Download Heart Failure - Derby Hospitals NHS Foundation Trust

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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
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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
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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
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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