Heart Failure

Scope

This guidance covers the diagnosis of heart failure.

Related Pathology guideline:

Assessment

Criteria for Emergency Admission

Signs and symptoms suggestive of acute heart failure (HF), or decompensated chronic HF, or associated acute coronary syndrome/ fast atrial fibrillation (AF) require immediate transfer to hospital for emergency treatment.

Indications for immediate referral include:

  • Acute pulmonary oedema - suggested by crepitations 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. 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
Routine Referral of Breathless Patients in whom Heart Failure is Suspected

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

Investigations

Full blood count (to exclude anaemia)
Chest X-ray and possibly spirometry if concurrent COPD/lung disease is suspected
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 LVH or be normal.

A recent ECG is a mandatory requirement prior to requesting echocardiography

NTproBNP test result is mandatory prior to requesting echocardiography unless there is a history of previous MI or in the case of male patients with leg 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 requests should be sent on the appropriate form (see referral)

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


  1. If suspected heart failure in a patient who has had a previous MI, refer direct for cardiology assessment – review within 2 weeks
  2. If the patient has had no previous MI check NTproBNP
    • Above 2000pg/mL – for echocardiogram and cardiology assessment within 2 weeks if patient unwell
    • 400-2000pg/mL – for echocardiogram and cardiology assessment within 6 weeks
    • Below 400pg/mL - heart failure is very unlikely except in patients under 75 years of age - please see table below

Normal values in Men (95% confidence interval)

Age 18 – 44 45 – 54 55 – 64 65 – 74 older than 75
NTproBNP ng/L 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 ng/L 116 169 247 285 738

Patients with BNP below these ranges should not routinely be referred

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-Northern-Echocardiogram- Devon CCG- 15N
Referral to Cardiology

eReferral service selection:

  • Specialty: Cardiology
  • Clinic Type: Heart Failure
  • Service: DRSS-Northern-Cardiology- Devon CCG- 15N

Referral Forms

Direct Access Echocardiography request form

DRSS Referral forms

Supporting Information

Pathway Group

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

Publication date: August 2015

 

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