dying within the next 6–12 months. The Prognostic Indicator Guidelines can be used to estimate prognosis

Indicators of end-stage heart failure include:

Frequent hospital admissions
Severe breathlessness at rest (New York Heart Association class IV).
Presence of cardiac cachexia.
Low serum albumin, Progressive deterioration in eGFR and hypotension
Poor quality of life and dependence on others for most activities of daily living.
People who are clinically judged to be close to the end of life.

Advice and Guidance

Send Cardiology advice and guidance via eRS for queries including initiating ARNIs, SGLT2 inhibitors and Spironolactone.

Referral instructions

Emergency

Via ED-consider calling 999.

Severe dyspnoea
Collapse

Same day assessment

arrange admission via Acute GP.

Decompensated heart failure
Acute deterioration in condition

Urgent cardiology referral criteria

NT-proBNP >2,000pg/ml will be triaged for an echo within 2 weeks and specialist review

Routine cardiology referral criteria

NT-proBNP 400-2,000pg/ml (will be triaged for an echo within 6 weeks and a specialist review depending on the case.)
Incidental diagnosis of HF on an echocardiogram showing left ventricular ejection fraction (LVEF) <50% within the last 12 months.
Established diagnosis of HF with uncontrolled/worsening symptoms and NT-proBNP >400pg/ml (this helps determine the aetiology of current symptoms and risk-stratify the urgency of review needed)
NT-proBNP <400pg/ml will be considered on a case-by-case basis if it can be demonstrated that other common causes for the patients’ symptoms have been excluded/optimised (anaemia, thyroid disease, respiratory/renal/liver disease, nutritional state (including iron, B12 and folate) and fluid retaining drugs (eg. calcium channel blockers, NSAIDs, steroids, glitazones)

Required information for referral

Recent ECG
Blood tests (within 1 month):

ICE Order Set “Heart Failure (Adults) Investigation” advised -FBC, UE, Albumin, TSH (FT4), NT-ProBNP (unless echocardiogram within 12 months shows LVEF <50%)

If BNP >400: Iron Saturation, Ferritin and Hba1c will be reported.
CXR and spirometry if NT-proBNP lower than 400pg/ml advised

Community Cardiac Specialist Nurse Service

Provide monitoring and/or optimisation of heart failure medication for patients with:

echo performed within the last 12 months. AND
proven left ventricular systolic dysfunction (LVSD) diagnosed on Echocardiogram or Cardiac MRI with an ejection fraction (EF) ≤ 40% OR
up to 45% if moderate/severe mitral regurgitation present.

Refer by letter with a brief summary of symptoms, sent to cpn-tr.CommunityCardiacServices@nhs.net

Supporting Information

For professionals

Heart Failure NICE CKS

For patients

Heart failure | British Heart Foundation - BHF

References

Page Review Information

Review date	28 March 2025
Next review date	28 March 2027
Clinical editor	Dr Melanie Schick
Contributors	Dr Parminder Chaggar, Consultant Cardiologist, RCHT