Heart Failure - Suspected Heart Failure Pathway For Patients With NTproBNP lower than 2000 Or An Existing Heart Failure Diagnosis

Key Messages

  • Patients with a suspected new diagnosis of heart failure AND an NTproBNP 400-1999 should be referred for a Direct Access Echo.
  • All other patients with suspected heart failure should be referred to General Cardiology without requesting a direct access echo:
  1. Patients where there is a high clinical suspicion of heart failure, despite an NTproBNP lower than 400.
  2. Patients with known/previously diagnosed heart failure who have developed new/deteriorating symptoms.
  3. Patients with an NTproBNP 400-1999, where there is clinical uncertainty regarding the interpretation/significance of the result and advice is required prior to requesting a direct access echo (please make this clear in the referral letter).
Please note:
  • The PPV of an NTproBNP result is significantly reduced (estimated to be a drop from ~80% to ~20%) in a patient who does not have classical signs and symptoms of heart failure (PND, orthopnoea, dyspnoea, fluid overload).
  • If you are uncertain regarding the significance of an NTproBNP result, consider a routine cardiology referral, prior to requesting a direct access echo (please make this clear in the referral letter you are asking for A&G).
  • Please see the investigation section for more detail.
BNP also raised in - including:
  • Other causes of left ventricular hypertrophy e.g., aortic stenosis, uncontrolled hypertension.
  • Age over 70 years
  • Atrial fibrillation, tachycardia
  • Right ventricular strain and hypoxaemia e.g., pulmonary embolus, pulmonary hypertension
  • Renal dysfunction (eGFR less than 60 ml/minute/1.73 m2
  • Sepsis, COPD, diabetes, or cirrhosis of the liver
  • BNP can be suppressed by:
  • Diuretics
  • ACEI/ARB
  • Beta blockers
    • Interpret with care

    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.

    Assessment

    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

    Red Flags

    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%)

    Investigations

    • 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.
    BNP also raised in - including:
    • Other causes of left ventricular hypertrophy e.g., aortic stenosis, uncontrolled hypertension.
    • Age over 70 years
    • Atrial fibrillation, tachycardia
    • Right ventricular strain and hypoxaemia e.g., pulmonary embolus, pulmonary hypertension
    • Renal dysfunction (eGFR less than 60 ml/minute/1.73 m2
    • Sepsis, COPD, diabetes, or cirrhosis of the liver
    		BNP can be suppressed by:
    • Diuretics
    • ACEI/ARB
    • Beta blockers
    Interpret with care

    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 must be attached to the referral. This allows for comparison and aids secondary care triage.

    Management

    • 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: South & West Devon

    Referral

    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

    Direct Access Echo Form

    Direct Access Echo Form - EMIS

    Direct Access Echo Form - Systmone

    Supporting Information

    Pathway Group

    This guideline has been signed off by NHS Devon

    Publication date: May 2023

    Last updated: 30-05-2023

     

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