Heart Failure - Undiagnosed

Scope

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

Out of Scope

Patients under active cardiology follow-up (refer back to usual consultant directly).

Patients with known/previously diagnosed heart failure (refer via known/previously diagnosed heart failure pathway).

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.

Key Message

The undiagnosed heart failure pathway has been updated to align with the current NICE guidance . The aim is to provide patients with suspected high-risk undiagnosed heart failure access to an appointment with a consultant heart failure specialist within 2 to 6 weeks.

Referral Criteria:

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

AND

  • a BNP greater than 100 (result attached)

AND

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

Referrals submitted which do not meet the referral criteria or don’t have the mandated results attached will be returned.

Referrals that don’t meet the above criteria but where a diagnosis of undiagnosed heart failure is still suspected - please consider an A&G cardiology referral or a routine general cardiology referral, with the same mandated results attached.

A recent ECG attached to the referral is no longer a mandatory requirement. However, it is part of the standard primary care assessment of a patient with symptoms, where heart failure is a possible diagnosis. Attaching any recent ECGs to referrals is still encouraged to allow comparison and aid secondary care triage.

GPs will no longer be expected to refer for Echo prior to cardiology referral. The cardiology administrative team will arrange an urgent Echo and ECG (at the same sitting) on receipt of the GP referral.

The referral and echo result will then be triaged by a member of the cardiology team into one of 3 outcomes:

  • Patient is discharged back to the GP with advice
  • Assigned routine outpatient priority to be seen within 6 weeks
  • Assigned Urgent priority to be seen within 2 weeks

Some low-risk routine patients can be seen by Heart Failure Specialist Nurses (HFSN), but predominantly will be seen by one of our three heart failure consultants.

Comprehensive management plans will be formulated, with the majority of the follow up provided by HFSN, ideally in the community.

​Assessment

The clinical features of heart failure are notoriously non-specific, emphasising the need for diagnostic tests such as the Brain Natriuretic Peptide (BNP) 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

Red Flags

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
  • 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

​Investigations

  • BNP is mandatory prior to a referral via the Undiagnosed Heart Failure pathway
    • BNP is very sensitive but not very specific - i.e. identifies possible heart failure but does not confirm a diagnosis. Other causes of raised BNP include: AF, severe lung disease, age over 70, and renal impairment amongst others.


BNP also raised in:


  • Other causes of left ventricular strain e.g. aortic stenosis, uncontrolled hypertension
  • Atrial fibrillation
  • Right ventricular strain e.g. pulmonary embolus, pulmonary hypertension
  • Renal failure, rheumatoid arthritis
BNP can be suppressed by:
  • Diuretics
  • ACEI/ARB
  • Beta blockers
Interpret with care
  • Please note that BNP will also 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 BNP. If the patient remains symptomatic with possible heart failure after rate control then check BNP and refer as usual. If minimally symptomatic at that stage consider community echo and/or general cardiology referral.

A normal BNP makes a diagnosis of heart failure very unlikely unless the patient is already established on treatment

  • Blood Tests
    • FBC and U&E taken within the last 6 months and attached to the referral is also 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

A recent ECG attached to the referral is no longer a mandatory requirement. However, it is part of the standard primary care assessment of a patient with symptoms, where Heart Failure is a possible diagnosis. Attaching any recent ECGs to referrals is still encouraged to allow comparison and aid secondary care triage.

  • Chest X-Ray (CXR)
  • Spirometry (if concurrent Chronic Obstructive Pulmonary Disease (COPD)/ lung disease is suspected)

Management

For all patients with suspected heart failure and a positive BNP (particularly when very high) please consider starting treatment with a loop diuretic immediately.

Please refer to the appropriate joint formulary – Chronic Heart Failure

Referral

Scope

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

Out of Scope

  • Patients under active cardiology follow-up (refer back to usual consultant directly).
  • Patients with known/previously diagnosed heart failure (refer to known/previously diagnosed heart failure clinic).
  • 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.

Referral Criteria:

  • Adults (over 18 years of age) with suspected Heart Failure

AND

  • a BNP greater than 100 (result attached)

AND

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

Although not mandated, please request an 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.

Referrals submitted which do not meet the referral criteria or don’t have the mandated results attached will be returned.

Referrals that don’t meet the above criteria but where a diagnosis of undiagnosed heart failure is still suspected - please consider an A&G cardiology referral or a routine general cardiology referral, with the same mandated results attached.

Referral instructions

Referral to Cardiology

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 forms

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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