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Uncontrolled when printed Southern Derbyshire Shared Care Pathology Guidelines Heart Failure Purpose of Guideline This guideline covers the investigation and referral of patients with suspected heart failure and refers to the NICE guidelines CG108 (Chronic Heart Failure) and CG187 (Acute Heart Failure). Natriuretic Peptides Either BNP or NT-proBNP can be used as a marker for heart failure. The assay used in Derby and Chesterfield measures NT-proBNP (N-terminal pro-Brain Natriuretic Peptide) and all levels in this guideline are for NT-proBNP. Measuring NT-proBNP greatly improves the ability to rule out heart failure before referring for ECHO Diagnosing Heart Failure Acute Heart Failure: NICE CG187 states that in patients presenting with new suspected acute heart failure, NT-proBNP <300 ng/L rules out the diagnosis of acute heart failure. Chronic Heart Failure: The following cut-offs are taken from NICE CG108 NT-proBNP (ng/L) <400 Interpretation In the absence of heart failure therapy, Heart Failure is an unlikely cause for the presentation 400 - 2000 Moderately raised >2000 Significantly raised The applicability of this interpretation when the patient has renal dysfunction is currently uncertain - suggest further advice is sought. Treatment of heart failure can bring BNP into the normal range. Therefore, when questioning the diagnosis in patients on treatment, either stop their medication for three days before taking the test or leave on treatment and get an ECHO. See the following flow chart for diagnosis and referral of patients with chronic heart failure: CHISCP21: Heart Failure, Revision No 2 st Expiry date: 31 May 2017 Authors: Dr S Burn (Consultant Cardiologist and Heart Failure Lead, RDH), Dr Mark Livingston (Clinical Scientist) Authorised by Julia Forsyth Page 1 of 4 Uncontrolled when printed If the patient has had a previous MI or the NT-proBNP level is high, refer for specialist assessment and ECHO as soon as possible • very high levels carry a poor prognosis • NTproBNP < 400 pg/ml in an untreated patient makes heart failure unlikely • the level does not differentiate between heart failure due to left ventricular systolic dysfunction and heart failure with preserved ejection fraction • obesity, diuretics, ACE inhibitors, beta-blockers, ARBs and aldosterone antagonists can reduce NT-proBNP levels • high levels can have causes other than heart failure (left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], GFR < 60 ml/minute, sepsis, COPD, diabetes, age >70 yrs and liver cirrhosis). CHISCP21: Heart Failure, Revision No 2 st Expiry date: 31 May 2017 Authors: Dr S Burn (Consultant Cardiologist and Heart Failure Lead, RDH), Dr Mark Livingston (Clinical Scientist) Authorised by Julia Forsyth Page 2 of 4 Uncontrolled when printed Are there any other useful tests for evaluating possible aggravating factors and alternative diagnoses? • • • perform an ECG consider chest X-ray, peak flow or spirometry Management of Chronic Heart Failure For the management of chronic heart failure, including treatment and monitoring (with information on laboratory tests required as part of management), please see the Derbyshire Joint Area Prescribing Committee (JAPC) local guidelines using the link below. http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by _BNF_chapter_prescribing_guidelines/BNF_chapter_2/Heart_failure.pdf Are there times when specialist secondary care is recommended? Consider referring for specialist advice in the following situations: • Refer patients to the specialist multidisciplinary heart failure team in the following situations. – Initial diagnosis of heart failure. – Management of severe heart failure (NYHA1 class IV), heart failure that does not respond to treatment, heart failure due to valve disease, or heart failure that can no longer be managed at home. – Advice and care of women with known heart failure who are planning a pregnancy or are pregnant. Care of pregnant women should be shared between the cardiologist and obstetrician. • Patients with previous MI o Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment as soon as possible. Contacts Duty Biochemist 01332 789383 (8am to 7pm) On Call Consultant Biochemist Via RDH switchboard, 01332 340131 Cardiology Advice Via RDH switchboard References Local guidelines: Derbyshire Joint Area Prescribing Committee (JAPC) guidelines. Management of Chronic Heart Failure with left ventricular systolic dysfunction (Last reviewed October 2010). http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by _BNF_chapter_prescribing_guidelines/BNF_chapter_2/Heart_failure.pdf CHISCP21: Heart Failure, Revision No 2 st Expiry date: 31 May 2017 Authors: Dr S Burn (Consultant Cardiologist and Heart Failure Lead, RDH), Dr Mark Livingston (Clinical Scientist) Authorised by Julia Forsyth Page 3 of 4 Uncontrolled when printed National guidelines: NICE Clinical Guideline No 108 (CG108). Chronic Heart Failure. Management of chronic heart failure in adults in primary and secondary care. August 2010. http://www.nice.org.uk/CG108 NICE Clinical Guideline No 187 (CG187). Acute Heart Failure: diagnosing and managing acute heart failure in adults. October 2014. http://www.nice.org.uk/CG187 http://guidance.nice.org.uk/CG108/QuickRefGuide/pdf/English Patient information website http://www.patient.co.uk/health/Heart-Failure.htm Authors: Dr S Burn, Ms M Livingston, August 2012 Reviewed by: Dr M Ahamed, Dr P Blackwell, Mrs H Seddon Date: May 2015 Expiry date: 31st May 2017 CHISCP21: Heart Failure, Revision No 2 st Expiry date: 31 May 2017 Authors: Dr S Burn (Consultant Cardiologist and Heart Failure Lead, RDH), Dr Mark Livingston (Clinical Scientist) Authorised by Julia Forsyth Page 4 of 4