Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Suspected Heart Failure

Heart Failure Suspected

Pathway Publish Date: February 2024
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