Heart Failure

Overview

Heart failure is a clinical syndrome with typical symptoms and signs (1):

• Breathlessness
• Ankle swelling / peripheral oedema
• Fatigue
• Elevated jugular venous pressure
• Basal crepitations

Heart failure is caused by a structural and/or functional abnormality that produces raised intracardiac pressures and/or inadequate cardiac output at rest and/or at exercise.

(1) Heart failure - chronic | Health topics A to Z | CKS | NICE

BNSSG Guidelines

BNSSG Guidelines  ***NEW PATHWAY FROM 23rd AUGUST 2023****

Please see the BNSSG Primary Care Heart Failure Treatment Guideline for advice on investigation and referral of patients including indications for fast track referral (also see Red Flag section below).

NT-proBNP

NT-proBNP testing is mandatory for all referrals with suspected Heart Failure (previous exclusions such as previous MI or AF no longer apply). Referrals without a NT-proBNP will be returned to the referrer. Refer to section on NT Pro BNP testing and interpretation.

• NT-proBNP >2000 pg/ml - refer urgently to Sirona HF service for a review at the one stop echo/consultant clinic within 2 weeks ➢ DO NOT REQUEST ECHO (see details below)
• NT-proBNP 400 - 2000 pg/ml - primary care to request echocardiogram at local hospital. See further guidelines on management and when to refer below. 
• NT-proBNP under 400 pg/ml - heart failure unlikely. Consider alternative diagnosis. Discuss with specialist if ongoing concerns.

Red Flags

Acute Heart Failure

If there is a rapid onset or worsening of heart failure symptoms (increasing breathlessness, fatigue, ankle /abdominal swelling or rapid weight gain) or other signs of cardiac decompensation (chest pain, arrhythmias, pre-syncope or syncope) consider emergency admission or same day discussion with on-call cardiology team within secondary care.

NT-proBNP >2000 pg/ml

Patients with suspected heart failure and NT-proBNP >2000 pg/ml should be referred urgently to the BNSSG Community Heart Failure Clinic. (unless already under follow-up or known to secondary care Cardiology*).

Prior to Referral

Include the following information in a referral:

• Cardiac examination (BP/pulse) - mandatory.
• NT-proBNP - mandatory.
• U&E - mandatory.
• FBC, TFTs, LFTs, HbA1c & lipids - recommended.

(Please note - Echocardiogram will be done at the one-stop clinic so does not need to be requested)

How to refer

Referrals must be made by email using the Sirona Community Heart Failure referral form (the form available as an EMIS document and will pre-populate) to sirona.heartfailureservice@nhs.net

Service Information

• Patients will be seen in a one-stop, echo & consultant led diagnostic clinic in the community. 
• A comprehensive management plan will be formulated, and any follow-up investigations will be arranged directly with secondary care.
• The outcome of the review will be communicated to primary care/patient via EMIS and by letter.  

*If the patient is already having ongoing follow-up with a cardiology team, please consider referring directly back to them before referring to the community heart failure service.

NT-proBNP 400-2000pg/ml

***NEW PATHWAY FROM 23rd AUGUST 2023****

Patients with suspected heart failure and NT-proBNP 400 - 2000  pg/ml should be assessed in primary care and managed according to the BNSSG Primary Care Heart Failure Treatment Guideline (unless already under follow-up or known to secondary care Cardiology).

Depending on the result of the echocardiogram, some patients can be managed in primary care if the GP is confident in managing their treatment and titration of medication. If referral is necessary or GP would like their patient to be reviewed by a cardiologist then please consider the following:

Prior to Referral

Include the following information in a referral:

• Cardiac examination (BP/pulse) - mandatory
• NT-proBNP - mandatory
• U&E - mandatory
• FBC, TFTs, LFTs, HbA1c & lipids - recommended.
• Echocardiogram - request on ICE at your local hospital trust.
• ECG - recommended to exclude arrhythmias
• CXR - recommended to exclude other pathology 

Treatment can be commenced according to guidelines while awaiting review or the GP can request cardiology advice and guidance.

How to refer

Refer to the Heart Failure Clinic in secondary care via eRS (please refer to the trust where the echo was performed) or consider Cardiology Advice and Guidance.

Service Information

• Patients may be seen, if necessary, in a hospital clinic.
• A comprehensive management plan will be formulated. The outcome of the review will be communicated to primary care/patient.
• Follow up will be arranged as appropriate in either a community or hospital setting.

Patients with known heart failure

Who to refer

• Patients previously known to the community heart failure service with existing Heart failure but who are deteriorating /decompensating.
• Patients with Heart Failure who have had a recent admission to hospital who require optimisation of medications e.g., not on all 4 pillars of treatment.

Prior to Referral

• NT-proBNP, U&E and results of cardiac examination (BP/pulse) - mandatory with all referrals.
• ECG - recommended to exclude arrhythmias but not mandatory.
• CXR - recommended to exclude other pathology 

How to refer

Refer to the Sirona Community Heart Failure service. Referrals must be made by email to: sirona.heartfailureservice@nhs.net using the referral form.

Service Information

Referrals to this service will be reviewed and triaged. Based on the clinical information either:

• The referrer will receive information directly with advice from a Heart Failure Specialist.
• If the patient requires optimisation, the patient will be reviewed by a Heart Failure Specialist Nurse in face-to-face clinics, home visits or telephone reviews.

If the patient is already under ongoing follow-up with a cardiology team, please consider referring directly back to them.

Advice and Guidance

Contact Sirona Heart Failure team on: 01179 617153 for advice 1-5pm Monday-Friday excluding bank holidays. The team has created a top-tips document for clinicians  managing heart failure patients. This contains advice to consider before contacting the team, and details on managing patients with common issues such as; increased breathlessness, signs of fluid overload, abnormal renal function and hypertension.

The cardiologists at UHBW and NBT both offer Cardiology Advice and Guidance via eReferral. These services should be utilised where advice is required on the management of a patient that may avoid the need for referral. It should not be used where immediate advice is required; in which case the on-call teams should be contacted in the usual way. 

Treatment considerations

Some of the drugs used in treatment of heart failure may cause changes in renal function. This can cause some concern in primary care and the following advice may help guide GPs on how to manage this and when to seek advice.

Use of ACE-/ARB/diuretics

Please see the document Traffic light: How to monitor renal function and potassium rises in stable Heart Failure in the Heart Failure guidance section of the BNSSG formulary.

Use of SGLT-2 Inhibitors (e.g Dapaglifozin,Empaglifozin)

Please see the BNSSG Formulary for a link to the Advice on the use of SGLT-2 inhibitors in Type 2 Diabetes, Heart Failure and Chronic Kidney Disease guidelines.

After initiation, renal function usually declines slightly, but resolves within 1-3 months. No specific renal monitoring is required before 3 months. If eGFR drops <30ml/ min/1.73m2 or >25% from baseline during treatment, do not stop treatment without discussion with the heart failure team. Please see full guidelines for details.

Use of Entresto (Sacubitril/Valsartan)

Entresto is a drug used to treat patients with Heart Failure and should be initiated by a specialist service only. Please refer to Shared Care Protocol for Entresto’ available on the BNSSG Formulary . The SCP includes contact details for relevant teams.

You can ring for advice from the Sirona Community Heart Failure team on: 01179 617153.

Heart failure with preserved ejection fraction

CKS/NICE have published guidelines on management of confirmed heart failure with preserved ejection fraction (HFpEF) (1) which may be helpful for guiding management in primary care.

HFpEF accounts for about 40–50% of all heart failure diagnoses and is associated with an older and multimorbid population. Given this, its prevalence is predicted to increase as the population continues to age and the incidence of co-morbidities escalates (2).

(1) Confirmed heart failure with preserved ejection fraction | Management | Heart failure - chronic | CKS | NICE

(2) NHS England » Heart failure with preserved ejection fraction: pathway support tool

Resources

BNSSG Guidelines

See the Heart Failure guidance on the formulary page for advice on the following:

• Primary Care Heart Failure Treatment Guideline
• Practical Guidance on how to use Heart Failure Medications
• Traffic light: How to monitor renal function and potassium rises in stable Heart Failure 

CKS/NICE Guidelines

• Heart failure - chronic

 Information for patients

• https://www.nhs.uk/conditions/heart-failure/ 
• https://www.bhf.org.uk/informationsupport/conditions/heart-failure 
• Support Guides | Pumping Marvellous - includes patient guides to medication and sick day rules.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.