Chronic Heart Failure in Adults: Diagnosis and Management – Primary Care Summary
Chronic Heart Failure in Adults: Diagnosis and Management – Primary Care Summary
Source:NICE guideline
Reference number: NG106
Published:
12 September 2018
Last updated:
03 September 2025.
1. Team working (MDT and Primary Care)
• MDT (Multidisciplinary Team) = a specialist team including:
• Cardiologist with HF expertise.
• Heart failure specialist nurse.
• Pharmacist or prescriber with HF expertise.
• The MDT works in close collaboration with primary care.
• Roles: MDT makes diagnosis, starts complex therapies, and manages advanced cases.
• Primary care ensures continuity: communication, record updates, recalls every 6 months, and linking all services.
2. Extended first consultation
• Newly diagnosed patients should be offered a long, detailed first appointment (not a quick visit).
• Purpose: explain the diagnosis, prognosis, treatment options, sudden death risk, and answer all patient/family questions.
• Followed by a second consultation (ideally within 2 weeks).
3. Written summary and care plan
• The MDT prepares a written summary including: diagnosis, medications, monitoring, functional status, and social needs.
• This becomes the individualised care plan, which must cover:
• Follow-up schedule.
• Warning signs for deterioration.
• Urgent contact details and named coordinator (often the HF nurse).
• Social support and rehab access.
• The care plan must be shared with the patient, family/carers, GP, and all professionals involved.
4. Diagnosis in primary care
• Take history, exam, and test NT-proBNP.
• >2000 ng/L: urgent referral → echo within 2 weeks.
• 400–2000 ng/L: referral → echo within 6 weeks.
• <400 ng/L (if untreated): HF unlikely.
• Remember: BNP can be lowered by obesity or some drugs, and raised by renal/lung/liver disease.
5. Transition after hospitalisation
• Discharge patients only when stable and with a written plan.
• Primary care should take over routine management once stability is achieved.
6. Treatment – HFrEF (reduced EF)
• Core therapy: ACE inhibitor + beta-blocker + MRA + SGLT2 inhibitor.
• If symptoms persist: switch ACE inhibitor → ARNI.
• If intolerance: consider ARB/ARNI depending on cause.
7. Treatment – HFmrEF (mildly reduced EF)
• Consider: ACE inhibitor (or ARB), beta-blocker, MRA, SGLT2 inhibitor.
• NICE specifically recommends empagliflozin or dapagliflozin as SGLT2 options.
8. Treatment – HFpEF (preserved EF)
• Consider: MRA + SGLT2 inhibitor (empagliflozin or dapagliflozin).
9. Chronic kidney disease considerations
• If eGFR ≤45 → start low doses, titrate slowly.
• If eGFR <30 → involve nephrology.
10. Medication monitoring
• Check renal function & electrolytes:
• 1–2 weeks after starting or changing dose.
• Every 3–6 months if stable.
• Monitor blood pressure and rhythm regularly.
• Watch for hyperkalemia, renal dysfunction, postural hypotension.
11. Other therapies & advice
• Diuretics: for congestion, lowest dose needed.
• IV iron: consider if HFrEF + iron deficiency.
• Anticoagulation: follow AF/stroke prevention guidance.
• Vaccination: flu annually, pneumococcal once.
• Lifestyle: avoid potassium salt substitutes, manage smoking/alcohol, consider travel/driving safety.
• Pregnancy/contraception: specialist advice is required.
12. Monitoring and follow-up
• Full review in primary care every 6 months: symptoms, fluid status, rhythm, renal function, Hb/iron, medication review.
• Shorter intervals if unstable or with medication changes.
• Encourage patient self-monitoring with clear guidance.
Key Points for GPs
• Work closely with the MDT; keep communication active.
• Always arrange a long, thorough first consultation for new diagnoses.
• Use NT-proBNP to triage urgency of referral.
• Start and optimise 4-pillars therapy (ACE/ARNI, beta-blocker, MRA, SGLT2i).
• Provide and share an individualised care plan with all stakeholders.
• Review every 6 months, or sooner if unstable.
