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Referral to Rapid Access Heart Failure Clinic Surname Forename(s) DOB NHS no Address Home tel Work tel Postcode Referrer Referrer address Referral criteria For new presentations please check BNP and refer as below. For all presentations please also check FBC, U&E, LFT, TFT, lipids and glucose and record an ECG if able. Symptoms due to suspected HF and BNP >400 ng/l – urgent HF clinic with echo Symptoms due to suspected HF and BNP 100 - 400 ng/l – routine HF clinic with echo If BNP <35 ng/l heart failure is very unlikely – please consider alternative causes If BNP 35-100 ng/l heart failure is unlikely, if clinical evidence or abnormal ECG refer for open access echo Previous MI with suspected HF – urgent HF clinic with echo Confirmed HF on echo with deteriorating symptoms – urgent HF clinic only Cardiac risk factors Hypertension Yes No Smoker Yes No Family history of CHD Yes No Cardiac history None Angina MI Valve disease Diabetes Yes No IDDM NIDDM Alcohol consumption ……………….units per week Details………………………………………………………………….. Heart failure Angioplasty CABG Other Details………………………………………………………………………………………………………………………….… Medical history Chest Yes No Asthma COPD/Emphysema Symptoms: Mild CKD Yes GI Yes TIA/Stroke Tumours No No Yes No Yes No Other comments: Moderate Other ………….………………………..…... Severe Last creatinine ………………..mol/l eGfr…………………………………….….. Peptic ulcer Hiatus hernia Residual disability: None Mild Dyspepsia Moderate Severe Details: …………………………………………………………………... Procedure for referral to Rapid Access Heart Failure Clinic For patients with no past history of CHD / HF please check BNP. If BNP is <35 ng/l heart failure is very unlikely, please consider other causes of breathlessness. If BNP is between 35 and 100 ng/l heart failure is unlikely. If there is good clinical evidence of heart failure and particularly if the patient has an abnormal ECG please refer for open access echo. If BNP is >400 ng/l or if the patient has a history of MI and presents with symptoms suggestive of heart failure please book into an urgent HF clinic with echo slot. These patients will have same day echo and we aim to see these patients within 2 weeks. If the patient has a BNP between 100 and 400 ng/l please book into a routine HF clinic with echo slot. These patients will have a same day echo and we aim to see these patients within 6 weeks. If the patient has known heart failure (confirmed previously on echo) and deteriorating symptoms please book into an urgent HF clinic only slot. These patients will usually not require same day echo but if an echo is required then this will be arranged following assessment. Please also send blood for FBC, U&E, TFT, LFT, lipids and glucose. Please record an ECG, if available, and ask the patient to bring it with them, along with a full list of current medication (or the actual medications in their containers).
