Signs and symptoms include:

• Shortness Of Breath On Exertion (SOBOE)
• Orthopnoea
• Paroxysmal Nocturnal Dyspnoea (PND)
• Bilateral leg oedema
• Sacral oedema
• Raised Jugular Venous Pressure (JVP)
• Hepatomegaly
• Tachycardia with additional heart sounds/ gallop rhythm

Please see the ‘Red Flags’ section for indications for same day secondary care discussion/admission.

Baseline Observations should include:

• Heart Rate (HR)
• Heart Rhythm
• Respiratory Rate (RR)
• Oedema (pedal and sacral)
• Blood Pressure (BP)
• Weight

Same Day Secondary Care discussion/admission for:

• Acute pulmonary oedema - suggested by crepitation’s throughout the lung
• Severe dyspnoea (shortness of breath) or respiratory distress, indicated by:
  • sudden onset
  • dyspnoea at rest
  • orthopnoea
  • oxygen saturation of less than 90%
  • agitation
  • associated haemoptysis or frothy pink sputum
• Associated chest pain
• Pulmonary oedema in the context of a tachyarrhythmia, e.g., fast atrial fibrillation (AF)
• General signs of hypoperfusion:
  • cool, clammy skin
  • cyanosis or pallor
• Syncope, dizziness, or altered level of consciousness

Urgent Referral to Secondary Care for:

• Direct Access Echo result highlighting significant abnormalities (e.g., EF lower than 40%)

NTproBNP

• NTproBNP is very sensitive but not very specific i.e. identifies possible heart failure but does not confirm a diagnosis.
• NTproBNP can also be depressed by concurrent use of drugs.

Other Blood Tests

• FBC and U&E
  taken within the last 6 months and attached to the referral is mandated for this pathway
• Although not mandated, please request a HbA1C, Ferritin and Transferrin Saturation when clinically indicated.
  Having these results available allows the specialists to consider all therapeutic options without the delay caused by requesting additional tests.

Electrocardiogram (ECG); in systolic heart failure a normal ECG is unusual

• ECG features of ischaemia are common
• In diastolic failure the ECG may show signs of Left Ventricular Hypertrophy (LVH) or be normal
• An ECG should be attached to the referral. This allows for comparison and aids secondary care triage.

For all patients with suspected heart failure and a positive NTproBNP please consider starting treatment with a loop diuretic immediately. Advice can be found on the Devon Formulary guidelines here.

Scope

• Adults (over 18 years of age) with suspected heart failure and an NTproBNP lower than 2000
• Adults (over 18 years of age) with known/previously diagnosed heart failure who have developed new/deteriorating symptoms

Out of Scope

• Adults (over 18 years of age) with suspected undiagnosed heart failure and an NTproBNP greater than 2000

These patients warrant urgent referral via the ‘Suspected Heart Failure For Patients With NTproBNP greater than 2000’ pathway

Referral Criteria:

• Adults (over 18 years of age) with suspected/previously diagnosed heart failure

AND

• FBC and U&E taken within the last 6 months (results attached)

AND

• ECG (result attached)

AND

• A direct access transthoracic echocardiogram (result attached) has confirmed a diagnosis of heart failure*

*unless requesting A&G on the appropriateness of a direct access echo request. Please make this clear in the referral letter.

Referral Instructions

Referral to: Suspected Heart Failure Pathway For Patients With NTproBNP lower than 2000 Or An Existing Heart Failure Diagnosis

e-Referral service selection:

• Specialty: Cardiology
• Clinic Type: Heart Failure
• Service: South = DRSS South Devon & Torbay – Cardiology Devon ICB – 15N

Referral Forms

DRSS referral form

Direct Access Echo Form

Direct Access Echo Form - EMIS

Direct Access Echo Form - Systmone

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: August 2021

Last updated: May 2023