Heart Failure

Initial assessment should include:

• History and examination, looking for peripheral oedema, bibasal crackles, raised JVP
• FBC
• U&E, LFT, ferritin
• NT-proBNP
• ECG

A NT-ProBNP of < 400 pg/mL effectively excludes symptomatic heart failure (the BNP will drop in well controlled heart failure)

NT-ProBNP is not specific to heart failure and levels rise moderately with age, in atrial fibrillation, in chronic kidney disease (typically to around 400-1000 pg/mL). However in the context of a patient with symptoms/signs of heart failure a NT-ProBNP > 400 merits referral for echo.

Very high NTProBNP (>2000 pg/mL) is highly suggestive of heart failure.

While awaiting echo:

• Manage fluid overload (e.g. low-dose loop diuretic such as furosemide 20–40 mg if needed for symptoms and advise about fluid restriction).
• Optimise management of comorbidities (e.g. hypertension, diabetes, COPD).
• Avoid NSAIDs and rate-limiting calcium channel blockers if suspecting HF.

Do not start ACE inhibitors, beta-blockers or mineralocorticoid receptor antagonists until diagnosis confirmed, unless guided by a cardiologist.

SGLT2 (Dapagliflozin) could be considered while awaiting formal diagnosis as it is indicated in both heart failure and heart failure with preserved ejection fraction.

Refer for echo via SCI Gateway...DGRI...Cardiology...Heart Failure if:

• NT-proBNP is >400 pg/mL AND
• patient has clinical features suggestive of heart failure

Include:

• ECG (attach)
• Relevant medical history
• Clinical findings
• Blood results as above

All referrals will be triaged by Clinical Physiology

• Urgent echo will be considered if:
  • NT-proBNP >2000 pg/mL or,
  • Clinical/ECG features suggest significant cardiac dysfunction .

Echo results will be returned to the referring clinician with a clear interpretation.

If a significant abnormality is identified the result will be discussed with the on-call cardiologist. Patients with confirmed LVSD will be referred on directly to the Heart Failure Nurse Specialist (HFNS).

You may also refer patients with confirmed heart failure to general cardiology via SCI Gateway for advice or outpatient review.

Do not refer:

• Patients with no specific symptoms of heart failure
• Patients with normal NTProBNP and no compelling clinical features
• Patients with preserved ejection fraction (see below)

Heart Failure with Preserved Ejection Fraction (HFpEF)

What is HFpEF?

Heart Failure with Preserved Ejection Fraction (HFpEF) is a form of heart failure where patients have typical symptoms and signs of heart failure, but echocardiogram shows normal or near-normal left ventricular systolic function (LVEF ≥50%).

It is common in older adults, especially women, and is often associated with:

• Hypertension
• Atrial fibrillation
• Diabetes
• Obesity
• Chronic kidney disease

Unlike heart failure with reduced ejection fraction (HFrEF), there is no proven disease-modifying treatment, and management is focused on symptom control and comorbidity optimisation.

Management of HFpEF?

If the echo report shows preserved ejection fraction and:

• There are symptoms consistent with heart failure, and
• There is no major structural abnormality requiring cardiology review (e.g. severe valve disease):

Then GPs should:  

1. Manage fluid overload:
   • Consider a loop diuretic (e.g. furosemide 20–40 mg) if oedema or breathlessness.
2. Consider SGLT2 (e.g. Dapagliflozin
3. Optimise comorbidities:
   • Tight control of blood pressure, blood sugar, and atrial fibrillation.
   • Weight management and physical activity as tolerated.
4. Avoid medications that may worsen symptoms:
   • NSAIDs
   • Rate-limiting calcium channel blockers in patients with pulmonary congestion

When to Refer

Consider referral to cardiology for review or advice when:

• There is uncertainty in diagnosis, or
• The patient has refractory symptoms despite optimal treatment, or
• There is another cardiac issue (e.g. arrhythmia, suspected amyloidosis, or severe valve disease)