When should I consider referring a patient with heart failure to a specialist for further evaluation or management?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 14 August 2025Updated: 14 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

You should consider referring a patient with heart failure to a specialist multidisciplinary heart failure team or cardiology service for further evaluation or management in several key situations .

Referral based on severity or treatment response:
  • Refer if the patient has severe heart failure (New York Heart Association [NYHA] class IV) .
  • Refer if heart failure does not respond to treatment in primary care or can no longer be managed in the home setting .
  • If there is no response to diuretic therapy for fluid overload, refer the person to a specialist for further advice on management .
Referral based on diagnostic findings:
  • Refer if the patient has a left ventricular ejection fraction of 35% or less .
  • For suspected heart failure, refer urgently within 2 weeks if the N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is above 2,000 ng/L (236 pmol/L) for specialist assessment and transthoracic echocardiography ,.
  • Refer within 6 weeks if the NT-proBNP level is between 400 and 2,000 ng/L (47–236 pmol/L) for specialist assessment and transthoracic echocardiography ,.
  • If NT-proBNP levels are below 400 ng/L but symptoms of heart failure persist, discuss with a physician with subspecialty training in heart failure .
Referral based on specific causes or symptoms:
  • Refer people with heart failure resulting from valvular heart disease for specialist assessment and advice ,.
  • If the patient experiences syncope or presyncope (unless clearly due to postural hypotension), refer to a cardiologist, especially if they have a reduced ejection fraction, as this may indicate ventricular tachycardia .
Referral for specific patient populations or comorbidities:
  • Refer women with heart failure and reduced ejection fraction (HF-REF) who are planning a pregnancy for specialist pre-conceptual advice .
  • Refer women who are pregnant for specialist management .
  • Consider referral for a person with heart failure and a comorbidity such as chronic kidney disease or chronic obstructive pulmonary disease .

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Educational content only. Always verify information and use clinical judgement.