Borders Ref Help Toolkit
Heart Failure Diagnostic Referral Pathway
This pathway has been introduced throughout NHS Borders to support the diagnosis of heart failure. Please follow the link below to the Heart Failure Diagnostic Referral Pathway flowchart which contains the key information.
Follow link for Borders heart failure pathway
Essential Investigations If patient symptoms and/or signs are suggestive of heart failure, check: • NT-pro BNP blood test (< 400ng/L suggests heart failure is unlikely) and ECG
- Full blood count (anaemia may cause breathlessness)
- If new symptoms of breathlessness are present, a chest x-ray should be considered (if not performed within the preceding six months). Chest x-ray may show suspicion of heart failure and/or lung disease
- HbA1c (high prevalence of diabetes in LVSD)
- Thyroid function tests (hypothyroidism may cause heart failure)
- Blood chemistry (renal function prior to initiation of disease modifying therapies)
- Echocardiogram (use Heart Failure Diagnostic Pathway; this will incorporate ECG and/or NT-pro BNP)
- Serum albumin (to exclude nephrotic syndrome)
Blood tests
If the NT-proBNP level is above the diagnostic threshold and the clinical history is consistent with heart failure, then the patient should be referred for open access echo via order comms.
Who to refer:
Inclusion criteria
Any patient who meets all referral criteria can be referred via this pathway:
- Exertional or nocturnal dyspnoea: new-onset or major worsening
- No echo or cardiology review (for dyspnoea) within last 12 months
- No history of complex coronary, valvular, arrhythmic or congenital heart disease and not currently under long term supervision by a Cardiology Consultant.
Heart Failure with Preserved Ejection Fraction (HFpEF)
The diagnosis of HFpEF remains challenging. The European Society of Cardiology recommend that HFpEF be considered in those with symptoms and signs of heart failure, a LVEF of ≥ 50% and objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures, including raised natriuretic peptides.
Management of atrial fibrillation, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, dyslipidaemia, hypertension and obesity are recommended as potential modifiable cardiac risk factors.
Diuretics are recommended to relieve congestion
Prescription of SGLT2i is indicated.
Frailty
Frailty is a multisystemic process leading to reduction of physiological reserve and a reduction in physical activity.
Heart failure is recognised as a global cause of morbidity and mortality, increasing in prevalence over recent decades.
Due to shared phenotypes and comorbidities, there is significant overlap and a bidirectional relationship, with frail patients being at increased risk of developing heart failure and vice versa.
While an attempt should be made to establish all patients with heart failure on guideline directed therapy, not all patients will tolerate all four agents/all four agents at full dose (e.g. due to symptomatic hypotension).
A person-centred approach, taking frailty and comorbidities into account is required to attain appropriate optimisation of therapy.
Consider seeking advice from care of the elderly team
Personalised Management
Initiation of heart failure therapy should be based on individualised assessment of the patient’s aetiology, symptom burden, clinical parameters and co-morbidities.
Sick Day Rules
Counsel patients to seek medical advice if diarrhoea and/or vomiting persist for more than 48 hours
Heart Failure Liaison Nurse Service
Patients diagnosed with moderate to severe left ventricular systolic impairment are reviewed by heart failure specialist nurses for optimization of heart failure medications.
Once heart failure symptoms are stable, treatment is optimised and appropriate self-management and social needs are met, patients will no longer receive planned HFLNS support. Any patient who develops worsening heart failure symptoms who are known to heart failure services should be referred through SCI Gateway for specialist advice if clinical deterioration.