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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Heart failure

Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Acute pulmonary oedema, hypoxia, cardiogenic shock or systolic BP below 90 mmHg, ongoing chest pain/ACS, sustained arrhythmia, syncope, confusion or oliguria needs emergency admission and monitored acute-heart-failure care.

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.
  • For HFrEF, 2025 NICE recommends four foundational classes: ACE inhibitor, evidence-based beta-blocker, mineralocorticoid receptor antagonist and SGLT2 inhibitor, introduced in a sequence and tempo tailored to the person.
  • If symptoms persist on maximum tolerated four-pillar treatment, consider replacing the ACE inhibitor with sacubitril/valsartan; seek specialist advice before starting ARNI in primary care.
  • Use a loop diuretic at the lowest dose that maintains euvolaemia; it relieves congestion but is not a substitute for disease-modifying therapy.
  • NICE now advises considering an MRA plus SGLT2 inhibitor in HFpEF and considering the four HFrEF classes in HFmrEF, with phenotype/comorbidity review.
  • Check renal function and electrolytes before and 1–2 weeks after starting or increasing ACEi/ARB/ARNI/MRA, then every 3–6 months at stable maximum tolerated dose.
  • Refer for ICD/CRT assessment when LVEF remains 35% or lower despite optimised therapy; QRS duration, LBBB morphology, NYHA class and ischaemic substrate determine the device.

Key red flags

Acute pulmonary oedema

Severe breathlessness at rest, hypoxia, widespread crackles, pink frothy sputum or inability to lie flat requires emergency treatment.

Low-output state

Hypotension, confusion, cold/clammy skin, oliguria, rising lactate or narrow pulse pressure suggests cardiogenic shock and needs critical-care/shock-team escalation.

Precipitant requiring urgent treatment

ACS, rapid AF or ventricular arrhythmia, infection, hypertensive emergency, pulmonary embolism, acute severe valve disease, renal failure or medication toxicity can destabilise heart failure.

Investigation priorities

01
Clinical assessment, observations and 12-lead ECGFirst step

Assess severity and identify ischaemia, AF, conduction disease, QRS width or a pacing/device clue.

Management branches

DiagnosisNatriuretic-peptide triage

Symptoms/signs suggest chronic heart failure and the patient is not already diagnosed.

  1. Measure NT-proBNP; do not use it to distinguish HFrEF from HFpEF.
  2. If above 2000 ng/L, arrange urgent specialist assessment and TTE within 2 weeks; if 400–2000 ng/L, arrange both within 6 weeks.
  3. If below 400 ng/L in an untreated person, review alternative causes; obesity, diuretics, ACEi/ARB/ARNI, beta-blockers and MRAs can reduce peptide concentration, so discuss persistent concern with a HF specialist.
  4. At specialist assessment establish phenotype, cause, severity, comorbidities and the person's goals.

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.Check BP, creatinine/eGFR and potassium before and 1–2 weeks after every start/increment. Avoid in pregnancy, previous ACE-inhibitor angioedema, bilateral renal artery stenosis and with sacubitril/valsartan; cough and hyperkalaemia may limit use.
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.Pretreatment ECG. Do not use with heart rate below 50 beats/min or unpaced second/third-degree AV block. Monitor pulse, BP, congestion and bronchospasm; slow or pause titration if decompensation occurs and never stop abruptly without a clinical reason.
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Sources and review status10 sources · checked 25 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.

  • NICE NG106: Chronic heart failure—recommendationsCurrent UK diagnosis and treatment pathway; updated September 2025.
  • NICE TA314: Implantable cardioverter defibrillators and cardiac resynchronisation therapyDevice selection by LVEF, QRS, LBBB and NYHA class.
  • Ramipril SmPCProduct-specific licensed HF initiation and titration.
  • Bisoprolol SmPCProduct-specific licensed chronic-HF titration.
  • Aldactone (spironolactone) SmPCProduct-specific severe-HF dosing and renal/potassium criteria.
  • Dapagliflozin SmPCLicensed chronic-HF dose and renal threshold.
  • Sacubitril/valsartan SmPCLicensed dosing, washout and contraindications.
  • Furosemide SmPCLicensed oral oedema dose examples.
  • Ferinject (ferric carboxymaltose) SmPCProduct-specific weight limits, weekly maximum, hypersensitivity observation and phosphate monitoring.
  • MHRA: SGLT2 inhibitors—interrupt for major surgery or acute serious illness and monitor blood ketones

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom