Heart Failure

Scope

The diagnosis of heart failure

Brain natriuretic peptide (BNP) testing is mandatory in most circumstances

Related Pathology guideline

Assessment

The clinical features of Heart Failure are notoriously non-specific emphasising the need for diagnostic tests such as N-terminal pro-brain natriuretic peptide (NTproBNP) level and echocardiography

Causes

  • Ischaemic heart disease
  • Cardiomyopathy
  • Hypertension

Signs and Symptoms

  • Shortness of breath on exercise
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Bilateral leg oedema
  • Raised jugular venous pressure (JVP)
  • Hepatomegaly
  • Tachycardia with additional heart sounds/ gallop rhythm

Criteria for emergency admission

Indications for immediate referral 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%
    • 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

The clinical features of Heart Failure are notoriously difficult non-specific emphasizing the need for diagnostic tests such as NTproBNP level and echocardiography

Investigations

  • Full blood count; to exclude anaemia
  • Chest x-ray and possibly spirometry if concurrent chronic obstructive pulmonary disease (COPD)/ lung disease is suspected
  • 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 is a mandatory requirement prior to requesting echocardiography or cardiology referral
  • BNP is mandatory prior to requesting echocardiography or cardiology referral unless there is a history of previous MI or in the case of male patients with ankle oedema

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

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

Echocardiography request should be sent on the appropriate Echo referral form

Management

For more information please refer to theJoint Formulary guidance on Chronic Heart Failure

Referral for Specialist Management /Assessment

Patient presents to GP with signs or symptoms of heart failure

and

Diagnosis of LVSD proven and Cardio-protective medications commenced

Urgent referral to secondary care for:

  • Acute presentation of severe or unresponsive heart failure
  • Fluid overload not responding to oral loop ± Thiazide therefore requiring IV diuresis
  • Acute presentation with syncope/arrhythmia
  • Acute presentation of chest pain

Referral to Cardiology for:

  • Specialist advice regarding clinical management
  • Severe valve disease
    • Surgical intervention
  • Consideration for cardiac resynchronisation therapy (CRT ±D) To qualify for this the patient should have:
    • Optimal medical therapy
    • NYHA III or IV
    • LVEF 35%
    • QRS duration greater than 120ms

Refer to Community Cardiac Specialist Nurses where locally available for:

  • Optimisation of Cardio-protective medications
  • Patient Education & Lifestyle advice
  • Cardiac Rehabilitation
  • Clinical management advice and support
    • Fluid overloaded patients
    • Second line medications
      • Aldosterone antagonists
      • Hydralazine & nitrate
      • Digoxin

Referral

A recent ECG is a mandatory requirement prior to requesting echocardiography or cardiology referral

BNP is mandatory prior to requesting echocardiography or cardiology referral unless there is a history of previous MI or in the case of male patients with ankle oedema

Should I request an echo or a clinical opinion?

If you feel confident in the diagnosis and management of heart failure then you can request echocardiography alone via the appropriate form with the required other initial investigations. This can be found in the Direct Access Echocardiogram clinical referral guideline. If a BNP has not been recorded or is under 400pg/ml then DRSS will return the referral to the GP. Heart Failure should have an underlying cause identified (i.e. ischemia, cardiomyopathy or hypertension).

If you feel that is it likely that you will require a clinical opinion or heart failure service input then please make a clinical referral and do not arrange prior echo. These patients may be seen by GPwSI for one-stop diagnostic assessment, advice on a clinical management plan and onward referral to the Heart Failure Nursing Service, if appropriate.

NYHA classification is used to grade the severity of functional limitations in a patient with heart failure:

  • Class I no limitation of physical activity
    • ordinary physical activity does not cause fatigue, breathlessness or palpitation (includes asymptomatic left ventricular dysfunction)
  • Class II slight limitation of physical activity
    • patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris (symptomatically 'mild' heart failure)
  • Class III marked limitation of physical activity
    • although patients are comfortable at rest, less than ordinary activity will lead to symptoms (symptomatically 'moderate' heart failure)
  • Class IV inability to carry out any physical activity without discomfortsymptoms of congestive cardiac failure are present even at rest. Increased discomfort with any physical activity (symptomatically 'severe' heart failure)

If suspected heart failure in a patient who has a recent MI (within 12 months), refer for cardiology assessment urgently if clinically appropriate

If the patient has had no previous MI check NTproBNP

  • Greater then 2000pg/ml – for cardiology assessment urgently
  • 400-2000pg/ml – for echocardiogram and cardiology assessment routinely
  • Lower than 400pg/ml with normal ECG - heart failure is very unlikely except in patients under 75 years old - please see table below. Routine referral not indicated.

Normal values in Men (95% confidence interval)

Age 18 – 44 45 – 54 55 – 64 65 – 74 older than 75
NTproBNP pg/ml 62.9 83.9 161 241 486

Normal values in Women (95% confidence interval)

Age 18 – 44 45 – 54 55 – 64 65 – 74 older than 75
NTproBNP pg/ml 116 169 247 285 738
NTproBNP 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
NTproBNP can be suppressed by:
• Diuretics
• ACEI/ARB
• Beta blockers

Interpret with care
  • Patients with a BNP below these ranges do not need to be routinely referred
  • If the patient has had an old MI (over 12 months) or is a male with ankle oedema, there is no need for a NTproBNP check before referral for echo as it does not add to the sensitivity/ specificity values

Referral Instructions

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-Devon CCG- 15N
Referral to Cardiology

e-Referral service selection:

  • Specialty: Cardiology
  • Clinic Type: Heart Failure
  • Service: DRSS--Cardiology-Devon CCG- 15N
Referral to Community Heart Failure Nurse

Referral Forms

Direct Access Echocardiography request form

DRSS Referral forms

Supporting Information

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: December 2015

 

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