Heart Failure - Suspected Heart Failure For Patients With NTproBNP lower than 2000 or known/previously diagnosed Heart Failure

The clinical features of heart failure are notoriously non-specific, emphasising the need for diagnostic tests such as the NTproBNP level and echocardiography

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
• Raised Jugular Venous Pressure (JVP)
• Hepatomegaly
• Tachycardia with additional heart sounds/ gallop rhythm

Please see the ‘Red Flags’ section for indications for immediate referral to secondary care

Baseline Observations should include:

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

Immediate Referral to Secondary Care 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 chest pain
• Symptomatic Tachyarrhythmia, e.g., fast atrial fibrillation (AF)
• General signs of hypoperfusion:
  • cool, clammy skin
  • cyanosis or pallor
• Syncope, dizziness, or altered level of consciousness
• Associated haemoptysis or frothy pink sputum
• Generalised oedema

NTproBNPis mandatory where heart failure is suspected

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

• Please note that NTproBNP willalso be elevated in patients with AF and so will not help to distinguish between the breathlessness of inadequate rate control and that of possible heart failure
• For patients with uncontrolled AF and no overt fluid overload (raised JVP, oedema) please consider rate control before checking NTproBNP. If the patient remains symptomatic with possible heart failure after rate control then check NTproBNP and refer. If minimally symptomatic at that stage consider general cardiology referral.
• A normal NTproBNP makes a diagnosis of heart failure very unlikely unless the patient is already established on treatment

• 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

• Patients with suspected heart failure but an NTproBNP of 400-1999
• Patients with suspected heart failure and an NTproBNP lower than 400 but high clinical suspicion where other causes of breathlessness have been excluded
• Patients with suspected heart failure and under active cardiology follow-up for another cardiology issue
• Patients with known/previously diagnosed heart failure
• Patients with incidentally discovered left ventricular systolic dysfunction

Out of Scope

• The following patients warrant referral to Suspected Heart Failure For Patients With NTproBNP greater than or equal to 2000
  • Adults (over 18 years of age) with suspected undiagnosed heart failure and an NTproBNP greater than or equal to 2000

• The following patients can be referred directly to the Community Cardiac Service
  • Patients who have previously been referred to the community cardiac service and discharged from their active case load, but who now require further community cardiac service input
• The following patients may not benefit from referral to Cardiology clinic but may require A&G management support:
  • Patients with suspected heart failure who cannot attend hospital appointments
  • Patients with suspected heart failure in who have severe competing comorbidities such that further investigation and specialist management of their heart failure are unlikely to improve quality of life or other outcomes.

Referral Criteria

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

AND

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

AND

• ECG (result attached)

AND EITHER:

• NTproBNP of between 400-1999 (result attached)
• NTproBNP lower than 400 but high clinical suspicion (result attached)
• Under active cardiology follow-up for another cardiology issue
• Known/previously diagnosed heart failure
• Incidentally discovered left ventricular systolic dysfunction (echo attached)

Refer via e-Referral system:

• Speciality: Cardiology
• Clinic Type: Heart Failure
• Service: DRSS-Western-Cardiology (PCT)- Devon CCG-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 by the Western Locality on behalf of NHS Devon CCG.

Publication date: August 2021

Last updated: March 2022