Heart Failure - Known/previously diagnosed


Adults (over 18 years of age) with a diagnosis of heart failure made by a cardiologist or heart failure specialist, who are not under active cardiology follow-up

Out of Scope

  • Patients under active cardiology follow-up (refer back to usual consultant directly)
  • Adults (over 18 years of age) with suspected undiagnosed heart failure (refer via the undiagnosed heart failure pathway)
  • Patients requiring access to the heart failure nurses (refer directly to the community teams - Community Cardiac Service).
  • Patients who cannot attend hospital appointments
  • Patients with severe competing comorbidity such that further investigation and specialist management of their heart failure are unlikely to improve quality of life or other outcomes.


The clinical features of Heart Failure are notoriously non-specific.

Causes include:
  • Ischaemic Heart Disease
  • Cardiomyopathy
  • Hypertension
Signs and symptoms include:
  • Shortness Of Breath On Exertion (SOBOE)
  • Orthopnoea
  • Paroxysmal Nocturnal Dyspnoea (PND)
  • Bilateral leg oedema
  • Sacral oedema
  • Pulmonary oedema
  • Raised Jugular Venous Pressure (JVP)
  • Ascites
  • Hepatomegaly
  • Tachycardia with additional heart sounds/ gallop rhythm

Please see the Management section for indications for immediate referral to secondary care

Baseline Observations should include:
  • Heart Rate (HR)
  • Heart Rhythm
  • Respiratory Rate (RR)
  • Blood Pressure (BP)
  • Weight


Investigations to consider:

  • Blood tests
    • e.g., BNP or NT pro-BNP, FBC, U&E, Ferritin, Transferrin Saturation, LFT, HbA1c, Lipids, TFT,
  • ECG
  • Echo
  • CXR
  • Spirometry (if concurrent Chronic Obstructive Pulmonary Disease (COPD)/ lung disease is suspected)

Red Flags

Reasons to consider immediate referral to secondary care for suspected acute heart failure include:

  • 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% (in a patient without COPD)
  • agitation
  • Associated chest pain
  • General signs of hypoperfusion:
    • cool, clammy skin
    • cyanosis or pallor
  • Syncope, dizziness, or altered level of consciousness
  • Associated haemoptysis or frothy pink sputum

Clinical advice can be sought through the acute medical team if in doubt


Address reversible causes e.g., alcohol, drugs

Manage aggravating co-morbidities e.g., anaemia, AF, thyrotoxicosis

Review aggravating drugs e.g., NSAIDs, CCBs, Steroids, Glitazones, alpha blockers

For prescribing advice, please refer to the appropriate joint formulary – Chronic Heart Failure


Referral to Cardiology for:
  • Specialist advice regarding clinical management
  • Severe valve disease
    • Surgical intervention
  • e-Referral service selection:
    • Specialty: Cardiology
    • Clinic Type: Heart Failure
    • Service: DRSS-Western-Cardiology-Devon CCG-15N / DRSS-Western-Cardiology-Cornwall-Devon CCG-15N
Referral to Heart Failure Cardiology Clinic for:

Consideration for cardiac resynchronisation therapy or implantable cardioverting defibrillator therapy. To qualify the patient should have:

  • Optimal medical therapy
  • NYHA of any class
  • LVEF lower than 35%

Consideration of specialist initiation drugs such as sacubitril-valsartan or dapagliflozin.

Referral to Community Cardiac Specialist Nurses where locally available for:

The Community Cardiac Service Specialist Nurses remit is to aid with the management of patients with a diagnosis by a cardiologist or heart failure specialist of confirmed heart failure, or patients requiring Cardiac Rehabilitation. All patients must meet one of the Referral Criteria below and be referred on a fully-completed referral form - Community Cardiac Service).

Email: Livewell.communitycardiacteam@nhs.net

Referral Criteria

  • Adults (over 18 years of age) with a diagnosis of heart failure made by a cardiologist or heart failure specialist with:
    • Left Ventricular Systolic Dysfunction with Ejection Fraction 40% or lower
    • Symptomatic Right sided failure – diagnosed on echo as “Dilated Right Ventricle”
    • Severe diastolic dysfunction
    • BNP above 400 and “housebound” i.e. Unable to attend for an echo and symptomatic
  • Cardiac Rehabilitation after:
    • STEMI
    • NSTEMI
    • Same day emergency PCI
    • CABG
Refer to Long Term Conditions Self-Management Programme Improving Lives Plymouth for:
  • Patient support with any long-term physical or low-level mental health condition.

The service helps people to better manage their condition and to achieve a better quality of life.

Referral for echocardiogram only, complete request form below:
  • Refer via e-Referral system:
    • Speciality: Diagnostic Physiological Measurement
    • Clinic Type: Cardiac Physiology – Echocardiogram
    • Service: DRSS--Echocardiogram-NEW Devon CCG- 99P

Referral forms

Direct Access Echocardiography request form

DRSS referral form

Supporting Information

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NHS Devon CCG.

Publication date: August 2021

Publication date: August 2021


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