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
- 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
- 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.