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

Consider referring a patient with chronic heart failure to a specialist for further evaluation in the following situations:

• If the heart failure is caused by valvular heart disease, as these patients require specialist assessment and advice regarding follow-up ¹.
• If the patient has a left ventricular ejection fraction (LVEF) of 35% or less, since they may be suitable for specialist treatments such as implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRT), or sacubitril valsartan therapy ¹.
• If the patient has syncope or presyncope not clearly due to postural hypotension, as this may indicate ventricular tachycardia requiring cardiologist evaluation, especially in those with reduced ejection fraction ¹.
• If there is no response to diuretic therapy (e.g., loop diuretics up to 80 mg furosemide or equivalent) to relieve fluid overload symptoms ¹.
• If the patient is pregnant or planning pregnancy, specialist advice should be sought due to potential teratogenic effects of drugs and the need for shared care between cardiologist and obstetrician ¹.
• If the patient has newly diagnosed, recently decompensated, or advanced heart failure (NYHA class III to IV), or heart failure not responding to treatment, specialist heart failure multidisciplinary team (MDT) involvement is recommended ².
• If NT-proBNP levels are very high (>2000 ng/L), urgent specialist assessment and echocardiography within 2 weeks is indicated ².
• If NT-proBNP levels are between 400 and 2000 ng/L with suspected heart failure, specialist assessment and echocardiography within 6 weeks is advised ².

Regular follow-up and monitoring should be individualized, but referral is warranted when clinical condition or treatment changes significantly ¹.