Synopsis
Diagnose heart failure promptly, phenotype it by LVEF, relieve congestion and deliver current NICE disease-modifying therapy with safe titration, specialist escalation and device referral.
- In untreated suspected heart failure, NT-proBNP above 2000 ng/L requires urgent specialist assessment and transthoracic echo within 2 weeks; 400–2000 ng/L requires both within 6 weeks.
- NT-proBNP below 400 ng/L makes heart failure less likely in an untreated person, but obesity and HF medicines can lower it; seek specialist advice if concern persists.
- Echocardiography must identify LVEF phenotype, valves, chamber size, diastolic function and alternative structural disease; do not diagnose solely from a natriuretic peptide.
Key red flags
Severe breathlessness at rest, hypoxia, widespread crackles, pink frothy sputum or inability to lie flat requires emergency treatment.
Investigation priorities
Assess severity and identify ischaemia, AF, conduction disease, QRS width or a pacing/device clue.
Management branches
Symptoms/signs suggest chronic heart failure and the patient is not already diagnosed.
- Measure NT-proBNP; do not use it to distinguish HFrEF from HFpEF.
- If above 2000 ng/L, arrange urgent specialist assessment and TTE within 2 weeks; if 400–2000 ng/L, arrange both within 6 weeks.
Key medicines
Ramipril — licensed symptomatic-heart-failure exampleStart 1.25 mg by mouth once daily in a diuretic-treated, stabilised patient; double at 1–2-week intervals to a maximum 10 mg/day, preferably in 2 divided doses for heart failure.
Bisoprolol — licensed stable chronic-HF example1.25 mg once daily for week 1; 2.5 mg once daily week 2; 3.75 mg once daily week 3; 5 mg once daily weeks 4–7; 7.5 mg once daily weeks 8–11; then 10 mg once daily maintenance/maximum, only as tolerated.