Questionnaire/history Breathlessness? - On exertion? - At rest? - On lying flat (orthopnoea)? - Nocturnal cough? - Waking from sleep (paroxysmal nocturnal dyspnoea)? Fluid retention? - Ankle swelling? - Weight gain Fatigue? Decreased exercise tolerance? Increased recovery time after exercise? Light headedness? History of syncope? Risk factors? - Coronary artery disease? - Hight blood pressure? - Atrial fibrillation? - Diabetes mellitus? - Alcohol? - Family history of heart failure or sudden cardiac death under the age of 40 years?

Past medical history? Current medication? Drug allergies? Examination: BMI? BP? Pulse? Heart murmur? Raised jugular venous pressure? Basal crepitations? Pleural effusions? Dependent oedema (eg legs, sacrum)? Investigations: N-terminal pro brain natriuretic peptide (NT-proBNP): > 2,000 ng/litre (236 pmol/litre)? - Referral for specialist assessment and echocardiography within 2 weeks 400 to 2,000 ng/litre (47 to 236 pmol/litre): - Referral for specialist assessment and echocardiography within 6 weeks < 400? - Diagnosis of heart failure less likely, consideration to discuss with specialist (Note: European Society of Cardiology (ESC) guidelines suggest lower threshold for normal value of 125 pg/ml) ECG Consider: - Chest X-ray - Blood tests: FBC, ferritin, transferrin saturation, renal, liver and thyroid function profile, fasting lipids, HbA1c - Urine dipstick - Peak flow and/or spirometry Management: Valve disease? Refer for specialist assessment and advice regarding follow-up Reduced ejection fraction (HFrEF): ACEI Betablocker (Notes: ESC guidelines also recommend an aldosterone antagonist and an SGLT2i licensed to treat heart failure. Start one drug at a time.) Mildly reduced ejection fraction: Considered: - ACEI - Betablocker - Aldosterone antagonist or sacubitril valsartan Preserved ejection fraction: Referred Symptoms of fluid overload? - Loop diuretic Atherosclerotic arterial disease? - Antiplatelet drug Indication for statin? Offered referral to a supervised exercise-based group rehabilitation programme if suitable? Annual influenza vaccine and a once-only pneumococcal vaccination? General information about heart failure and its management? Offered discussion regarding advance care planning and advance decisions, if appropriate? Arranged follow-up? Advised: - To report symptoms of worsening heart failure (eg increasing breathlessness, fatigue, ankle or abdominal swelling and/or rapid weight gain)? - To monitor weight at the same time (eg after waking and voiding but before dressing or eating) - If sudden and sustained weight gain (eg > 2 kg in 3 days) to seek medical advice, increase diuretic dose, reduce fluid intake or a combination of actions - Deterioration can occur without weight gain - To avoid excessive salt intake and not to exceed 5 g of salt each day - If severe symptomatic heart failure to restrict fluid intake (eg to < 1.5-2 L a day or 30 ml/kg (35 ml/kg for those over 85 kg) - To stop ACEI/AIIRA if acutely unwell (eg diarrhoea and vomiting) until drinking normally (Medicine Sick Day Rules card) - Smoking cessation if relevant - Not to drink alcohol beyond the recommended levels - Regular low-intensity physical activity if stable heart failure - Supervised exercised-based rehabilitation programme - Healthy weight - Normal sexual activity that does not provoke undue symptoms if stable heart failure - Sources of information and support ----- NHS Health A to Z ----- British Heart Foundation ----- European Society of Cardiology: Heart failure matters

----- British Society of Heart Failure - To inform Driver and Vehicle Licensing Agency (DVLA) of any condition that may affect the ability to drive (see Medical Standards of Fitness to Drive) - Information from the Civil Aviation Authority regarding fitness for flying Referral: NYHA class IV No response to treatment in primary care or can no longer be managed in the home setting Still symptomatic (NYHA class II-IV) in spite of treatment Valvular heart disease. Left ventricular ejection fraction of 35% or less NT‑pro-BNP > 2000 ng/L (236 pmol/L) (urgent referral for specialist assessment and transthoracic echocardiography within 2 weeks) NT‑pro-BNP level between 400 and 2000 ng/L (47–236 pmol/L) (referred for specialist assessment and transthoracic echocardiography within 6 weeks) Consider referral: Comorbidity (eg chronic kidney disease or chronic obstructive pulmonary disease) Specialist treatment: Combination of loop and thiazide diuretic Aldosterone antagonist (spironolactone or eplerenone) Sacubitril valsartan Hydralazine in combination with a nitrate (especially if the person is of Afro-Caribbean origin) Digoxin Ivabradine (slows the heart rate in sinus rhythm) SGLT2 inhibitors, dapagliflozin (recommended for people with reduced ejection fraction heart failure to reduce the risk of hospitalization and death) Anticoagulation (may be indicated for people with heart failure who are in sinus rhythm and have a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus) Intravenous iron Surgical intervention Cardiac resynchronization therapy Insertion of an implantable cardioverter defibrillator (ICD) Coronary revascularization Cardiac transplantation End-stage heart failure: Liaised with a cardiologist if uncertainty about the use of further treatments (including planned deactivation of implantable cardioverter-defibrillator (ICD) if appropriate)? Explored understanding and provided appropriate explanation of the situation including realistic goals of care? Involved and coordinated care with the multidisciplinary team (MDT)? Reviewed the need for medication and provision of symptom relief? Ensured advanced care plan (ACP)? Discussed advanced decisions (advanced directives or living wills)? Resource(s): Clinical Effectiveness (CE) Southwark: Heart Failure NICE CKS: Heart failure - chronic