GP Guidance Summary | Heart Failure Oxfordshire

Diagnosis and initial treatment of heart failure, including BNP testing
Expected treatment pathways for patients with heart failure with reduced and preserved ejection fraction
Checklist for regular review of patients with heart failure
Further information available online

Diagnosis of Heart Failure

History and examination suggestive of possible heart failure (further information)

Arrange initial tests (further information on tests)

Bloods: NT-proBNP, U&E, LFT, TFT, FBC
ECG
Do not request open access echocardiogram
Consider in addition to help with severity / differentials
- Chest x-ray
- Urinalysis
- Spirometry or peak flow

Consider initial treatment of fluid overload or breathlessness with diuretics, or of fast atrial fibrillation with beta blockers or digoxin. See further information below.

If symptoms are severe, especially if paroxysmal nocturnal dyspnoea or lung crepitations, consider referral to medicine at JR or Horton for inpatient / ambulatory assessment.

NT-proBNP greater than 2000ng/L

Refer urgently to Heart Failure clinic via ERS,
Target to be seen within 2 weeks

NT-proBNP greater than 400ng/L, but less than 2000ng/L

Refer to Heart Failure clinic via ERS,
Target to be seen within 6 weeks

NT-proBNP less than 400ng/L

Reconsider diagnosis of HF
Further advice

NT-proBNP testing

Blood testing for BNP is a key step in the diagnostic pathway for heart failure. This is now recommended by NICE as the first investigation when heart failure is suspected on clinical grounds. NT-proBNP testing is available to all GPs in the region via the OUH FT pathology labs.

NT-proBNP has replaced the previously used assay for BNP. The normal and abnormal ranges are different. Unlike BNP assays, NT-pro BNP is not subject to the issue of degradation with falsely low readings if the sample is delayed in transit to the lab. Nonetheless, samples need to reach the lab within 24h. Please send a serum sample (gold/yellow top tube).

Expected pathway for patients with Heart Failure with reduced ejection fraction (HF-REF; Left ventricular ejection fraction <40%; severe LV systolic dysfunction )

Diagnosis should be made only after an echocardiogram, with input from a cardiology specialist.

Commence HF disease modifying therapies: ACEi / ARB and beta blockers
Diuretics if needed
Titrate ACEi / ARB and beta blockers to maximum tolerated dose

Identify and treat comorbidities

Hypertension
Renal Dysfunction
Diabetes
Pulmonary Disease
Ischaemic Heart Disease
Anaemia

If remains symptomatic (any degree of breathlessness or other HF symptoms):

Community Heart Failure Nurses can assist with medication titration and education.

Cardiac Rehabilitation is indicated

If remains symptomatic (any degree of breathlessness or other HF symptoms):
Please refer back to hospital HF clinic for review and consideration of other HF therapies such as:

Sacubitril-valsartan
Cardiac resynchronisation therapy
Intravenous iron infusion
Ivabradrine or other drug therapies

Community Heart Failure Nurses can assist with medication titration and education, and may start these drug therapies as indicated.

Once diagnosis made and medications have been introduced and uptitrated, likely to be discharged out of hospital care back to community care.

NICE suggest a 6-monthly review for all patients with heart failure, and a 12-month review is in the quality outcome framework – see suggested template for review

Expected pathway for patients with Heart Failure with preserved ejection fraction (HF-PEF; LV ejection fraction >40%)

Diagnosis should be made only after an echocardiogram, with input from a cardiology specialist.

Start Dapagliflozin or empagliflozin for heart failure
No evidence for other disease modifying therapies in HF-PEF
Prescribe diuretics to relieve symptoms and signs of fluid overload

Identify and treat comorbidities

Hypertension
Renal Dysfunction
Diabetes
Pulmonary Disease
Ischaemic Heart Disease
Anaemia

Consider addition of Mineralocorticoid Receptor Antagonist (eplerenone for most men, spironolactone for women) to assist diuresis

Community Heart Failure Nurses are not currently commissioned to see these patients.
No evidence for cardiac rehabilitation

Once diagnosis made, likely to be discharged out of hospital care back to GP care.

Whilst the hospital clinic can discuss or see these patients if they continue to be problematic, as there are no additional available therapies we are unlikely to be able to add to the above.

NICE suggest a 6-monthly review for all patients with heart failure, and a 12-month review is in the quality outcome framework – see suggested template for review

The term heart failure with a ‘moderately reduced’ or ‘mid-range’ ejection fraction (HF-mREF) is sometimes used for patients with an ejection fraction of 40-50%. At the current time there is no robust evidence that these patients should be treated differently to other patients with HF – PEF, although we would have a low threshold for the use of ACE inhibitors / ARBs.

General Practice Heart Failure Review Template

Symptoms	Are symptoms stable? Are they still symptomatic? If so escalate treatment as per pathways Are they becoming fluid overloaded or dehydrated? Record weight, blood pressure and pulse Check and record pulse rhythm using a code
Medication review	For Heart Failure with a reduced ejection fraction: ACEi / ARB at maximum tolerated licenced dose? If not titrate up unless BP less than 90 systolic or side effects Beta blocker at maximum tolerated licenced dose? If not titrate up unless BP less than 90 systolic or side effects Mineralocorticoid Receptor Antagonist (MRA; e.g. Eplereonone for men or Spironolactone for women) at maximum tolerated licenced dose? Start Dapagliflozin or empagliflozin for heart failure If they remain symptomatic after the above (any degree of breathlessness or other HF symptoms) – refer to hospital clinic for consideration of other therapies. For Heart Failure with preserved ejection fraction: No evidence for disease modifying therapies Titrate diuretics to symptoms and oedema
Bloods	Renal function, potassium, sodium, haemoglobin stable?
Comorbidities and risk factors	Hypertension, Diabetes, Atrial fibrillation Smoking cessation Alcohol intake Cognitive status and nutritional status
Other tests and treatments	Flu / pneumococcal vaccine is recommended for all HF patients Annual ECG: if QRS width is newly >130ms (3.25 small squares) then refer for reassessment in hospital HF clinic (to consider Cardiac Resynchronisation Therapy) Consider resuscitation status and advanced care planning

Other advice available online

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