Recommended approach to diagnosing heart failure in primary care, including role

The recommended approach to diagnosing heart failure in primary care involves a detailed history and clinical examination, followed by specific investigations. A key investigation is the measurement of N-terminal pro-B-type natriuretic peptide (NT‑proBNP).

• NT-proBNP Levels and Referral: If the NT‑proBNP level is less than 400 ng/litre in an untreated individual, a diagnosis of heart failure is less likely, and alternative causes for symptoms should be investigated. If concerns persist, discuss with a heart failure specialist. For NT‑proBNP levels between 400 and 2,000 ng/litre, refer for specialist assessment and transthoracic echocardiography within 6 weeks. For levels above 2,000 ng/litre, urgent referral (within 2 weeks) for specialist assessment and transthoracic echocardiography is recommended due to a poor prognosis. It is important to note that certain factors like obesity, African or African–Caribbean background, or treatment with ACE inhibitors, beta-blockers, ARBs, or MRAs can lower natriuretic peptide levels. Conversely, high levels can be caused by conditions other than heart failure, such as age over 70, left ventricular hypertrophy, ischaemia, tachycardia, renal dysfunction, sepsis, COPD, diabetes, or liver cirrhosis. The level of natriuretic peptide does not distinguish between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).
• Imaging Modalities: Transthoracic echocardiography is essential to exclude significant valve disease, assess left ventricular systolic and diastolic function, and detect intracardiac shunts. This imaging should be performed using high-resolution equipment by experienced operators. If transthoracic echocardiography provides poor images, consider alternative methods like radionuclide angiography, cardiac MRI, or transoesophageal echocardiography.
• Other Investigations: An ECG should be performed, and other tests to evaluate possible aggravating factors or alternative diagnoses should be considered, including a chest X-ray and blood tests (renal function, thyroid function, liver function, lipid profile, HbA1c, full blood count, urinalysis). Peak flow or spirometry may also be considered.
• Excluding Other Conditions: It is crucial to exclude other disorders that may present similarly to heart failure.
• Care Plan: Once a diagnosis of heart failure is made, assess its severity, aetiology, precipitating factors, type of cardiac dysfunction, and correctable causes. The primary care team should manage routine care once heart failure is stabilized and optimized. A specialist heart failure multidisciplinary team (MDT) should create a summary including diagnosis, aetiology, medications, functional abilities, social circumstances, and this summary should form the basis of a care plan. This care plan should include management plans, symptoms of deterioration to watch for, access to the specialist MDT, and contact details. A copy of the care plan should be given to the patient, their family/carer, and all involved healthcare professionals.