Heart Failure Treatment Pathways

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:

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.

No evidence for 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

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.

Consultant Cardiologist at Oxford University Hospitals NHS Foundation Trust | Website

I have specialist interests in heart failure and implantable cardiac devices (pacemakers, ICDs, CRT). I currently lead the heart failure service, and have set up this website.