Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Left Ventricular Systolic Dysfunction (LVSD)

Left Ventricular Systolic Dysfunction (LVSD) Management

Known Left Ventricular Systolic Dysfunction

If no established diagnosis of heart failure, please see referral for suspected diagnosis of heart failure page

For patients with an established diagnosis of heart failure:

Classify severity according to NYHA score

  • Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
  • Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
  • Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances. Comfortable only at rest.
  • Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Optimise patient management as per pathway attached - pharmacological, management of comorbidities, self-management and lifestyle

  • Stop contraindicated medicines including: NSAIDs and calcium-channel blocker
  • 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)
  • Beta blockers should only be considered when the patient is stable
  • Consider lifestyle management advice
  • Monitor weight and hydration status
  • See relevant pathways elsewhere on website for management of co-morbidities

Indications for referral:

  • Severe heart failure - NYHA Class IV (symptomatic at rest) – refer to specialist multidisciplinary heart failure team
  • Heart failure not responding to treatment – refer to specialist multidisciplinary heart failure team
  • Heart failure that can no longer be effectively managed in the community – refer to specialist multidisciplinary heart failure team
  • If the patient is pregnant, or planning a pregnancy – refer to cardiology for specialist advice
  • If the patient has certain co-morbidities (listed below) – refer to cardiology if  the co-morbidity is: severe, contributing significantly to HF in the patient or  complicating the management of HF
    • Angina
    • Renal impairment (e.g. Creatinine >200)
    • Anaemia
    • Thyroid disease
    • Asthma or COPD
    • Gout
    • Peripheral arterial disease
    • Cardiac valve disease
  • LV ejection fraction <35% and previous MI – refer to cardiology for consideration of complex cardiac conditions CRD-D or ICD
  • NYHA Class III or IV symptoms and known left bundle branch block (LBBB) on ECG – refer for consideration of CRT-D or ICD

Referral letter should include:

  • Type, onset and duration of symptoms
  • Past medical history including cardiac history and significant co-morbidities
  • Examination findings - signs of heart failure and basic observations
  • Current heart failure medications
  • Blood test results as relevant (FBC, U&Es, TFTs, BNP/pro-NT BNP)
  • ECG findings (where indicated)
  • Most recent echo findings