Heart Failure - Suspected Heart Failure For Patients With NTproBNP greater than 2000

Scope

  • Adults (over 18 years of age) with suspected undiagnosed heart failure and an NTproBNP greater than or equal to 2000

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 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
  • 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.
    • 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

Key Message

The Suspected Heart Failure For Patients With NTproBNP greater than or equal to 2000 pathway has been updated to align with the current NICE guidance. The aim is to provide patients with suspected heart failure with an NTproBNP greater than or equal to2000 a one-stop diagnostic and clinical assessment within 2 weeks.

Referral Criteria:

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

AND

  • a NTproBNP greater than or equal to 2000 (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.

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.

On receipt of a referral, the cardiology administrative team will arrange a one-stop appointment which will include:

  • an echocardiogram
  • an electrocardiogram (ECG)
  • a consultation with a heart failure specialist

​Assessment

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

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
  • 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

​Investigations

  • NTproBNPis mandatory prior to areferral 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 and it can be depressed by concurrent use of drugs.
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
  • 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. 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.

Management

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.

Referral

Scope

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

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).

The following patients may not benefit from referral to Cardiology clinic but may require A&G management support:

  • 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 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

Referral Criteria:

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

AND

  • an NTproBNP greater than or equal to 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.

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 or equal to 2000

Referral to Cardiology

Refer via e-Referral system:

  • Speciality: Cardiology
  • Clinic Type: Heart Failure
  • Service: DRSS-Western-Cardiology (PCT)- 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

Last updated: March 2022

Last updated: 21-03-2022

 

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