Proposed National System for Early Identification and Diagnosis of Heart Failure in Jordan
Proposed National System for Early Identification and Diagnosis of Heart Failure in Jordan
Source: Taskforce Proposal for Implementing National HF Protocols (JCS 2025)
1. Background and Purpose
Early detection of heart failure (HF) in primary care is increasingly important given rising rates of hypertension, diabetes, obesity, and chronic kidney disease.
The national question was: Is there a simple screening or assessment tool that can be used for early detection of HF in primary care?
The following summarizes the proposed national approach.
2. Do We Need a Screening Test? What Is Recommended?
1. Current national and international guidelines do not recommend mass population screening for HF.
2. They strongly support targeted early detection among high-risk individuals, using:
• A simple symptom checklist + brief physical exam
• NT-proBNP and ECG when HF is suspected
• Timely referral for echocardiography when uncertainty remains
3. This approach is feasible, low-cost, and suitable for primary care, and can reduce complications and repeated hospitalizations when integrated into a clear referral pathway.
3. Who Is Considered High-Risk? (Simple Rule First, Detailed List Next)
Simple Rule
• Older age + hypertension or diabetes or previous heart disease → treat as high-risk.
Detailed High-Risk Criteria (1 or more → high risk)
1. Hypertension (especially uncontrolled)
2. Diabetes mellitus
3. Previous heart disease
• Myocardial infarction
• Coronary stent
• Angina
4. Atrial fibrillation or irregular pulse
5. Chronic kidney disease (CKD)
6. Clear obesity or metabolic syndrome
7. Age ≥ 60 years
Any patient with ≥ 2 of these factors → complete symptom checklist + vital signs + consider NT-proBNP and ECG if symptoms are present.
4. Practical Roles of the Healthcare Workforce (Three-Level Model)
Level 1: Nurse or Community Health Worker (in centers without a doctor)
Primary role: Early suspicion and referral
1. Identify high-risk patients
• Based on age, hypertension, diabetes, and heart disease history
2. Complete the HF Symptom Checklist
Ask whether the patient had any of the following in recent weeks:
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Leg swelling or unexplained weight gain
• Fatigue or reduced exercise tolerance
• Palpitations
• Nocturnal cough or sudden nighttime dyspnea
If ≥ 2 symptoms → consider HF suspicion
3. Perform rapid vital-sign assessment
• Blood pressure
• Heart rate
• Weight
• Oxygen saturation (< 90% is concerning)
• Check for lower-limb edema
4. Refer suspected cases to the general practitioner
• The nurse does not diagnose – only identifies and escalates.
Level 2: General Practitioner / Family Physician
Primary role: Confirm suspicion and decide on referral
1. Review symptoms, vital signs, and risk factors.
2. Order ECG + NT-proBNP when suspicion is confirmed.
3. Exclude non-cardiac causes of dyspnea:
• COPD
• Anemia
• Obesity
• Thyroid disorders
4. Begin basic management of risk factors (hypertension, diabetes, fluid overload).
5. Refer to cardiology if:
• NT-proBNP is elevated
• ECG is abnormal
• Symptoms strongly suggest HF
6. Some centers may allow the GP to order echocardiography directly.
The GP’s role is suspicion—not definitive HF diagnosis.
Level 3: Cardiologist (or Internist/Family Physician where cardiology is unavailable)
Primary role: Definitive diagnosis and management
1. Confirm HF diagnosis by echocardiography, assessing:
• LVEF
• Cardiac structure and chamber size
• Valves and pericardium
2. Classify HF
• HFrEF ≤ 40%
• HFmrEF 41–49%
• HFpEF ≥ 50%
3. Start or optimize guideline-directed medical therapy (GDMT)
• ARNI / ACEI / ARB
• Beta-blocker
• MRA
• SGLT2 inhibitor
4. Register the patient in the National HF Registry (NHFR-JO)
• Can be done by the cardiologist, nurse, or assistant
5. Determine need for advanced therapies
• ICD
• CRT
• LVAD
• Heart transplantation
5. National Diagnostic Pathway (Summary)
Community → Primary Care → HF Center
This pathway reflects the National JCS Heart Failure Protocols (2025), emphasizing:
• Early identification
• Structured referral
• Early GDMT initiation
• Integration with the national HF registry
• Clear workforce roles at every level
This system is practical, scalable, and aligns with Jordan’s primary healthcare capabilities.
6. Diagnostic Criteria for Heart Failure (Simplified)
Heart failure is diagnosed only when all three elements are present:
1. Symptoms or signs
• Dyspnea, orthopnea, leg swelling, fatigue, nocturnal dyspnea, palpitations
2. Abnormal echocardiography
• Reduced LVEF
• Diastolic dysfunction
• Structural heart disease
• Elevated pulmonary pressures
3. Elevated NT-proBNP
• ≥ 300 pg/mL (acute presentations)
• ≥ 125 pg/mL (chronic cases)
• Very low NT-proBNP effectively excludes HF
HF is confirmed when:
Symptoms + Abnormal Echo + Elevated NT-proBNP → definite diagnosis.
7. Conclusion
The proposed detection system is fully feasible for primary care in Jordan, requiring only basic training for nurses and community health workers.
Definitive diagnosis and long-term management remain the responsibility of cardiologists or trained physicians.
This structured model ensures early identification, timely treatment, and fewer hospitalizations—supporting national priorities for chronic disease control.
