All case notes for patients with a primary diagnosis of heart failure are reviewed and audited with data presented nationally. Our CCGs EXPECT all patients coded a heart failure to be followed up by the community or secondary care heart failure teams.

Therefore, all patients admitted with a primary or suspected diagnosis of heart failure should be referred to the Heart Failure Specialist Team. Referrals can be made via EPIC using the congestive heart failure nurse referral or for further advice

Other access points for the Heart Failure Team include:

1. Formal referral to the Consultant Cardiologist of the Week.

2. Additionally, Dr Sturridge performs a weekly 'outreach' heart failure ward round for difficult patients or complex patients being cared for on non cardiac wards referrals via e-mail or EPIC message to Dr Sturridge. Please leave a bleep number when referring to Dr Sturridge. Please indicate whether the Team wishes to be bleeped at the time of assessment. Dr Sturridge welcomes these patients to be presented by the junior doctor: The Tooke report highlights chronic disease as an educational priority for junior doctors.

3. Dr Metaxa performs a weekly ward round on Tuesday morning for difficult or complex patients identified by the HF nurse during their hospital round or by colleagues.

4. In Wexham Park Hospital every Wednesday afternoon there is the IP HF meeting where junior doctors present their patients for advice/management plan

Heart Failure is one of the most common medical emergencies, up to 5% of each medical take. One in seven people over the age of 85 have heart failure. Therefore, this should be a differential for all elderly patients presenting with breathlessness. However, despite the high prevalence, NICE Guidance from 2010 acknowledges that clinical diagnosis of heart failure alone is not recommended as this has low specificity. Objective evidence of heart failure should be sought.

There are two readily available objective indicators to diagnose heart failure. These include the bio-marker, NT Pro BNP and transthoracic echocardiogram. There are other specialist modalities available if these two indicators fail to clarify diagnosis. NT pro BNP is a blood test requiring EDTA tube. NT Pro BNP has no positive or negative value. NT pro BNP can be useful as a rule out test but is non specific and therefore is not a useful rule in test. NT Pro BNP can be raised in situations other than heart failure which commonly present via A&E and therefore its use in the emergency setting is even less specific. NT pro BNP is raised in heart failure, atrial fibrillation, valvular disease, PE, sepsis, liver disease and CKD for example.

NT pro BNP tends to rise with age and may not necessarily indicate heart failure.

A full history, examination, Chest X ray, ECG and blood tests to include FBC, U and E's, LFTs are required.

Patients presenting as an emergency with exacerbation of heart failure who already have a known diagnosis of heart failure should be admitted to a cardiology bed (either on CCU or G9 depending on clinical status for Frimley and CCU or ward W4 for Wexham Park Hospital).

Patients presenting with a new diagnosis of heart failure in whom there is high clinical suspicion, should be admitted to a cardiology bed. Red flags which support a high chance of patients having heart failure include:

1. Previous history of Ml

2. Abnormal ECG to include Q waves, atrial fibrillation or BBB. Left bundle branch block increases the likelihood of a patient having heart failure.

3. Massive cardiomegaly on chest x-ray. Please note that this does not include high cardiothoracic ratio.

4. Overt pulmonary oedema on chest x-ray to include interstitial oedema, Kerley B lines, fluid in the horizontal fissure, peri-hilar shadowing, diffuse alveoli shadowing. Please note that this does not include upper lobe diversion which is common and very non specific.

5. The presence of clinical findings which suggest significant aortic stenosis or significant mitral regurgitation. Please note that this does not include faint ejection systolic murmur which may represent a flow murmur.

6. A LOW NT Pro BNP can be used to RULE OUT heart failure in a previously untreated patient. A raised BNP does not confirm a diagnosis of heart failure however and further evaluation with an echocardiogram as an inpatient followed by Specialist opinion is mandatory. For Wexham Park Hospital NT Pro BNP should be requested only for new diagnosis. Consultant Cardiologist only may occasionally choose to use NT pro BNP for monitoring purposes.

Patients presenting with new suspected heart failure should have echocardiography performed within 48 hours of admission to confirm diagnosis and to guide specialist management.

Known HF patients do not routinely need echocardiogram unless there is a specific clinical indication identified by a heart failure specialist.

All patients with a new diagnosis of heart failure must be seen by Heart Failure Specialist.

Known HF patients should be re-assessed for the discharge plan and follow-up by the

HF team.

It is IMPORTANT that for known HF patients the team is always informed about a re-admission.

This should include the heart failure specialist nurse AND cardiology registrar or consultant.

Acute LVF or acute pulmonary oedema is a medical emergency and it is important to involve a senior medical review as soon as possible. In most cases patients may need to be cared for in a high dependency zone such as CCU with early ICU involvement if there is evidence of cardiogenic shock.

Patients need careful clinical evaluation, but initial management usually includes oxygen to maintain SATS at 95-98% and IV diuretics to relieve pulmonary and peripheral oedema.

IV Furosemide can be given as 40-80 mg bolus followed by an infusion at 5-20 mg per hour as required. OR continue bolus doses if stable BP.

Do not routinely offer opiates, but IV morphine as 2.5 mg bolus (plus PRN anti-emetic) can be given if the patient is distressed and/or in pain and repeated as necessary until symptoms are controlled.

Do not routinely give IV nitrates, but IV GTN infusion titrated to maintain systolic blood pressure more than 90-100 mm Hg is particularly useful if heart failure is associated with hypertension or ischaemia.

CPAP may be required for patients with pulmonary oedema and acidaemia and this mandates caring for a patient in high dependency unit such as Coronary Care Unit, HDU or ICU.

Acute LVF general measures

1. Monitor ECG continuously, check oximetry and BP every 5 minutes. If cardiogenic shock develops, contact a Cardiology Consultant in hours, liaising with Medical SpR, ICU outreach team. Consultant Cardiology and Consultant ICU out of hours.

2. Review medication. Review and discontinue steroids and NSAIDS where possible.

3. Patients with diabetes or hyperglycaemia (Blood glucose>11mmol/I) consider switching to sliding scale Insulin for tight glycaemic control. USE CCU VRII protocol

4. Request chest x-ray, U&E's, FBC, TFTs, LFTs, Troponin, glucose, lipids, arterial blood gases if in respiratory distress.

5. Hourly urine output with urinary catheter.

6. If a patient presenting with acute heart failure is already taking beta-blockers, continue treatment unless heart rate <50bpm, or second or third degree heart block.

1. Diuretics are often required to relieve symptoms of congestion. Intravenous therapy is often required initially. Please see Hospital guidelines for loop diuretics and monitor weight and U & E's daily.

2. For people already taking diuretics, consider a higher dose of diuretic than that the patient was admitted on unless there are concerns with patient adherence.

3. If a patient with known heart failure is admitted with decompensation, often converting their usual dose of oral diuretic to an equivalent IV dose at similar doses or slightly higher may prompt quite a swift diuresis due to increased viability in the setting of gut oedema. Once the episode is resolved please switch the new defined dose of diuretic to oral which should be kept for the discharge (do not revert to pre-admission dose).

4. Patients with congestive heart failure in whom diuresis appears to be ineffective, i.e., no weight loss or deteriorating renal function, require specialist review. Whilst awaiting review, if no weight loss at Furosemide 80 mg bd, consider 240 mg IV Furosemide over 24 hours (there is no evidence that continuous infusion is better than split doses but often at this stage relative bed rest is useful and 24 hour infusion can incur less hypotension).

5. If no response to 240 mg Furosemide, the addition of an oral thiazide may help. Metolazone 2.5mg as a single dose once or twice a week can promote significant diuresis. It is important that this is under specialist supervision with tight U&E's monitoring. Please see Hospital Guidelines on Metolazone. If loop diuretics and thiazide fail, there are other options to include inotropic support and/or ultra­ filtration under specialist guidance.

6. For patients needing higher dose of diuretic with or without association with metolazone, as the patient returns to dry weight they may become more diuretic sensitive and doses may need to be decreased.

7. Please discuss with patients the best strategy for management of increased urine output.

Loop diuretics relieve congestion but do not confer prognostic benefit.

Clinical evaluation cannot differentiate between left ventricular systolic dysfunction and heart failure with preserved ejection fraction. Echocardiography is therefore important to confirm the diagnosis of heart failure and characterise the type of heart failure so appropriate therapy can be offered. For patients with left ventricular systolic dysfunction, it is imperative that patients are started on Class 1 heart failure drugs unless there is a contraindication. All contraindications must be documented in the notes. All patients with left ventricular systolic dysfunction should be offered an ACE inhibitor, beta blocker, sodium-glucose transporter protein 2 (SGLT2) inhibitor, and an aldosterone antagonist which should be initiated prior to discharge. If the patient is in SR with HR above 70bpm despite beta blocker, please consider adding ivabradine. This medication does not affect blood pressure. New clinical trials have identified this new HR control medication as second line treatment for improving symptoms and outcome.

Please see Hospital Guidelines for beta blockers, ACE inhibitors, ARBs, spironolactone, eplerenone, dapagliflozin, sacubitril valsartan and ivabradine for tips on initiation, contraindications, troubleshooting and monitoring.

During treatment monitor daily renal function, electrolytes, heart rate, BP, and weight.

Ensure that a patient's condition is stable for 48hours after starting or restarting beta­ blockers, before discharging from hospital.

Therapeutic algorithm for a patient with symptomatic heart failure with reduced ejection fraction as per European Society of Cardiology. Green indicates a class I recommendation; yellow indicates a class Ila recommendation.

These patients often need loop diuretics to relieve symptoms of congestion but extra care should be given to ensure that they are maintained on the minimum dose of diuretic needed to maintain euvolaemia as they are prone to pre-renal failure, hypotension and dehydration. There is much less evidence in terms of which medication affects disease progression in these groups of patients. NICE has approved the use of dapagliflozin and empagliflozin in the treatment of HFpEF based on the findings of the clinical trials. Please refer to the Dapaglifozin Guideline for prescribing information. These medications should be started on the advice of a heart failure specialist. There is some evidence to say that hospital admissions are reduced with ACE inhibitor but in essence treatment for diastolic heart failure includes a minimal dose of loop diuretics to maintain euvolaemia and optimum treatment of systemic hypertension but there is no evidence-based role for beta blockade, spironolactone, sacubitril valsartan or ivabradine for prognostic purposes.

Comorbidities such as IHD, hypertension and diabetes should be addressed and managed in line with NICE guidance. Reducing body weight in obese patients and increasing exercise may further improve symptoms and exercise capacity and should therefore be considered in appropriate patients.

Atrial fibrillation is common in both left ventricular systolic impairment and heart failure with preserved ejection fraction. It is important patients receive adequate rate control with beta blockers being the first choice in most patients (left ventricular systolic dysfunction, ischaemic heart disease, and hypertension). Digoxin being an additional agent if beta blocker alone has not provided adequate rate control or beta blocker is contraindicated.

Be aware that calcium antagonists such as diltiazem and verapamil are negatively inotropic and should not be used in the setting of heart failure without specialist advice.

It is important that all patients with atrial fibrillation are assessed for anticoagulation using the CHA2DS2-VASc score and Orbit score. This should be documented in the notes and patients offered anticoagulation if indicated. Please refer to the guideline ‘Anticoagulation Treatment for Atrial Fibrillation’. Be aware that patients with heart failure and preserved ejection fraction often have a high burden of paroxysmal AF which can confer a significant stroke risk. Please assess for anti-coagulation for PAF in the same way as for persistent AF.

All patients should receive specialist heart failure opinion before discharge. Discharge planning should include documentation to clarify heart failure follow up at discharge. The Heart Failure Specialist Nurse is best placed to advise on this as there are a range of possibilities to include Consultant Cardiologist, Consultant Heart Failure Specialist, Heart Failure Specialist Nurse, Community heart failure nurse, Cardiac Pharmacist, Palliative care etc.

It is not unusual for patients with heart failure to be admitted to non-cardiac beds initially, as in line with many Trusts, bed capacity routinely runs in excess of 90%. In most cases there should be active re-patronisation to G9 when a diagnosis of heart failure is confirmed. Please ensure that Bed Manager and the Heart Failure Specialist Nurse are aware of any outliers so that patients can continue to receive specialist input no matter which zone they are within Frimley Park Hospital.

1. Whilst echocardiography is considered gold standard, some patients have non diagnostic images. There are alternative modalities which can be used. Please seek specialist advice if needed.

2. Patients with congestive heart failure in whom diuresis appears to be ineffective, i.e. no weight loss or deteriorating renal function, require specialist review. Whilst awaiting review, if no weight loss at Furosemide 80 mg bd, consider 240 mg IV Furosemide over 24 hours (there is no evidence that continuous infusion is better than split doses but often at this stage relative bed rest is useful and 24 hour infusion can incur less hypotension).

3. If no response to 240 mg Furosemide, the addition of an oral thiazide may help. Metolazone 2.5 mg as a single dose once or twice a week can promote significant diuresis. It is important that this is under specialist supervision with tight U&E's monitoring. Please see Metolazone Guideline. If loop diuretics and thiazide fail, there are other options to include inotropic support and/or ultra­ filtration under specialist guidance.

4. If a patient with known heart failure is admitted with decompensation, often converting their usual dose of oral diuretic to an equivalent IV dose at similar doses or slightly higher may prompt quite a swift diuresis due to increased viability in the setting of gut oedema.

5. As the patient returns to dry weight, they may become more diuretic sensitive and doses may need to be decreased.

It is important to recognise that even with specialist review, in hospital mortality remains high for patients with heart failure. Mortality at 12 months after initial diagnosis can be as high as 30-40%. Access to palliative care for patients with heart failure nationally is low. It is important that patients who are approaching end of life are recognised and offered access to palliative care. There is an end of life palliative care document available for Frimley Park and Wexham Park Hospital on the intranet. Red flags that may indicate a patient is approaching end of life include:

1. Recurrent admissions for heart failure, e.g., two or more over the last 6-12 months without any obvious precipitating or reversible cause.

2. Cardiac cachexia

3. Symptomatic hypotension or deteriorating renal function requiring a step down in heart failure medications despite worsening symptoms of heart failure

4. Hyponatraemia

5. Refractory oedema.

If in doubt, please seek specialist advice.

The average length of stay with patients with heart failure is in excess of 10 days, but should any patients be identified with symptoms indicating possible heart failure, who do not require admission, but do NOT have a confirmed diagnosis, then please access the rapid access heart failure OPD service - referrals to Dr. Sturridge.

1. National Institute for Health and Care Excellence [NICE] (2018) Chronic heart failure in adults: diagnosis and management. NG106. Available at: https://www.nice.org.uk/guidance/ng106 (Accessed: 09 November 2023)
2. National Institute for Health and Care Excellence [NICE] (2021) Acute heart failure: diagnosis and management. CG187. Available at: https://www.nice.org.uk/guidance/cg187 (Accessed: 09 November 2023).
3. McDonagh, T.A. et al. (2023) '2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC', European Heart Journal, 44(37), pp. 3627-3639. Available at: https://doi.org/10.1093/eurheartj/ehad195
4. National Institute for Health and Care Excellence [NICE] (2023) Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. TA902. Available at: https://www.nice.org.uk/guidance/ta902
5. National Institute for Health and Care Excellence [NICE] (2023) Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. TA929. Available at: https://www.nice.org.uk/guidance/ta929

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Related Documents