Executive summary
- Diagnosis: Symptoms + NT-proBNP. If elevated (>400) -> Echo.
- Management (HFrEF): The "Four Pillars" of prognostic therapy should be started early (often concurrently or rapid sequence).
- Fluid Status: Loop diuretics (Furosemide/Bumetanide) are for symptom relief only (titrate to "dry weight"). They do not improve mortality.
Diagnosis Pathway
- NT-proBNP > 2,000 ng/L: Urgent referral (2 week) for Echo + Specialist Assess.
- NT-proBNP 400 - 2,000 ng/L: Routine referral (6 week) for Echo + Specialist Assess.
- NT-proBNP < 400: HF unlikely. Consider other causes (obesity, lung disease, anaemia).
The 4 Pillars of Treatment (HFrEF)
- 1. ACE-inhibitor / ARNI:
- Start Ramipril 1.25mg/2.5mg -> Target 10mg od.
- Switch: To Sacubitril/Valsartan (Entresto) if symptomatic despite optimal ACEi+BB.
- 2. Beta-Blocker (Licensed):
- Start Bisoprolol 1.25mg od -> Target 10mg od. (Or Carvedilol/Nebivolol).
- Wait: Ensure patient is stable (no acute fluid overload) before starting.
- 3. MRA (Mineralocorticoid Receptor Antagonist):
- Spironolactone 25mg od (or Eplerenone).
- Monitor: U&Es at 1 week and 4 weeks. Stop if K+ >6.0.
- 4. SGLT2 Inhibitor:
- Dapagliflozin 10mg od or Empagliflozin 10mg od.
- Indicated for HFrEF regardless of diabetes status (and often HFpEF).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.