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 prior to a referral via the Suspected Heart Failure For Patients with NTproBNP greater than or equal to 2000 pathway
  • 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

• 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 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
  • A recent ECG attached to the referral is no longer a mandatory requirement. Attaching any recent (within the last 12 months) ECGs that are available on the primary care clinical system is still encouraged to allow comparison and aid secondary care triage.
    

For all patients with suspected heart failure and a positive NTproBNP (particularly when very high) 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 undiagnosed heart failure and an NTproBNP greater than 2000.

If referring a patient for advice only, please make this clear in your referral letter. If it is not made clear, then these patients will be invited to clinic. 

Examples of when this may be appropriate include:

• 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.

Out of Scope

The following patients warrant referral to General Cardiology Clinic:

• 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 known/previously diagnosed heart failure
• Patients with incidentally discovered left ventricular systolic dysfunction
• Patients under active cardiology follow-up (refer back to usual consultant directly).

Referral Criteria:

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

AND

• an NTproBNP greater than 2000 (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. A recent ECG attached to the referral is no longer a mandatory requirement.

Attaching any recent (within the last 12 months) ECGs that are available on the primary care clinical system is still encouraged to allow comparison and aid secondary care triage.

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

Referral instructions

Referral to: Suspected Heart Failure For Patients With NTproBNP greater than 2000

Referral to Cardiology

Refer via e-Referral system:

• Speciality: Cardiology/Heart failure hub
• Clinic Type: Heart Failure 
• Priority: Urgent
• Service: West (inc East Cornwall) DRSS Western Suspected Heart Failure for patients with NTproBNP> 2000 -Devon - ICB-15N

Referral form

DRSS referral form

Pathway Group

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

Publication date: August 2021

Last updated: May 2023