RAG rating

n/a

Document type

Clinical pathways

Place

Hertfordshire and West Essex ICB

Output type

Clinical Pathways

Pathway

Suspected Heart FailureHeart failure with reduced ejection fraction (HFrEF) in primary care (Confirmed) | Follow up pathway

Heart Failure

Next Review Date: February 2026

• Conduct cardio vascular examination, assess for red flags (see pathway)
• Perform ECG
• Take BNP/ pro-NT BNP
• FBC, U&Es, LFTs, TFTs, HbA1c/glucose

The following patients should be referred to emergency care:

• Acute pulmonary oedema
• Symptoms and signs of heart failure associated with
  • Anginal chest pain at rest – suggestive of possible acute coronary syndrome (ACS)
  • Tachyarrhythmias
  • Syncope or pre-syncope
  • Severe fluid retention            
• Heart failure with symptomatic hypotension and signs of hypoperfusion, e.g. cold peripheries, cyanosis, confusion

Suspected heart failure and previous myocardial infarction - refer to rapid access heart failure clinic

BNP/ pro-NT BNP normal - unlikely to be heart failure, consider differential diagnosis (see pathway)

Suspected heart failure and BNP >400 or Pro-NT BNP >2000 - refer to rapid access heart failure clinic

Suspected heart failure and BNP 100-400 or Pro-NT BNP 400-2000 - refer for direct access ECHO (available at the Lister.  NB: if direct access ECHO not available refer to heart failure clinic)

ECHO results:

• Minor abnormality or normal ECHO - consider diferential diagnosis
• Abnormal results follow instructions on interpretation guide

Consider referral for ongoing specialist advice:

• For the management of:
  • Severe heart failure (New York Heart Association [NYHA] class II-IV)
  • Heart failure that does not respond to treatment in primary care or can no longer be managed in the home setting
  • Heart failure resulting from severe valvular heart disease
  • New left ventricular systolic impairment (ejection fraction of 45% or less)
• If the patient is pregnant, or is planning a pregnancy
• If the patient has certain co-morbidities (e.g. angina, renal impairment (e.g. Creatinine >200), anaemia, thyroid disease, asthma/COPD, gout, peripheral arterial disease, valve disease)
• For consideration of CRT-D or ICD if:
  • LV ejection fraction  <35% and patient has had previous myocardial infarction; OR
  • NYHA Class III or IV symptoms and known left bundle branch block (LBBB) on ECG

Include in referral:

• Type, onset and duration of symptoms
• Past medical history including cardiac history
• Examination findings- signs of heart failure and basic observations
• BNP/pro-NT BNP levels
• Routine bloods, including creatinine, thyroid function and blood glucose
• ECG findings
• Most recent ECHO findings 

Recommendations for management:

• Stop contraindicated medicines including: NSAIDs and calcium-channel blockers
• Consider a loop diuretic as symptom management. Titrate dose to control symptoms
• Monitor urea and electrolytes at baseline and 1-2 weeks after medication initiation (or dose increase)
• Monitor weight and hydration status

Patient information leaflet: Suspected Heart Failure