Heart Failure

1

Step 1

History Taking — Open Question First · Symptoms · ICE · Psychosocial Context

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Heart failure history has two purposes: diagnosing the condition AND identifying the precipitant. In known HF, finding why they have deteriorated is as important as grading severity. Always start with an open question — the patient's narrative reveals the precipitant, the impact on life, and the hidden fear.

🎓 SCA opener — acknowledge what you know first

"I can see from the letter that you've been having increasing breathlessness over the past few weeks. Before I ask anything specific, I'd like to hear it in your own words — how has this been affecting you and your daily life?"

Asking for information already in the letter = Domain 1 deduction. Open Q first — let the patient reveal severity, precipitant, and emotional impact simultaneously.

1A — Open question first, then targeted history

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION — always start here"Can you tell me, in your own words, how your breathing has been — and how this has been affecting your life day to day?"	Reveals severity, precipitant and functional impact simultaneously. A patient who says "I used to walk to the shops, now I can't make it to the end of the garden" has told you NYHA class III in one sentence. Also uncovers fears (prognosis, death) and impact on relationships before you impose structure.In SCA: finishing data gathering by 6–7 min requires this efficiency. Rigid tick-box history misses the emotional agenda entirely.	NYHA classHidden fearUrgency
Breathlessness — onset and progression?"When did it start? Is it getting worse, and how quickly?"	Acute onset (hours-days) = pulmonary oedema, arrhythmia, PE, pneumonia. Gradual (weeks-months) = chronic HF or COPD. Rate of progression determines urgency — deteriorating over days is different from stable over months.	Acute → 999Rapid progression → same-day
Orthopnoea?"Do you need more pillows to sleep? How many?"	Orthopnoea is highly specific for HF (fluid redistribution supine → pulmonary congestion). More pillows = more severe. New orthopnoea in known HF = decompensation.	Supports HF DDxSeverity grading
Paroxysmal nocturnal dyspnoea?"Do you wake at night gasping or fighting for breath?"	PND is almost pathognomonic for HF. Highly specific. Waking with severe dyspnoea 1–3 hours after sleep = classic. Differentiates from COPD (no PND) and anxiety (no fluid redistribution).	Strong HF markerSeverity/urgency
Ankle swelling?"Have your ankles or legs been swelling — worse in the evening?"	Bilateral pitting oedema = RHF or biventricular HF. Unilateral = DVT until proven otherwise. Evening worsening = gravitational + poor cardiac output. Oedema alone is non-specific (venous insufficiency, CCB, hypoalbuminaemia).	HF vs other causesBNP + echo
Exercise tolerance?"What can you manage now? What could you manage 3 months ago?"	Change over time defines NYHA class and disease trajectory. NYHA I = asymptomatic. II = mild exertion symptoms. III = minimal exertion. IV = rest symptoms. This drives both prognosis and treatment urgency.	NYHA classTreatment urgency
Chest pain?"Any chest pain — tightness, pressure, or aching?"	Ischaemic HF (IHD → LV dysfunction) is the most common cause in the UK. Anginal chest pain = possible ongoing ischaemia → ACS needs exclusion. Pleuritic pain = PE or pericarditis.	ACS → 999Aetiology of HF
Palpitations?"Have you noticed your heart racing, fluttering, or going irregular?"	AF is the most common precipitant of acute decompensation in HF. New AF → loss of atrial kick → 20% ↓ CO → pulmonary oedema. Also: VT in HFrEF = high-risk arrhythmia → urgent.	VT → 999New AF → same-day ECG
Reduced urine output / weight gain?"Have you noticed less urine than usual? Any sudden weight gain in the last week?"	Oliguria = low cardiac output → AKI. Rapid weight gain (≥2kg/3 days) = fluid retention = decompensation trigger. This is a key self-monitoring parameter for HF patients.	AKI → urgent U&EsDiuretic titration
Precipitant screen?"Any recent infections, extra salt intake, missed tablets, new medications?"	Identifying the precipitant is essential in decompensated HF. Common triggers: infection (50%), dietary (excess Na⁺), non-adherence, new AF, NSAID/steroid use, ischaemia. Treating the trigger is part of treatment.	Treat the triggerReversible cause

1B — Red flags: act before continuing history

🚨

Red Flags in Heart Failure — act before continuing

Red flag	Why dangerous	Action
Acute severe dyspnoea at rest + SpO₂ <94% + pink frothy sputum	Acute pulmonary oedema — drowning in their own fluid. Mortality 10–20% without treatment. Needs IV diuretics, nitrates, CPAP urgently.	999 immediately
Cardiogenic shock: BP <90 systolic + cold clammy peripheries + confusion + oliguria	Cardiac output critically reduced. Inotropes required. 40–80% in-hospital mortality. IV access, O₂, immediate transfer.	999 immediately
Chest pain + new breathlessness (ACS precipitating HF)	STEMI or NSTEMI may have caused or decompensated HF. Aspirin 300mg if no contraindication. Urgent reperfusion may save myocardium.	999 + aspirin 300mg
New palpitations + haemodynamic instability (VT/SVT)	Ventricular tachycardia in HFrEF is life-threatening. Unstable SVT or rapid AF with hypotension needs DC cardioversion urgently.	999 immediately
NYHA IV (rest symptoms) new or worsening — not manageable in community	End-stage HF. IV diuretics, inotropes, or palliative care pathway required. Cannot be safely managed at home without specialist input.	Same-day hospital
AKI on diuretics (creatinine rise >50% or K⁺ >6.0)	Cardiorenal syndrome — bidirectional deterioration. Stopping diuretics → worse HF. Continuing → worse AKI. Specialist input required urgently.	Urgent — same day U&Es + cardiology

🛡️

Safeguarding Considerations — HF Context

Heart failure creates specific vulnerability. Breathlessness, reduced mobility, fatigue, and cognitive impairment from low cardiac output all increase dependence — and therefore risk of exploitation or neglect.

🏠 Carer Stress & Domestic Situation

HF severely restricts mobility and independence — carer burden is high
Partner/carer may be elderly themselves or overwhelmed
Carer may not be administering medications correctly
Ask: "Who helps you at home? How are they coping?"
Refer to carer support services; consider social care assessment

👴 Cognitive Impairment & Consent

Low cardiac output → reduced cerebral perfusion → confusion, cognitive decline
Patient may not have capacity to make informed decisions about treatment
Is the medication actually being taken? Who is managing it?
Consider MCA 2005 assessment if concern about capacity
DOLs if admission needed for patient who lacks capacity

💊 Medication Safety

Complex polypharmacy in HF — risk of unintentional wrong dosing
If someone else is administering medication: is it appropriate? Is it correct?
Diuretics in wrong doses cause dangerous electrolyte disturbances
Digoxin toxicity risk if doses given incorrectly by carers

😔 Depression, Isolation & End of Life

Depression affects 20–40% of HF patients — associated with worse outcomes
Social isolation increases mortality in HF independently
NYHA III–IV patients may have unaddressed end-of-life wishes
ACP conversations may need to be initiated if not already done

If safeguarding concern: Document clearly. Discuss with safeguarding lead. Refer to adult social care, IMCA if needed. Do not let clinical agenda override safety concern. A concern is enough to act — no certainty needed.

1C — PMH · Drug history · Social history: changes management

🧬 PMH / Aetiology — changes drug choice

Factor	Why it matters	Management impact
Ischaemic heart disease	Most common cause of HFrEF in UK. Ongoing ischaemia worsens function.	ACEi/ARB + BB + MRA. Ensure optimised anti-anginal therapy. Consider revascularisation if viable myocardium.
Hypertension	Long-standing HTN → LVH → diastolic dysfunction → HFpEF. Also causes HFrEF via ischaemia.	Tight BP control (<130/80). SGLT2i + diuretics first in HFpEF.
Atrial fibrillation	Most common precipitant of decompensation. Loss of atrial kick = 20% CO reduction.	Rate control (BB or digoxin). Consider rhythm control. Anticoagulate (CHADS₂VASc).
Valvular disease	Severe AS / MR can cause HF independently. Correctable cause.	Urgent echocardiography. Refer for valve assessment. AVR/TAVI for severe AS.
CKD	Cardiorenal syndrome — bidirectional. Diuretics worsen renal function. ACEi/ARB may raise creatinine/K⁺.	Careful fluid balance. Monitor U&Es closely. Nephrology input if eGFR <30.
Diabetes	Independent cardiac risk. Cardiomyopathy. SGLT2i have dual benefit (HF + DM).	SGLT2i (dapagliflozin/empagliflozin) for ALL HFrEF + DM. Also now indicated in HFpEF.
Thyroid disease	Hypothyroidism → HF. Hyperthyroidism → AF → HF. Both reversible.	TFTs in all new HF. Treat thyroid disease first — may resolve cardiac problem.
Alcohol use	Alcoholic cardiomyopathy — reversible with abstinence (up to 50% recover EF).	Abstinence is treatment. CAGE/AUDIT screening. Alcohol cessation service referral.

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
NSAIDs (ibuprofen, naproxen)	Na⁺/water retention → fluid overload. Reduce diuretic efficacy. Worsen renal function. Major precipitant of decompensation.	STOP NSAIDs — absolute. Switch to paracetamol. This alone may allow decongestion.
CCBs (verapamil, diltiazem)	Negatively inotropic → worsen systolic function in HFrEF. Amlodipine is safer but still causes oedema.	Avoid verapamil/diltiazem in HFrEF. Amlodipine only if absolutely needed for BP/angina.
Thiazolidinediones (glitazones)	Cause fluid retention → can precipitate/worsen HF.	STOP pioglitazone in HF.
Antiarrhythmics (flecainide)	Pro-arrhythmic in structural heart disease → VT → sudden death.	Avoid flecainide in HFrEF. Use amiodarone only with cardiology input.
High salt diet	Na⁺ → fluid retention → pulmonary/peripheral oedema. Major driver of decompensation.	Ask about salt intake; NICE NG106 advises against routine sodium restriction but advises reducing intake when salt consumption is high. Refer to dietitian if needed. Weigh daily — 2kg gain in 3 days = escalate diuretics.
Fluid intake	Excessive fluid intake worsens congestion — especially in severe HF.	NICE NG106: do not routinely restrict fluids; restrict for dilutional hyponatraemia or high fluid intake, and review the need regularly. Educate on self-management.
Alcohol	Cardiomyopathy, AF trigger, drug interactions (warfarin). Negative inotrope acutely.	Reduce to <14u/wk minimum. Complete abstinence advised in alcoholic cardiomyopathy.
Smoking	Accelerates IHD progression. CO reduces oxygen delivery. Endothelial damage.	Cessation service every consultation. NRT + varenicline safe in HF.

1D — ICE: Ideas · Concerns · Expectations

💭 Ideas

"What do you think is causing your breathlessness? Has anyone mentioned the words 'heart failure' to you before — and what does that mean to you?"

The term "heart failure" is catastrophically misunderstood. Many patients believe it means the heart has stopped. Clarifying this is therapeutic and enables informed discussion.

😟 Concerns

"I can see you're worried about this. What is the thing you're most frightened of when it comes to your heart? Is it about dying, or is it about not being able to do the things that matter to you?"

Distinguishing fear of death from fear of disability shapes the conversation entirely. Both are valid — but they lead to different management discussions (ACP vs rehabilitation vs symptom control).

🎯 Expectations

"What were you hoping we might be able to do today? Were you hoping to understand more about what's happening, or were you hoping for something to make you feel better quickly?"

Managing expectations about heart failure treatment is essential — it takes weeks-months to optimise. Explaining this prevents premature medication discontinuation from perceived lack of effect.

1E — Psychosocial context: the person living with heart failure

💼 Work & Activities

NYHA III–IV = likely unfit for most physical work. Driving may be restricted (DVLA notification required for certain arrhythmias). Benefits entitlements may need addressing (PIP, ESA).

"Has the breathlessness affected your ability to work or do the things you enjoy?"

💑 Relationships & Sexuality

Sexual activity equivalent to climbing 2 flights of stairs — usually safe in NYHA I–II. Erectile dysfunction common with BB and diuretics. Relationship strain from role reversal (independent → dependent).

"Has this affected your relationship with your partner at all — or aspects of your relationship that are important to you?"

😰 Mood & Mental Health

Depression affects 20–40% of HF patients and worsens prognosis independently. Anxiety about symptoms (every breathless episode = fear of dying). PHQ-9 / GAD-7 should be offered.

"How has your mood been through all of this? It's very common to feel anxious or low — how are you doing emotionally?"

🏠 Home & Independence

Stairs, bathing, shopping — all may become impossible in NYHA III. Home adaptations, OT assessment, community nursing may be needed. Is the patient safe at home?

"Are you managing at home — things like getting upstairs, washing, or going out? Do you have enough support?"

🔮 Prognosis & End of Life

5-year mortality in HF is 50% — worse than many cancers. ACP conversations are important but rarely initiated. Many patients want to discuss this but are not given the opportunity.

"Some people find it helpful to talk about what they'd want if things got harder. Is that a conversation you'd like to have when the time feels right?"

💰 Financial Impact

Work capacity may be reduced or lost. Medication costs (prepayment certificates). Equipment costs (home monitoring). Benefits navigation. Social prescribing referral may help.

"Has this had any impact financially? There may be benefits or support we can help you access."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I can see from the letter that you've been having breathlessness..."

"Tell me in your own words how this has been affecting your day-to-day life..."

"What does the term 'heart failure' mean to you?"

"What is the thing you're most frightened of right now?"

"Has this affected your relationship or things that are important to you?"

Deductions

Asking information already in the referral letter
Starting with NYHA class questions before open Q
Not exploring the emotional meaning of "heart failure" diagnosis
Missing NSAIDs / precipitant screen
No psychosocial — work, relationships, mood not explored
Missing ACP opportunity in advanced disease

🔴 Red

Ignores letter; closed Qs throughout; no ICE; "heart failure" not addressed emotionally; no psychosocial; prescribing lecture

🟠 Amber

Opens reasonably; ICE formulaic; prognosis fear not explored; precipitant not sought; mood mentioned but not explored

🟢 Green

Reads letter; open Q; ICE with "heart failure" meaning explored; precipitant sought; psychosocial (work, mood, relationships, ACP if appropriate); data gathering complete by 6–7 min

2

Step 2

Triage Engine — Emergency · Urgent · Routine

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Heart failure triage is high stakes. Acutely decompensated HF carries significant in-hospital mortality. The key question before any assessment: is this patient safe to manage in primary care, or do they need hospital today? Get this wrong and patients die at home or are admitted unnecessarily.

🔴 Emergency

999 or Same-Day Hospital

Call 999 / A&E now

Acute pulmonary oedemaSevere dyspnoea at rest · SpO₂ <94% · Pink frothy sputum · Unable to speak
Cardiogenic shockBP <90 systolic · Cold/clammy · Confusion · Oliguria
ACS precipitating HFChest pain + new breathlessness → 999 + aspirin 300mg
Unstable arrhythmiaVT · Rapid AF with hypotension · Haemodynamic compromise
NYHA IV at rest, new or rapidly worseningNot manageable in community setting

🟠 Urgent

Same-Day Assessment / Days

Hours to days

Decompensation without shockWorsening oedema · ↑ breathlessness · Weight gain ≥2kg/3 days but stable obs
NT-proBNP >2000 ng/L (new)Specialist assessment + echo ≤2 weeks per NICE NG106
AKI on background of HF treatmentCreatinine ↑ >50% or K⁺ >6.0 → same-day U&Es + review
New AF in known HFRate control + anticoagulation + decompensation risk
Suspected new diagnosis of HFNT-proBNP raised → specialist + echo per NG106 clock (≤2 or ≤6 weeks)

🟢 Routine

Primary Care Management

GP practice

Stable known HF — routine reviewReview at least 6-monthly (QS9) · Medication optimisation · Symptom monitoring
NT-proBNP 400–2000 ng/LSpecialist assessment + echo within 6 weeks per NICE NG106
NYHA I–II, stableTitration of disease-modifying drugs · Lifestyle · Monitoring
Post-hospital discharge follow-up2-week follow-up after HF admission (specialist HF team; GP checks it happens)
Medication review / optimisationUp-titration of ACEi/BB/MRA/SGLT2i to target doses

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Say before management

"Before I explain my thinking, I want to make sure nothing needs urgent attention today — can I ask specifically about your breathing at rest, your blood pressure, and whether you've noticed any chest pain?"

Deductions

Moving to management without explicit triage screen
Missing cardiogenic shock signs (BP, peripheries, urine output)
Not recognising acute pulmonary oedema as 999
Failing to verbalise safety screen — examiners score what they hear

🔴 Red

Goes to management without triage; misses acute decompensation; no safety screen verbalised

🟠 Amber

Some triage questions asked but reasoning not verbalised; misses one key red flag cluster

🟢 Green

All red flags named aloud; correctly triages emergency/urgent/routine; rules in/out serious disease explicitly before management

3

Step 3

Do I Need This Examination?

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"Will this examination change management?" In HF, the examination is not merely diagnostic — it stages severity, detects decompensation, and guides immediate treatment decisions (e.g. signs of congestion → increase diuretics TODAY).

Examination	Why it matters in HF	Finding that changes management	Changes management?
Pulse rate & rhythm	AF is the most common precipitant of decompensation. Rate >100 in HF = inadequate rate control → suboptimal cardiac output → symptoms.Rate >140 = haemodynamic compromise → urgent ECG + rate control.	Irregular → ECG → rate control (BB or digoxin) + anticoagulate. Bradycardia (<50) → review BB dose.	YES — urgently
BP both arms	Hypotension (SBP <90) = cardiogenic shock or over-diuresis. Hypertension = poorly controlled HTN driving HF. Guides drug titration — symptomatic hypotension slows titration; asymptomatic low BP needs no action.	Symptomatic hypotension → reduce the diuretic first if euvolaemic, then stop nitrates/alpha-blockers/CCBs before touching a pillar; SBP <90 with hypoperfusion → same-day assessment. SBP >140 → optimise antihypertensives.	YES — drug doses
JVP (jugular venous pressure)	Elevated JVP = right heart failure / fluid overload. Best bedside marker of volume status. JVP >4cm above sternal angle = raised. Requires adequate positioning (45°).	Raised JVP → increase diuretics. Absent JVP in symptomatic patient → consider cardiorenal syndrome (may be dehydrated despite HF symptoms).	YES — diuretic dose
Apex beat	Displaced apex = LV dilatation (HFrEF). Thrusting = volume overload. Tapping = mitral stenosis. Documents LV size at baseline and tracks response to treatment.	Displaced apex → confirms LV dilatation → echo urgently if not done.	YES — echo urgency
Heart sounds (S3, S4, murmurs)	S3 gallop = HF — poor LV compliance, raised filling pressures. Highly specific. Murmurs may indicate valvular aetiology (AS, MR) — correctable cause of HF.	S3 → confirms HF diagnosis, increases urgency. New murmur → urgent echo for valvular disease.	YES — urgency + aetiology
Lung auscultation	Bibasal crepitations = pulmonary oedema. Absent breath sounds + dullness = pleural effusion (common in HF). Wheeze = cardiac asthma (HF-induced bronchospasm) — often misdiagnosed as COPD.	Crepitations → increase diuretics urgently. Pleural effusion confirmed → diuretics + consider drainage if large.	YES — treatment urgency
Peripheral oedema (severity + extent)	Pitting oedema graded 1–4 / ankle to thigh. Documents severity and tracks response to diuretics. Sacral oedema in bedbound patients — do not miss.	Severe (to thigh) → hospital admission likely. Improving → diuretic working. Worsening on treatment → refractory HF.	YES — admission vs community
Weight (daily monitoring)	Weight gain ≥2kg in 3 days = fluid retention = early decompensation. Should be checked at every HF review. Patients should self-monitor and have an action plan.	>2kg in 3 days → increase diuretic per HF self-management plan. Consistent weight loss → diuretics working.	YES — always
SpO₂ (oxygen saturation)	SpO₂ <94% = significant hypoxaemia → O₂ supplementation. <90% + respiratory distress = 999. Normal SpO₂ does not exclude early pulmonary oedema.	<94% → supplemental O₂. <90% + symptoms → 999.	YES — urgency
Cachexia / BMI	Cardiac cachexia = very advanced HF, poor prognosis. Low BMI in severe HF = loss of lean body mass (not just fat). Indicator for palliative discussion.	Severe cachexia → specialist palliative input + ACP discussion.	YES — prognosis

🎓 SCA Checkpoint — Step 3Tasks

How to propose examination

"I'd like to check a few things — your pulse, blood pressure, the veins in your neck which tell me about fluid levels, listen to your heart and chest, and check your ankles. Each of these tells me how your heart is coping right now."

Deductions

Not checking JVP — the single best bedside fluid status marker
Not checking weight or daily weight trend
Not documenting oedema severity (grade/extent)
Not linking examination findings to immediate management changes

🔴 Red

Pulse and BP only; no JVP; no lung auscultation; no oedema grading; findings not linked to management

🟠 Amber

Most examination proposed; JVP mentioned but rationale unclear; weight not checked; some findings not acted upon

🟢 Green

Full targeted examination with rationale; JVP, apex, heart sounds, lungs, oedema, weight, SpO₂; each finding linked to specific management decision

4

Step 4

Do I Need This Investigation?

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BNP is the gateway test in HF. Every investigation should answer a specific question. In HF, the diagnostic pathway is BNP-led; echocardiography defines phenotype (HFrEF vs HFpEF); bloods protect from drug harm; ECG guides arrhythmia management.

Investigation	Clinical question it answers	What result changes management?
BNP / NT-proBNP	The gatekeeper test — rules HF in or out before echo. BNP released by ventricular myocytes under stretch. NICE NG106 pathway: NT-proBNP >2000 ng/L → specialist assessment + echo ≤2 wks. 400–2000 → ≤6 wks. <400 → HF unlikely.	NT-proBNP <400 = HF unlikely — pursue alternative diagnosis. 400–2000 = possible HF → echo within 6 weeks. >2000 = high risk → specialist + echo within 2 weeks. Falsely LOW in obesity, African or African-Caribbean family background and on diuretics, ACEi/ARB/ARNI, beta-blockers or MRAs; falsely high with age, AF, CKD, LVH, PE, sepsis, COPD.
Echocardiogram (transthoracic)	Defines HF phenotype (HFrEF/HFpEF/HFmrEF), identifies aetiology (valvular, ischaemic, dilated, hypertrophic), quantifies severity (EF%), guides specific treatment. Cannot prescribe disease-modifying HF drugs without echo.	EF ≤40% = HFrEF → offer all four pillars (ACEi + BB + MRA + SGLT2i). EF 41–49% = HFmrEF → consider the same four classes. EF ≥50% = HFpEF → SGLT2i + diuretic + consider an MRA too (NG106, Sept 2025) + treat cause. Valvular disease → urgent cardiology for intervention.
12-lead ECG	Identifies AF (most common precipitant), LVH (hypertensive cardiomyopathy), ischaemia/previous MI (ischaemic aetiology), bundle branch block (CRT candidacy — LBBB + EF ≤35% → CRT may help), QTc prolongation (drug monitoring).	AF → rate control + anticoagulate. LBBB + EF ≤35% → refer for CRT assessment. ST changes → rule out ACS. Normal ECG makes HF less likely but does not exclude it.
U&E + eGFR + K⁺	Baseline before ACEi/ARB/MRA. Monitors cardiorenal syndrome. K⁺ determines safety of spironolactone. eGFR determines drug dosing. Electrolytes critical in diuretic therapy.	K⁺ >5.0 → caution starting an MRA. K⁺ 5.5–5.9 → stop K⁺-raisers, check for dehydration/AKI, recheck; reduce or withhold MRA per SPC/local HF protocol. K⁺ ≥6.0 → urgent assessment. eGFR <30 → specialist input, reduce doses. Creatinine ↑ >50% (heart failure monitoring, NG106) → local protocol, seek heart failure team advice.
FBC (full blood count)	Anaemia is a common comorbidity in HF (25–40%) and worsens symptoms independently. Hb <10g/dL worsens exercise capacity and is associated with worse prognosis.	Anaemia identified → investigate cause (iron, B12, folate, renal, haemolytic). Consider IV iron in symptomatic HFrEF with iron deficiency (ferritin <100 µg/L or TSAT <20%) AND Hb <150 g/L — the haemoglobin trigger gates eligibility and is the bit most often missed. Consider IV iron (NG106); IV iron improves symptoms and function (hospitalisation outcomes vary by trial).
TFTs (thyroid function)	Hypothyroidism causes HF directly. Hyperthyroidism causes AF → HF. Amiodarone (used in HF arrhythmias) causes both hypo- and hyperthyroidism. Should be checked in all new HF and if amiodarone used.	Hypothyroidism → levothyroxine; may resolve HF. Hyperthyroidism → treat before optimising HF drugs (BB doses affected by thyroid status).
LFTs + Albumin	Hepatic congestion (congestive hepatopathy) is common in right HF — raised ALP, bilirubin. Low albumin = poor nutritional state or protein-losing enteropathy from gut oedema. Also needed before spironolactone.	Raised hepatic enzymes → confirm congestive hepatopathy; diurese more aggressively. Low albumin + peripheral oedema → differentiate from HF oedema (important DDx).
HbA1c + glucose	DM is a major HF comorbidity and affects drug choice. SGLT2i are indicated in HFrEF regardless of diabetes — but knowing DM status guides glycaemic management alongside.	DM confirmed → SGLT2i have dual benefit (HF + glucose). Pre-DM → lifestyle. Metformin is safe in stable HF (previously avoided — evidence now supports use if eGFR >30).
Chest X-ray	Cardiomegaly (cardiothoracic ratio >0.5), pulmonary venous congestion, Kerley B lines, pleural effusions, pulmonary oedema (bat-wing shadowing). Useful in acute decompensation to assess severity.	Evidence of pulmonary oedema → IV diuretics urgently. Pleural effusions → diuretics + consider thoracocentesis if large. Cardiomegaly alone does not diagnose HF but supports the diagnosis.

🎓 SCA Checkpoint — Step 4TasksRelating to Others

How to explain investigations

"I'd like to do a blood test called BNP — it's released by the heart when it's under strain, so it acts like a 'stress hormone' for the heart. If it's raised, we'll need a scan of the heart urgently."

"The heart scan — the echocardiogram — is crucial because it tells us exactly what type of heart problem we're dealing with, which determines which tablets will help most."

Deductions

Not mentioning BNP as the gateway test in new suspected HF
Starting treatment before echo result in non-emergency
Missing K⁺ monitoring before ACEi/MRA prescription
Not explaining the investigation to the patient in plain language

🔴 Red

BNP not mentioned; echo not requested; starts HF drugs without diagnosis confirmed; bloods not ordered

🟠 Amber

BNP requested but NICE NG106 urgency pathway not applied; partial blood panel; echo mentioned but rationale not explained to patient

🟢 Green

BNP as gateway with NICE NG106 urgency thresholds applied; echo explained in plain language; full blood panel with rationale; each test linked to a management question

5

Step 5

Reaching a Diagnosis — Classification · DDx · Plain Language Explanation

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Heart failure is a syndrome, not a single disease. The phenotype (HFrEF vs HFpEF), aetiology (ischaemic vs non-ischaemic), and NYHA class all determine management. Always explain the diagnosis in plain language — the word "failure" is catastrophically misunderstood.

🗣️ Explaining heart failure in plain language — say something like this

"The term 'heart failure' is misleading — it doesn't mean the heart has stopped or is about to stop. It means the heart muscle isn't pumping as efficiently as it should be. Think of it like a pump that's lost some of its squeeze. Because it can't push blood around as forcefully, fluid can build up in the lungs and legs — which is why you've been breathless and swollen. The good news is that with the right treatment, many people feel significantly better and live well for many years. The treatment doesn't cure it, but it slows it down and improves how you feel."

💬 Addressing the patient's own explanation

"Heart failure means my heart is failing — it's going to stop soon."
"I can completely understand why the words 'heart failure' would sound frightening — it's a terrible name for the condition. What it actually means is that your heart is working less efficiently than it should be, not that it's about to give up. Many people live for many years with heart failure, feeling well and doing the things they love, with the right treatment. The goal of everything we do is to make sure your heart has as much support as possible."

"I feel breathless — surely it must be my lungs, not my heart?"
"That's a really understandable thought — breathlessness does feel like a lung problem. But when the heart isn't pumping efficiently, blood can back up into the lungs and make them feel waterlogged — that's why breathing becomes difficult. The heart and lungs are so closely connected that a heart problem very often shows itself through breathing symptoms first."

5A — HF Classification: phenotype + NYHA + aetiology

I

No limitation

Ordinary activity causes no symptoms

Walking hills, climbing stairs — all fine

II

Slight limitation

Comfortable at rest; symptoms on ordinary exertion

Breathless walking fast or uphill

III

Marked limitation

Comfortable at rest; symptoms on minimal exertion

Breathless dressing, short walks indoors

IV

Symptoms at rest

Unable to carry on any activity without discomfort

Breathless lying flat; in bed or chair

HFrEF — EF ≤40%

Most common · Most evidence

Reduced ejection fraction — the heart contracts weakly. Ischaemic cardiomyopathy most common cause in UK. Four pillars of treatment: ACEi/ARB, BB, MRA, SGLT2i.

ICD discussion if EF ≤35% despite optimal meds (ESC: ~3 months) (SCD risk)

CRT assessment if EF ≤35% + LBBB on ECG

HFpEF — EF ≥50%

Common · Harder to treat

Preserved ejection fraction — the heart contracts well but is stiff (diastolic dysfunction). Associated with HTN, DM, obesity, AF. No drug has proven mortality benefit; SGLT2i (and MRA) reduce worsening HF and hospitalisation.

SGLT2i now indicated in HFpEF (dapagliflozin — DELIVER trial)

Diuretics for symptoms. Treat comorbidities aggressively.

HFmrEF — EF 41–49%

Mid-range · Evolving evidence

Mildly reduced ejection fraction — a heterogeneous group, often transitional (recovering from acute HFrEF or deteriorating HFpEF). NICE NG106 (2025) says consider an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor for HFmrEF.

Consider an ACEi (or ARB), beta-blocker, MRA and SGLT2i — weigh comorbidity; ask the HF team if uncertain.

Specialist guidance often appropriate.

🔍 Differential Diagnosis — conditions that mimic or coexist with HF

Condition	Distinguishing features	Key difference from HF
COPD / Asthma	History of smoking/atopy; wheeze; reversible airflow obstruction; BNP usually <100 in pure COPD	No orthopnoea, no PND, no raised JVP. Spirometry shows obstruction. BNP normal or mildly elevated.
Pulmonary Embolism	Pleuritic pain, haemoptysis, risk factors (immobility, malignancy, thrombophilia), Wells score >4	Acute onset. No peripheral oedema. D-dimer / CTPA to confirm. Wells score >4 → CTPA urgently.
Hypoalbuminaemia	Liver disease, nephrotic syndrome, malnutrition. Oedema but no breathlessness or raised JVP.	Oedema without breathlessness. BNP normal. LFTs + albumin + urine ACR to differentiate.
Obesity hypoventilation	BMI >35, daytime somnolence, hypercapnia. Breathlessness from reduced chest wall compliance, not fluid.	SpO₂ normal lying flat. No PND. Obesity lowers natriuretic peptide levels — a normal result does not exclude HF.
Chronic venous insufficiency	Unilateral or bilateral oedema; varicosities; haemosiderin; no dyspnoea; no JVP elevation	Oedema without breathlessness. Normal BNP. Echo normal.
Pneumonia	Fever, purulent sputum, consolidation on CXR, raised CRP/WCC	Acute onset. No chronic HF features. CXR and inflammatory markers distinguish. Note: pneumonia can precipitate HF.

🎓 SCA Checkpoint — Step 5TasksRelating to Others

Verbalising diagnosis in plain language

"'Heart failure' is a misleading name — it doesn't mean your heart is about to stop. It means the heart pump isn't as efficient as it should be, so fluid backs up. Think of it like a pump that's lost some of its squeeze."

"I want to directly address the worry that this means you're about to die — many people live well for many years with good treatment. Our aim is to give your heart as much support as possible."

Deductions

Using "heart failure" without explaining the term
Not distinguishing HFrEF from HFpEF (treatment differs significantly)
Not addressing the patient's fear about prognosis/death
Missing NYHA class — drives treatment urgency and ACP

🔴 Red

Uses "heart failure" without explanation; doesn't address fear of dying; no phenotype distinction; no NYHA assessment

🟠 Amber

Some lay language; HFrEF vs HFpEF mentioned but not explained; prognosis fear acknowledged but not directly addressed

🟢 Green

Pump/squeeze analogy; "heart failure" term demystified; prognosis fear named and addressed directly; HF phenotype and NYHA class communicated clearly in lay terms

6

Step 6

If Referral Is Needed — What the GP Does Before & During

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Referral in HF is not the end of GP involvement. The GP must initiate treatment before echo is back, communicate the BNP urgency to the echo department, bridge-treat decompensation, and ensure follow-up happens. The gap between referral and specialist appointment is where deterioration occurs.

Scenario	Urgency	What GP does before/during referral	What GP must NOT do
Acute pulmonary oedema / cardiogenic shock	999 now	Sit patient upright. High-flow O₂. IV access if trained. Reassure. Do NOT give loop diuretic IV unless trained — can cause vasodilation → ↓BP → worse shock.	Do NOT give furosemide IV in community without haemodynamic monitoring. Do NOT lie patient flat.
New HF — NT-proBNP >2000	≤2 weeks	Mark referral as urgent with BNP level. Start loop diuretic for symptom relief (furosemide 40mg). Check baseline U&Es, ECG. Do NOT start ACEi until echo confirms phenotype.	Do NOT start ACEi/BB/MRA before echo confirms HFrEF — could harm HFpEF or valve disease patients.
New HF — NT-proBNP 400–2000	≤6 weeks	Lifestyle advice. Baseline bloods. Symptom diary. Furosemide if symptomatic oedema. Await echo before starting disease-modifying drugs.	Do NOT delay referral — echo within 6 weeks is the NICE NG106 standard (NT-proBNP 400–2,000 ng/L).
Decompensated known HF (stable obs)	Same week — review 48 h	Increase the loop diuretic per the person's individualised HF action plan / HF-nurse or specialist advice — NICE NG106 gives no blanket "double the dose" rule (it advises titrating diuretics up and down to need), and the safe increment depends on the current dose, renal function and how dry they already are. Review at 48 hours and check U&Es in 3–5 days; keep the beta-blocker going; involve the HF nurse the same week. Identify and treat precipitant (AF rate control, stop NSAID, antibiotics for infection).	Do NOT increase diuretic without U&Es follow-up — AKI/hypokalaemia risk. Do NOT miss the precipitant.
EF ≤35% — ICD/CRT assessment	Routine	Ensure on optimal medical therapy for ≥3 months first (ICD/CRT indication only applies to optimised patients). Refer to cardiology for device assessment. Document ECG (LBBB needed for CRT).	Do NOT refer for device without confirming patient is on optimal drug therapy first.
Post-hospital discharge	2 weeks	Follow-up by the specialist HF team within 2 weeks of discharge (NICE CG187; QS103) — GP checks it is booked and reviews discharge medications, titration plan, BNP trend, weight, and functional status. Link in with HF nurse specialist.	Do NOT let discharge letter sit without acting — post-discharge period is highest risk for re-admission.

🎓 SCA Checkpoint — Step 6TasksGlobal Skills

How to explain referral

"I'm going to refer you for a heart scan called an echocardiogram as a priority — the blood test suggests your heart may be working harder than it should. In the meantime, I'll start you on a water tablet to help with the fluid and arrange a follow-up with you personally within two weeks."

Deductions

Starting ACEi/BB/MRA before echo confirms HFrEF
Not applying NICE NG106 urgency thresholds for echo
Missing mandatory 2-week post-discharge review
Not explaining the referral purpose to the patient

🔴 Red

Starts full HF drug regimen before echo; wrong urgency for referral; post-discharge review not mentioned

🟠 Amber

Echo requested but NICE NG106 urgency threshold not correctly applied; interim management partial; patient not told what to expect

🟢 Green

BNP threshold applied correctly to echo urgency; interim management (diuretic) initiated; disease-modifying drugs deferred until echo; patient informed; 2-week follow-up arranged

7

Step 7

Management — Expectation · Lifestyle · Drug Selector · Drug Reference · Psychosocial · Follow-Up · Safety-Netting

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7A — Address expectation first: validate → explain → negotiate

🤝

Never start with the drug regimen — address what the patient came in fearing first

1

Validate the fear

The word "heart failure" is terrifying. Acknowledge this explicitly before any clinical discussion.

"I completely understand why the word 'failure' sounds so frightening — it's a terrible name for this condition. I want to take a moment to address that directly before we talk about treatment."

2

Explain with honesty

Be honest about prognosis but emphasise what treatment can achieve. Don't give false reassurance.

"Heart failure is a serious condition that we need to take seriously. But with the right treatment, many people feel significantly better and live well for many years. The goal of everything we do is to give your heart as much support as possible — and to keep you doing the things that matter to you."

3

Negotiate the plan

Offer something today that addresses the immediate concern. Treatment takes weeks — manage this expectation.

"Today I'm going to start you on a tablet to help clear the fluid and make your breathing easier within a few days. The other tablets — the ones that protect your heart long-term — we'll add gradually once we have the scan result, so we can tailor them exactly to you."

7B — Treatment goals: targets tailored to this patient

Treatment goals — HFrEF

Reduce all-cause mortality (4 pillars)Achieve LVEF improvement on treatment Relieve symptoms: breathlessness, oedema, fatiguePrevent HF hospitalisation Achieve euvolaemia — titrate diuretic to drynessHR <70 bpm at rest (once euvolaemic) BP <130/80 mmHgTitrate all 4 pillars to maximum tolerated dose

Motivational language for patients

"Heart failure is serious, but it is very treatable. The four tablets we use together — when taken consistently and at the right doses — can improve how your heart pumps and significantly reduce the risk of you ending up in hospital or dying from this condition. The goal is for you to live well with heart failure, not just survive it."

"Weighing yourself every morning before breakfast is one of the most important things you can do. If your weight goes up by 2 kilograms in 3 days, your body is retaining fluid — that’s your early warning sign to take the extra water tablet dose written in your plan and contact us."

7C — Non-medication management: lifestyle + self-management

Lifestyle — specific targets with mechanism

Intervention	Target / Mechanism	Evidence
Salt restriction	Ask about salt intake; reduce it if consumption is high. ↓ fluid retention → ↓ diuretic dose needed.	NICE NG106: do not routinely advise sodium restriction — target it to people with high intake and review regularly.
Fluid restriction	Not routine (NICE NG106). Restrict for dilutional hyponatraemia or high fluid intake.	Review the need for restriction on an ongoing basis. Not beneficial as a blanket rule.
Daily weighing	Same time each morning, same scales, after toilet, before eating. Action plan: ≥2kg in 3 days → increase diuretic.	↓ emergency admissions. Empowers patient. Must have a written action plan.
Exercise (cardiac rehab)	Supervised exercise training in stable NYHA I–III. ↓ peripheral vascular resistance. ↑ exercise capacity. ↓ sympathetic tone.	HF-ACTION trial: ↓ 11% all-cause hospitalisation. Refer to cardiac rehab.
Alcohol cessation	Abstinence in alcoholic cardiomyopathy — EF may recover 50% with abstinence. ≤14u/wk maximum.	Potentially curative in alcoholic cardiomyopathy. CAGE/AUDIT + cessation referral.
Vaccinations	Annual flu vaccine. Pneumococcal vaccine. COVID-19 boosters. Respiratory infections = major decompensation trigger.	↓ infection-related hospitalisations. Check and document vaccination status every review.

7D — Prescribing guide: what to start, in what order, and why

HFrEF and HFpEF require fundamentally different prescribing strategies. HFrEF has four evidence-based pillars that reduce mortality — each must be started, titrated to maximum tolerated dose, and maintained. HFpEF has no drug proven to reduce mortality — SGLT2i reduce worsening HF and hospitalisation (DELIVER, EMPEROR-Preserved) and NG106 (2025) says consider an SGLT2i and an MRA; treatment otherwise focuses on symptom control and underlying causes. Never start a beta-blocker in decompensated or fluid-overloaded heart failure.

HFrEF (≤ 40% EF) — Four Pillars: start all four, titrate all four Each pillar independently reduces mortality. Combination is additive. Not starting one is a clinical decision that must be documented.

Pillar 1 — First-line: ACEi (ARNI or ARB if not tolerated)

Start as soon as HFrEF confirmed, haemodynamically stable, and K⁺ <5.0 mmol/L. Reduces all-cause mortality and HF hospitalisation (CONSENSUS, SOLVD trials). NICE NG106 (updated September 2025): all four pillars are first-line; the order is set by symptoms, comorbidities and preference, with no need to optimise one before adding the next.

Ramipril 1.25mg OD → titrate to 10mg OD (target dose) over weeks. Check BP, eGFR, K⁺ at each step.
If an ACEi is not tolerated (e.g. cough): offer an ARNI, or consider an ARB such as candesartan 4mg OD → 32mg OD (NICE NG106).
Sacubitril/valsartan (ARNI) — superior to enalapril in PARADIGM-HF (20% ↓ CV death). If symptoms persist on maximum tolerated doses of all four pillars, consider switching the ACEi to an ARNI if LVEF ≤35% (NICE TA388; NG106 — consider HF-specialist advice before starting in primary care). Washout ACEi 36h before switching to avoid angioedema.

⛔ Never combine ACEi + ARB + ARNI. Do not start if K⁺ >5.0 or eGFR <30. If K⁺ rises to 5.5–5.9, stop K⁺-raisers and recheck; ≥6.0 → urgent assessment.

Pillar 2 — First-line (start when euvolaemic): Beta-blocker

Start only when patient is euvolaemic (no signs of fluid overload). Starting in a wet, decompensated patient causes acute deterioration. Reduces mortality 34% (MERIT-HF, COPERNICUS trials).

Bisoprolol 1.25mg OD → titrate to 10mg OD per the SPC schedule (1.25 → 2.5 → 3.75 mg weekly, then 5 → 7.5 mg 4-weekly, then 10 mg). ECG before starting (NG106). Most evidence; preferred first choice.
Carvedilol 3.125mg BD → 25mg BD (or 50mg BD if >85kg). Alternative with vasodilatory properties.
Nebivolol — for elderly patients (>70 years) with HF: 1.25mg OD → 10mg OD (SENIORS trial).

⛔ Never start in decompensated / wet HF. Contraindicated in severe asthma. Do not stop abruptly — rebound deterioration.

Pillar 3 — First-line: MRA (Mineralocorticoid Receptor Antagonist)

Offer to EVERYONE with HFrEF (K⁺ <5.0) — NG106's September 2025 update makes all four pillars first-line, so the MRA is no longer reserved for those still symptomatic on ACEi/ARB + BB or for EF ≤35%. Reduces mortality 30% in severe HF (RALES trial) and 37% in mild-moderate HF (EMPHASIS-HF).

Spironolactone 25mg OD → 50mg OD — first choice. Causes gynaecomastia in men (~10%). Check K⁺ + eGFR before, 1–2 weeks after starting and after each dose increase, then every 3–6 months.
Eplerenone 25mg OD → 50mg OD — if gynaecomastia or post-MI. Licensed for post-MI HF.

⛔ Do not start if K⁺ >5.0 or eGFR <30. High hyperkalaemia risk when combined with ACEi/ARB — monitor K⁺ 1–2 weeks after starting and after each dose increase.

Pillar 4 — First-line: SGLT2 inhibitor

Now a 4th pillar in HFrEF — and the best-evidenced drug class in HFpEF. Reduces HF hospitalisation and CV death in HFrEF independently of diabetes status; in HFpEF the benefit is fewer worsening-HF events and hospitalisations rather than proven lower mortality.

Dapagliflozin 10mg OD — DAPA-HF: 26% ↓ worsening HF/CV death in HFrEF. DELIVER: benefit in HFpEF.
Empagliflozin 10mg OD — EMPEROR-Reduced: 25% ↓ CV death/HF hospitalisation in HFrEF. EMPEROR-Preserved: benefit in HFpEF.
Use in HFpEF (EF >40%) — NICE TA902 recommends dapagliflozin; check local formulary.

⚠️ Counsel on sick day rules — stop if vomiting/diarrhoea/surgery (euglycaemic DKA risk). Check eGFR: glucose-lowering effect lost below eGFR 45, but CV benefit persists to eGFR 20.

Symptom control: loop diuretic (not a pillar — for congestion only)

Furosemide or bumetanide — titrate to lowest dose that keeps patient dry. Loop diuretics relieve symptoms of congestion (breathlessness, oedema) but do NOT reduce mortality. They are a symptom-management drug, not a disease-modifying one.

Furosemide 20–40mg OD → titrate up to 80–120mg OD (or BD) in resistant oedema. IV if not absorbing orally.
Bumetanide 0.5–1mg OD — better GI absorption, useful if furosemide ineffective.
Dose down once euvolaemic — over-diuresis causes pre-renal AKI and hypotension, preventing BB uptitration.
Weight action plan: ≥2kg in 3 days → the patient takes the pre-agreed extra diuretic dose written in their personal plan (specify the actual dose and duration for THAT patient — not a generic "double it") and contacts the practice/HF nurse. Document in notes and give the written plan.

HFpEF (EF ≥50%) — prescribing strategy

No ACEi, ARB, or BB have been shown to reduce mortality in HFpEF. Treatment targets symptoms and the underlying cause (AF, HTN, obesity, DM).

SGLT2i (dapagliflozin) — reduces worsening HF and hospitalisation in HFpEF (DELIVER, EMPEROR-Preserved; no proven mortality benefit). NICE NG106 (2025): consider, unless contraindicated.
Loop diuretic — furosemide for symptomatic congestion. Titrate to dryness.
Treat the cause: AF rate/rhythm control (target HR <80 in HFpEF); BP <130/80 (ACEi/ARB useful here for BP, not EF); DM optimisation; weight loss.
MRA (spironolactone) — reduces HF hospitalisation in HFpEF (TOPCAT trial); consider if K⁺ <5.0 and eGFR >30.

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE NG106 / SPC

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Medication options — guideline summary (no patient selection)

Situations this summary covers

❤️ HF Phenotype & Severity
HFrEF — EF ≤40% (reduced)
HFpEF — EF ≥50% (preserved)
HFmrEF — EF 41–49% (mildly reduced)
⚠ Currently fluid overloaded / decompensated
✓ Comorbidities & Indications
Diabetes mellitus (type 2)
Atrial fibrillation
Post-MI (within 12 months)
Gynaecomastia on spironolactone
✗ Contraindications & Cautions
Asthma or severe COPD
CKD — eGFR <30
Hyperkalaemia — K+ >5.0 mmol/L
ACEi intolerance (dry cough)

What the guidance says, by situation

Phenotype

HFrEF — EF ≤40% (reduced): HFrEF — 4 pillars

HFpEF — EF ≥50% (preserved): HFpEF — consider MRA + SGLT2i + diuretic + treat cause

HFmrEF — EF 41–49% (mildly reduced): HFmrEF — consider the four HFrEF classes

⚠ Currently fluid overloaded / decompensated: ⚠ Decompensated

⚠ Special considerations

Atrial fibrillation + HFrEF — EF ≤40% (reduced) or HFmrEF — EF 41–49% (mildly reduced): AF + HFrEF: Bisoprolol for rate control. Consider digoxin as add-on if rate uncontrolled. Anticoagulate per CHA2DS2-VASc score — DOAC first-line unless valvular AF. AF is the most common precipitant of HF decompensation.

⚠ Currently fluid overloaded / decompensated: Decompensation: Identify precipitant first (AF, NSAID, infection, dietary indiscretion, missed meds). Increase loop diuretic. DO NOT start BB. DO NOT up-titrate ACEi. Weigh daily. U&Es 48h. If no improvement in 48h — admit.

Post-MI (within 12 months) + HFrEF — EF ≤40% (reduced) or HFmrEF — EF 41–49% (mildly reduced): Post-MI HFrEF: Start ACEi within 24h of MI if tolerated. Eplerenone preferred over spironolactone. High-intensity statin. Consider ICD if EF 35% or less persists despite optimal medical therapy (ESC: after about 3 months).

HFrEF — EF ≤40% (reduced) + without HFpEF — EF ≥50% (preserved): EF 35% or less on optimal meds: Refer for ICD assessment (sudden cardiac death prevention). If LBBB on ECG + EF 35% or less: refer for CRT (cardiac resynchronisation) assessment.

CKD — eGFR <30: CKD: On ACEi/ARB (NICE NG203), creatinine rise >30% or eGFR fall >25%: look for reversible causes; reduce or stop if no alternative cause is identified. Heart failure monitoring (NG106): rise >50% or K⁺ >5.5 → seek heart failure team advice. Avoid MRA if eGFR < 30. SGLT2i: do not initiate below the SPC limit (dapagliflozin eGFR < 15, empagliflozin < 20); do not stop for eGFR decline alone.

Pillar 1 — ACEi / ARB / ARNI

HFpEF — EF ≥50% (preserved) + without HFrEF — EF ≤40% (reduced) + without HFmrEF — EF 41–49% (mildly reduced): ACEi/ARB

No proven mortality benefit in HFpEF. May be used to treat underlying hypertension (which is a major HFpEF driver) or coexisting conditions. Not part of core HFpEF regimen.

ACEi intolerance (dry cough) + without HFpEF — EF ≥50% (preserved): ARNI or ARB (candesartan)

ACEi dry cough (up to 15% of patients) — NICE NG106 (updated September 2025): offer an ARNI (sacubitril-valsartan; 36h ACEi washout) or consider an ARB such as candesartan, which provides equivalent renal and cardiac protection. Do NOT give ACEi + ARB together. Check U&Es + K+ within 1-2 weeks of switch.

⚠ Currently fluid overloaded / decompensated: ACEi — hold up-titration

Do not up-titrate ACEi/ARB during acute decompensation. Continue existing dose if already prescribed (do not stop). Restart/increase only when haemodynamically stable and euvolaemic. U&Es before each dose increase.

None of the situations above: ACEi — Ramipril

None of the situations above · without HFpEF — EF ≥50% (preserved): or ARNI — Sacubitril-valsartan

None of the situations above:

Start ramipril 1.25mg OD, titrate to a maximum of 10mg daily (1-2 divided doses) over 4-8 weeks (SPC). U&Es + K+ within 1-2 weeks of each dose change. If symptoms persist on maximum tolerated four-pillar therapy, consider switch to ARNI (sacubitril-valsartan) if LVEF ≤35% (TA388), with HF-specialist advice — PARADIGM-HF showed 20% further mortality reduction vs enalapril. 36h washout between ACEi and ARNI.If Hyperkalaemia — K+ >5.0 mmol/L: ⚠ K+ > 5.0: caution with ACEi — check U&Es urgently before prescribing.

Pillar 2 — Beta-blocker

HFpEF — EF ≥50% (preserved) + without HFrEF — EF ≤40% (reduced) + without HFmrEF — EF 41–49% (mildly reduced): Beta-blocker

No proven mortality benefit in HFpEF. May be used for rate control in coexisting AF, or post-MI cardioprotection. Not a core HFpEF pillar for mortality reduction.

Asthma or severe COPD: Beta-blocker — AVOID

Significant asthma is a contraindication to beta-blockers. Ivabradine is specialist-led (NICE TA267: sinus rhythm, HR ≥75, LVEF ≤35%, persisting symptoms). Seek specialist advice. COPD alone is a relative CI — use with caution if mild/moderate.

⚠ Currently fluid overloaded / decompensated: Beta-blocker — do NOT start yet

Never start a beta-blocker during acute decompensation / fluid overload. Initiate ONLY when the patient is euvolaemic (fluid-balanced). If already on BB, continue at current dose (do not stop abruptly — rebound ischaemia and arrhythmia risk).

Atrial fibrillation: Bisoprolol

Bisoprolol 1.25mg OD, titrate to 10mg OD. Dual benefit in AF + HFrEF: heart failure mortality reduction AND rate control. Target resting HR 50-70 bpm (sinus) or < 110 bpm (AF). Check HR and BP before each dose increase.

None of the situations above: Bisoprolol

Bisoprolol 1.25mg OD, titrate to 10mg OD. Start only when euvolaemic. Mortality benefit 34% (CIBIS-II, MERIT-HF). Warn patient: may feel worse for 1-2 weeks — do NOT stop without calling the GP. Never stop abruptly.

Pillar 3 — MRA

HFpEF — EF ≥50% (preserved) + without HFrEF — EF ≤40% (reduced) + without HFmrEF — EF 41–49% (mildly reduced): MRA — consider (NG106, Sept 2025)

NICE NG106 now says consider an MRA and an SGLT2 inhibitor for HFpEF — the MRA is the new recommendation. It is “consider” rather than “offer”: the benefit shown is in symptoms and hospitalisation rather than a clear mortality signal (RALES was HFrEF; TOPCAT inconclusive), so it is a shared decision. Monitor K⁺ and renal function as in HFrEF.

Hyperkalaemia — K+ >5.0 mmol/L: MRA — CONTRAINDICATED

K+ > 5.0: do NOT start MRA (spironolactone/eplerenone). Risk of life-threatening hyperkalaemia. If K+ rises to 5.5 or above, reduce or withhold per SPC and the local HF protocol; 6.0 or above needs urgent assessment. Recheck U&Es urgently. Sodium zirconium cyclosilicate (confirmed K+ ≥5.5, not on dialysis) may be started in primary care (NICE TA1148; UKKA July 2026) but never replaces emergency treatment; patiromer (≥6.0, TA623) via the HF team.

CKD — eGFR <30: MRA — avoid if eGFR < 30

eGFR < 30: MRA accumulates and causes severe hyperkalaemia. Specialist input required. If eGFR 30-45, use with extreme caution and very frequent U&E monitoring (weekly initially). K+ must be < 5.0 to start.

Gynaecomastia on spironolactone: Switch to Eplerenone

Gynaecomastia / breast tenderness (up to 10% with spironolactone) — switch to eplerenone 25-50mg OD. Same mortality benefit, far less anti-androgenic side effect. Also preferred post-MI (EPHESUS trial). Do not stop the MRA class altogether.

Post-MI (within 12 months): Eplerenone (preferred post-MI)

Post-MI with HFrEF: eplerenone 25-50mg OD preferred over spironolactone (EPHESUS trial — started 3-14 days post-MI). Less hormonal side effects. K+ must be < 5.0. U&Es 1-2 weeks after starting and after each dose increase, then every 3-6 months.

None of the situations above: Spironolactone

Spironolactone 25-50mg OD. Offered first-line alongside ACEi, BB and SGLT2i (NICE NG106, Sept 2025). Mortality reduction 30% (RALES trial). K+ must be < 5.0 to start. U&Es before, 1-2 weeks after starting and after each dose increase, then every 3-6 months. K+ 5.5 or above: reduce or withhold per SPC and the local HF protocol; 6.0 or above needs urgent assessment. Warn men about gynaecomastia.

Pillar 4 — SGLT2i

CKD — eGFR <30: Dapagliflozin — check eGFR

SGLT2i indicated for ALL HF phenotypes regardless of diabetes. If eGFR 20-30: benefit less certain, use with caution. Do not initiate if eGFR < 15 (dapagliflozin SPC); do not stop for eGFR decline alone; seek advice if eGFR < 15 or on dialysis. If Diabetes mellitus (type 2): DM dual benefit: HF outcomes AND glycaemic control. Sick day rules essential — withhold during vomiting, surgery, or prolonged fasting.

Without CKD — eGFR <30: Dapagliflozin 10mg OD

SGLT2i for ALL HF phenotypes (HFrEF: DAPA-HF; HFpEF: DELIVER trial). If Diabetes mellitus (type 2): Dual benefit in diabetes — HF mortality AND HbA1c reduction. Metformin also safe if eGFR > 30.Otherwise: Works regardless of diabetes status — do not restrict to diabetic patients. Sick day rules: withhold during vomiting, severe diarrhoea, surgery, or prolonged fasting. eGFR at 2-4 weeks after starting.

Loop Diuretic — symptom control (no mortality benefit)

⚠ Currently fluid overloaded / decompensated: Furosemide — increase urgently

Decompensation: increase the loop diuretic per the individualised action plan / specialist advice (no blanket doubling rule — titrate to the patient, their current dose and renal function). If no response, escalate to IV furosemide (hospital). Review at 48 hours and check U&Es in 3-5 days — AKI and hypokalaemia risk. Identify and treat precipitant (AF, NSAID, infection, missed meds, excess salt/fluid).

Without ⚠ Currently fluid overloaded / decompensated: Furosemide — symptom control only

Loop diuretic for oedema and breathlessness — no mortality benefit. Dose titrated to daily weight. Action plan: if weight up > 2kg in 3 days, take the extra dose written in the individualised plan and call GP. U&Es after any dose change. Maintain K+ > 3.5 (diuresis lowers K+ — risk of digoxin toxicity).

Guideline summary — each situation is shown with what the guidance says for it, as written. Nothing is selected or worked out for an individual patient. Check doses in the SPC and your local formulary.

7F — Drug reference cards: the four pillars of HFrEF + loop diuretic + add-on agents

All four pillars are evidence-based mortality-reducing treatments in HFrEF. They are titrated up gradually over weeks-months to target doses. Do not delay starting — each pillar reduces mortality independently. Only loop diuretics are for symptoms alone (no mortality benefit in HFrEF). HFpEF: SGLT2i and consider an MRA (NG106 Sept 2025) + diuretic for congestion + treat comorbidities.

ACEi / ARB / ARNI

Ramipril · Candesartan · Sacubitril-valsartan

✓ Pillar 1 — First-line (with pillars 2–4)

Pillar 1Rami 1.25→10mg daily

✓ Indication & benefit

All HFrEF (EF ≤40%) unless contraindicated — start after echo confirmation

ACEi: ↓ mortality 23% (CONSENSUS, SOLVD). If ACEi not tolerated: ARNI, or consider an ARB (NICE NG106).

ARNI (sacubitril-valsartan): ↓ mortality 20% vs enalapril (PARADIGM-HF). Consider switching from ACEi if symptoms persist on maximum tolerated four-pillar therapy and LVEF ≤35% (TA388); HF-specialist advice first

Titrate to target dose over 4–8 weeks. Check U&Es at each step.

✗ Contraindications

Pregnancy — teratogenic

Bilateral RAS — AKI risk

K⁺ >5.5 — hyperkalaemia risk

SBP <90 — withhold until haemodynamically stable

eGFR <30 — specialist input. ACEi cough → switch to ARB.

Never start ARNI within 36h of ACEi — angioedema risk

⚠ Side effects

Hypotension (especially first dose) · Cough (ACEi 10–15%, not ARB/ARNI)

Hyperkalaemia · AKI (small stable creatinine rise expected)

Angioedema (ACEi 0.1–0.5%, ARNI higher — carry epipen if history)

🔬 Monitor

U&Es + K⁺ within 1–2 weeks of each dose change

K⁺ 5.5–5.9 → stop K⁺-raisers, recheck, adjust per SPC; ≥6.0 → urgent assessment. Creatinine rise >50% (heart failure monitoring, NG106) → local protocol + heart failure team advice

💬 Counselling

"This tablet protects your heart long-term — even if you feel no different at first. It takes weeks to see the full benefit. Don't stop it without telling us — it's protecting you even when you can't feel it working."

ARNI switch if still symptomatic on all four pillars at maximum tolerated doses and LVEF ≤35% (TA388), with HF-specialist advice. Never ACEi + ARB together. 36h washout before ARNI. U&Es 1–2 weeks post every dose change.

Beta-blocker

Bisoprolol · Carvedilol · Metoprolol succinate

✓ Pillar 2

Pillar 2Biso 1.25→10mg OD

✓ Indication & benefit

All stable HFrEF — start only when patient is euvolaemic (not in acute decompensation)

↓ mortality 34% (CIBIS-II, MERIT-HF, COPERNICUS). ↓ SCD risk.

↓ Heart rate → ↑ diastolic filling time → ↑ cardiac output paradoxically

Also: AF rate control. Post-MI cardioprotection.

✗ Contraindications

Acute decompensated HF — initiate only when stable and euvolaemic

Asthma (relative CI) · Severe COPD · 2°/3° heart block

HR <50 at rest → do not start or reduce dose

NEVER stop abruptly — rebound ischaemia and arrhythmia

⚠ Side effects

Initial worsening of HF symptoms (transient — titrate slowly)

Bradycardia · Fatigue · Cold peripheries · Erectile dysfunction

Masks hypoglycaemia symptoms in DM

🔬 Monitor

HR and BP before each dose increase. Target HR 50–70 bpm.

Warn: may feel worse for first 2 weeks — must not stop without asking.

💬 Counselling

"You might feel a little more tired or slightly worse for the first couple of weeks as your body adjusts — this is normal and expected. Please don't stop it without calling us first. It's protecting your heart even during that adjustment period."

Start only when euvolaemic — NOT in acute decompensation. Worsening initially is expected — counsel this before prescribing. Never stop abruptly. Bisoprolol preferred (once daily, well tolerated).

MRA — Spironolactone / Eplerenone

Spironolactone · Eplerenone (post-MI)

✓ Pillar 3

Pillar 3Spiro 25→50mg OD

✓ Indication & benefit

All HFrEF (K⁺ <5.0, eGFR ≥30) — offered alongside ACEi/ARB, BB and SGLT2i as first-line (NICE NG106, Sept 2025)

↓ mortality 30% (RALES), ↓ SCD, ↓ hospitalisation (EMPHASIS-HF for eplerenone)

Eplerenone preferred post-MI (EPHESUS trial). Less gynaecomastia.

Also: diuretic effect (K⁺-sparing) — can reduce loop diuretic dose

✗ Contraindications

K⁺ >5.0 — risk of life-threatening hyperkalaemia

eGFR <30 — accumulates, severe hyperkalaemia risk

Addison's disease · Pregnancy

K⁺ 4.5–5.0 — use with extreme caution, frequent monitoring

⚠ Side effects

Hyperkalaemia — K⁺ 5.5–5.9 → reduce or withhold per SPC; ≥6.0 → stop + urgent assessment

Gynaecomastia / breast tenderness (up to 10% with spironolactone) → switch to eplerenone

AKI · Hyponatraemia

🔬 Monitor

U&Es + K⁺ before, 1–2 weeks after starting and after each dose increase, then every 3–6 months

K⁺ 5.5–5.9 → stop K⁺-raisers, check for dehydration/AKI, recheck; reduce or withhold MRA per SPC/local HF protocol. K⁺ ≥6.0 → urgent assessment.

💬 Counselling

"Men sometimes notice breast tenderness with this tablet — if so, call us and we can switch to a very similar one without that side effect. Don't stop it without calling us first."

K⁺ must be <5.0 before starting. U&Es at 1–2 weeks. Gynaecomastia → switch to eplerenone (not stop the class). Post-MI → eplerenone preferred.

SGLT2 Inhibitor

Dapagliflozin · Empagliflozin

✓ Pillar 4 — All EF types

Pillar 4Dapa 10mg OD

✓ Indication & benefit

HFrEF AND HFpEF AND HFmrEF — offered in HFrEF; considered in HFmrEF and HFpEF (NG106)

HFrEF: dapagliflozin ↓ CV death/worsening HF 26% (DAPA-HF). With or without DM.

HFpEF: dapagliflozin ↓ worsening HF 18% (DELIVER trial)

Mechanism: osmotic diuresis, natriuresis, ↓ preload/afterload, metabolic cardioprotection

✗ Contraindications

eGFR <15 at initiation — do not start (dapagliflozin SPC; empagliflozin <20); seek advice if on dialysis

Type 1 DM — high DKA risk without specialist input

Recurrent UTIs / DKA history

Withhold during acute illness, surgery, fasting — "sick day rules"

⚠ Side effects

Genital mycotic infections (thrush) — common, more in women

UTIs · Polyuria · Volume depletion (reduce loop diuretic if needed)

Euglycaemic DKA (rare but serious — withhold in sick day rules)

🔬 Monitor

eGFR before starting and after 2–4 weeks. No routine glucose monitoring needed in non-DM.

Sick day rules card essential — withhold if vomiting, surgery, prolonged fasting.

💬 Counselling

"This tablet works partly by making your kidneys remove a little more sugar and salt in your urine — that takes pressure off your heart. You may notice passing urine a little more. If you become unwell with vomiting or need surgery, stop it temporarily and call us."

SGLT2i for ALL EF types — this is new (post-DELIVER trial). Do not restrict to HFrEF. Sick day rules are essential patient education. Works with or without diabetes.

Loop Diuretic

Furosemide · Bumetanide

Symptom control only

SymptomsFuro 20–250mg OD

✓ Role in HF

Symptom relief — reduces pulmonary and peripheral oedema

No mortality benefit — for symptom control only. Never use alone as HF treatment.

Flexible dosing: extra dose as written in the individualised action plan if weight gain ≥2kg in 3 days

IV furosemide in hospital for acute decompensation

✗ Cautions

Over-diuresis → AKI → worsening renal function → cardiorenal syndrome

Hypokalaemia → fatal arrhythmias (especially with digoxin)

Hyponatraemia · Gout · Ototoxicity (high doses IV)

⚠ Side effects

Polyuria — patient must know this is expected

Electrolyte disturbance (K⁺, Na⁺, Mg²⁺) — check regularly

Postural hypotension · Thirst · Fatigue

🔬 Monitor

U&Es + electrolytes at 1–2 weeks after any dose change

Daily weight — adjust dose based on weight, not symptoms alone

💬 Counselling

"This tablet will make you pass more urine — that's it working, removing the extra fluid from your body. Take it in the morning so it doesn't disturb your sleep. Weigh yourself every morning and let us know if you gain more than 2 kg in 3 days."

Loop diuretics have NO mortality benefit — symptom control only. They must be prescribed alongside the four pillars, not instead of them. U&Es after every dose change.

Digoxin

✓ Add-on

Add-on62.5–250mcg OD

✓ When to consider

AF + HFrEF: rate control when BB insufficient or contraindicated

Sinus rhythm + HFrEF: add-on if still symptomatic despite 4 pillars — ↓ hospitalisation (DIG trial) but no mortality benefit

Specialist initiation recommended. Very narrow therapeutic window.

✗ Contraindications

WPW syndrome · 2°/3° heart block · Hypertrophic obstructive cardiomyopathy

Hypokalaemia → toxicity risk (diuretics lower K⁺ → potentiates digoxin)

eGFR <30 → reduce dose substantially

⚠ Toxicity signs

Nausea, vomiting, confusion, visual disturbance (yellow halos) = toxicity

Bradycardia, heart block — check ECG if suspected

Digoxin level: target 0.5–1.0 ng/mL (lower range reduces toxicity)

🔬 Monitor

Digoxin level + U&Es + K⁺ at baseline and every 6 months

K⁺ must be maintained >3.5 — loop diuretics lower K⁺ → increases toxicity risk

💬 Counselling

"If you notice nausea, vomiting, seeing yellow halos around lights, or your heart feels very slow — stop the tablet and contact us urgently. These can be signs the dose is too high."

Digoxin toxicity signs = nausea + yellow vision + slow pulse. K⁺ must be normal (diuretics lower it → digoxin toxicity). Narrow therapeutic index — level 0.5–1.0 ng/mL.

7G — Psychosocial impact: driving, work, relationships & planning ahead

🤝

Heart failure changes life — address the real-world impact proactively

Managing HF medications and symptoms is only part of the GP's role. The condition profoundly affects the patient's ability to work, drive, have relationships, and plan for the future. Raising these topics proactively — rather than waiting for the patient to ask — is what distinguishes excellent patient-centred care.

🚗

Driving

DVLA must be notified for: arrhythmias causing symptoms (syncope, VT), ICD implantation (Group 1: at least 1 month off driving after a prophylactic ICD, longer after an ICD for arrhythmia; Group 2 HGV/PCV: ICD is a permanent bar), severe HF with impaired consciousness or cognitive impairment.

Stable HF alone does not require DVLA notification for private licence. HGV/PCV licences have stricter criteria — refer to DVLA guidance.

"Some aspects of heart failure — particularly if you have a heart device or rhythm problems — may need to be declared to the DVLA. Let me explain what applies to you specifically."

💼

Work & Benefits

NYHA III–IV: likely significantly impaired or unable to work physically. May qualify for PIP, ESA, or Universal Credit. Employer may need Fit Note. Occupational health referral may be appropriate.

Some HF medications (BB) may cause fatigue that affects work performance — important to flag and manage.

"Has the breathlessness or fatigue been affecting your ability to work? There may be financial support we can help you access — and I can write a Fit Note if needed."

💑

Relationships & Sexuality

Sexual activity is equivalent to climbing 2 flights of stairs — safe in NYHA I–II if stable. NYHA III–IV: discuss individually. BB may cause erectile dysfunction. Sildenafil is safe in HF (not with nitrates).

Role reversal (independent → dependent) causes significant relationship strain. Partner may need their own support.

"Heart conditions can affect relationships in lots of ways. Has any of this had an impact on your relationship, or aspects of your relationship that are important to you?"

🧘

Mental Health

Depression affects 20–40% of HF patients and independently worsens prognosis (↑ mortality 2–3x). Anxiety is also very common. Both are underdiagnosed and undertreated.

Screen with PHQ-9/GAD-7 at every significant review. CBT and exercise are evidence-based treatments. SSRIs are safe (avoid TCAs — arrhythmia risk).

"It's very common to feel anxious or low with a diagnosis like this — how has your mood been? I'd like to ask you a few questions about that."

🔮

Advance Care Planning

HF has worse 5-year mortality than many cancers. ACP conversations are appropriate from NYHA III onwards. Gold Standards Framework / DNAR / preferred place of care / anticipatory medications.

Many patients want to discuss end-of-life wishes but are never asked. The Gold Standards Framework Prognostic Indicator: "Would I be surprised if this patient died in the next 12 months?" If no → initiate ACP.

"Some people find it helpful to think about and document their wishes for the future, so their family and doctors know what matters most to them. Is that something you'd feel comfortable talking about today or at a future visit?"

💰

Financial & Practical

Prepayment certificates reduce medication costs. Blue Badge may be appropriate for significant functional limitation. Home adaptations (stair rail, shower seat, ground floor bedroom) may be needed — OT referral.

Social prescribing can connect patients with peer support groups, befriending services, and practical help — particularly important given isolation risk.

"Is there anything practical at home that's becoming difficult? There may be equipment or adaptations that could help, and financial support I can point you towards."

7H — Follow-up schedule: NICE NG106 standards

1

Within 2 weeks of initiating treatment

U&Es + K⁺ (ACEi/MRA). Weight. BP + HR. Symptom response. Titration plan. Sick day rules education.

ACEi/MRA: U&Es at 1–2 weeks

2

Within 2 weeks of hospital discharge

Follow-up clinical assessment by the specialist HF team within 2 weeks of discharge (NICE CG187; QS103). GP: review discharge medications, titration plan, BNP trend, weight. Link with HF nurse specialist. Check adherence.

NICE CG187 / QS103HF nurse link

3

Every 2–4 weeks during drug titration

Up-titrate each pillar to target dose. Check U&Es after each dose change. Target: ACEi full dose, BB HR 50–70, spiro 50mg, SGLT2i 10mg.

4

3–6 months: specialist HF clinic review

Repeat echocardiogram if EF borderline. ICD/CRT assessment if EF ≤35%. BNP trend. NYHA reassessment. ACP if NYHA III–IV.

Echo repeatICD/CRT if EF ≤35%

5

Structured review at least 6-monthly (QS9) — all HF patients

NYHA class · LVEF trend · U&E+ACR · HbA1c · Ferritin/TSAT · Vaccinations · Medication review · Psychosocial · ACP update · Cardiac rehab referral if not done

7I — Monitoring: electrolytes, renal function & haemodynamic targets

Memory rule for HF monitoring

ACEi / ARB / ARNI / MRA → U&Es within 1–2 weeks of each dose change | Loop diuretic change → U&Es within 1–2 weeks | All HF patients → structured review at least 6-monthly (QS9) | Post-hospital discharge → specialist HF team follow-up within 2 weeks (NICE CG187)

Drug	Test	Timing	Action threshold
ACEi / ARB / ARNI	U&E + K⁺ + eGFR	1–2 weeks post change	K⁺ 5.5–5.9 → stop K⁺-raisers, recheck, adjust per SPC; ≥6.0 → urgent. Creatinine rise >50% (heart failure monitoring, NG106) → local protocol + heart failure team advice.
MRA (spiro/eplere)	K⁺ + eGFR + Na⁺	1–2 weeks post each change	K⁺ 5.5–5.9 → reduce or withhold per SPC/local protocol; ≥6.0 → stop + urgent. eGFR <30 → stop/seek advice. Then every 3–6 months once on the maximum tolerated dose, and whenever renal function may be compromised (NG106).
Loop diuretic	Na⁺ + K⁺ + eGFR	1–2 weeks post change	K⁺ <3.5 → supplement or reduce loop diuretic. Na⁺ <130 → stop urgently.
SGLT2i	eGFR	2–4 weeks post-start	Do not stop for eGFR decline alone (expected early dip); initiation limits per SPC (dapagliflozin eGFR <15, empagliflozin <20); seek advice if eGFR <15 or on dialysis. Withhold during sick day.
Digoxin	Digoxin level + U&E + K⁺	6-monthly	Level >1.0 ng/mL → reduce dose. K⁺ <3.5 → urgent correction (toxicity risk).
Beta-blocker	HR + BP	Before each dose increase	HR <50 → ECG, review other rate-limiting drugs, reduce the BB last. Symptomatic hypotension → reduce diuretic first; asymptomatic low BP needs no action.

Target	Goal	Notes
Heart rate	50–70 bpm (sinus rhythm)	BB titrated to achieve this. Below 50 = reduce BB. AF: rate <100 target.
BP (HFrEF)	SBP 100–130 mmHg	Symptomatic hypotension → reduce diuretic first if euvolaemic; asymptomatic low BP needs no action. Hypotension with hypoperfusion = same-day/999.
K⁺	4.0–5.0 mmol/L	Too low → arrhythmia (esp with digoxin). Too high → stop K⁺-raisers, recheck; MRA per SPC; ≥6.0 urgent.
eGFR / Creatinine	Small, stable creatinine rise	Rise >50% or K⁺ >5.5 (heart failure monitoring, NG106) → local protocol + heart failure team advice.
Weight	Stable (±1kg/day)	>2kg in 3 days → take the extra diuretic dose specified in their individualised plan + contact GP/HF nurse. Daily self-monitoring essential.
BNP / NT-proBNP	Not routine	Diagnostic test in new suspected HF — not a routine serial monitor in established HF; clinical status guides intensification.

7J — Safety-netting: exact phrases + when to call 999

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting is especially important in HF

HF has the highest 30-day readmission rate of any condition — most are preventable

Written action plans reduce hospitalisation by 30–40% (multiple RCTs)

Patient-activated early response prevents the cascade to acute pulmonary oedema

Sick day rules are mandatory patient education for SGLT2i + diuretics

Digoxin toxicity can be fatal — patients must know the symptoms

ACP documentation prevents unwanted resuscitation and ensures preferred place of care

Within 1–2 weeksU&Es after drug initiation / dose change

2 weeks post-dischargeSpecialist HF team follow-up (NICE CG187)

Daily self-monitoringWeight chart + action plan card given to patient

📋 SCA Consultation Scorecard — self-assess your heart failure consultation

"Doctor, I've been looking things up online and I think I might have heart failure. I'm terrified."

Who you are

68yo retired teacher. Lives alone since wife died 2 years ago. Progressive breathlessness over 3 months — now can't climb stairs without stopping. Sleeps with 3 pillows. Ankles swollen. GP has ordered NT-proBNP (result: 2,450 ng/L). Referred for today's consultation.

Hidden agenda

Wife died of "heart failure" 2 years ago — deteriorated rapidly in final months, died in hospital. You believe "heart failure = death." You are terrified of the same fate. You came hoping to be told it's something else. You have not told your daughter because you don't want to worry her.

Symptoms if asked

Breathless climbing stairs (NYHA III)
3 pillows at night (orthopnoea)
No PND (yet)
Both ankles swollen — worse evenings
Fatigue — can't do garden anymore
Taking ibuprofen for knee pain (OTC)

Psychosocial + bonus details

Lives alone — daughter lives 2 hours away
Drives — uses car for everything
Very low mood since wife's death
Doesn't want to "be a burden" to daughter
Has not updated his will or discussed wishes
Takes ibuprofen — only reveals if asked about medications

"My wife had heart failure and she died within a year of diagnosis. Am I going to die the same way? Why can't you just tell me the truth?"

Resolution: Accept plan only when: (1) wife's death acknowledged by name and prognosis fear addressed directly and honestly, AND (2) ibuprofen identified and stopped, AND (3) specific follow-up date named. Isolation/mood rewards observant candidates who ask about support at home.

🏥

Clinic Quick Reference

Heart Failure — Clinical Decision Framework

NICE NG106 · First Presentation & Review

▼expand

🚦 1 — Triage System

Suspected or known Heart Failure — haemodynamics FIRST, then BNP, then phenotype

↓

🔴 999 Now

Acute pulmonary oedema (SpO₂ <94%, pink frothy sputum, severe dyspnoea at rest)
Cardiogenic shock (SBP <90, cold/clammy, oliguric, confused)
ACS precipitating HF (chest pain + new breathlessness → 999 + aspirin 300mg)
Haemodynamically unstable arrhythmia (VT, rapid AF with hypotension)
NYHA IV — new or rapidly worsening at rest

Sit upright · O₂ · IV access · 999 · Do NOT give IV furosemide without monitoring

🟠 Urgent — same-day / days

NT-proBNP >2000 → specialist + echo ≤2 weeks (NICE NG106)
Decompensation: worsening oedema, ≥2kg weight gain in 3 days, stable obs
AKI on HF treatment (Cr ↑>50% or K⁺ >6.0) → same-day U&Es + review
New AF in known HF → rate control + anticoagulate + decompensation risk
NT-proBNP 400–2000 → echo ≤6 weeks

Furosemide · U&Es · Treat precipitant · Do NOT start ACEi/BB/MRA before echo

🟢 Routine GP

Stable known HF — structured review at least 6-monthly (QS9)
Drug titration (up-titrate 4 pillars to target doses)
NT-proBNP <400 → HF unlikely (beware false-low), pursue alternative diagnosis
Post-hospital discharge (specialist HF team follow-up within 2 weeks — NICE CG187)
NYHA I–II stable, medication optimisation

Optimise 4 pillars · Monitor U&Es · Lifestyle · Weight action plan

🔬 2 — Diagnostic Pathway

BNP-led pathway — NICE NG106

Suspected HF → BNP / NT-proBNP first (gateway test)

NT-proBNP <400 → HF unlikely (falsely low in obesity, African/African-Caribbean background, on HF drugs). Pursue DDx (COPD, PE, anaemia, obesity).

NT-proBNP 400–2000 → Possible HF. Echocardiogram within 6 weeks.

NT-proBNP >2000 → High risk. Echocardiogram within 2 weeks. Start furosemide for symptoms now.

Echo confirms phenotype: EF ≤40% = HFrEF (all 4 pillars offered) · EF 41–49% = HFmrEF (consider the same four classes) · EF ≥50% = HFpEF (consider MRA + SGLT2i, NG106 2025, + diuretic)

⛔ Do NOT start ACEi/BB/MRA before echo confirms HFrEF — could harm HFpEF or valvular disease

Key investigations with rationale

U&E + eGFR + K⁺ — baseline before ACEi/MRA. K⁺ drives MRA safety.

FBC — anaemia worsens HF (25–40%). Consider IV iron in symptomatic HFrEF with ferritin <100 or TSAT <20% and Hb <150 g/L.

TFTs — hypothyroidism causes HF. Hyperthyroidism → AF → HF.

ECG — AF (most common precipitant), LBBB (CRT candidacy if EF ≤35%), LVH.

HbA1c — DM affects SGLT2i choice and glycaemic co-management.

LFTs + Albumin — congestive hepatopathy; low albumin → DDx oedema.

CXR — cardiomegaly, pulmonary venous congestion, Kerley B lines, effusions.

BNP caveats: Falsely LOW in obesity, African or African-Caribbean family background and on diuretics, ACEi/ARB/ARNI, beta-blockers or MRAs — a normal result does not exclude HF. Falsely high with age, AF, CKD, LVH, PE, sepsis, COPD. A diagnostic test in new suspected HF, not a routine serial monitor.

📊 3 — Key Numbers

NT-proBNP <400

HF unlikely — pursue DDx (beware false-low)

NT-proBNP 400–2000

Echo ≤6 weeks (NICE NG106)

NT-proBNP >2000

Specialist + echo ≤2 weeks

EF ≤40%

HFrEF → all 4 pillars

EF 41–49%

HFmrEF → consider the four classes

EF ≥50%

HFpEF → consider MRA + SGLT2i (NG106 2025) + diuretic + treat cause

EF ≤35%

ICD + CRT if LBBB (after 3 months optimal meds)

K⁺ 5.5–5.9

Stop K⁺-raisers, recheck; MRA per SPC · ≥6.0 urgent

≥2kg/3days

Extra diuretic per individualised plan + call GP

Cr ↑ >30%

Stop ACEi + seek specialist advice

2 weeks

Post-discharge follow-up by specialist HF team (NICE CG187)

SGLT2i all

Dapagliflozin for ALL HF phenotypes

💊 4 — Medication Decision & Choice

HFrEF (EF ≤40%) — 4 pillars, all after echo confirmed

Pillar 1 → ACEi (Ramipril); if not tolerated, ARNI (sacubitril-valsartan) or consider an ARB; switch ACEi → ARNI if symptoms persist on all four and LVEF ≤35% (TA388; specialist advice). U&Es 1–2wks. 36h washout before ARNI. ↓mortality 23%.

Pillar 2 → Bisoprolol — START ONLY when euvolaemic. Never in acute decompensation. HR target 50–70. ↓mortality 34%.

Pillar 3 → Spironolactone (or eplerenone post-MI/gynaecomastia). K⁺ <5.0 to start. U&Es at 1–2 weeks. K⁺ ≥5.5 → reduce/withhold per SPC. ↓mortality 30%.

Pillar 4 → Dapagliflozin 10mg OD — ALL HF phenotypes. Sick day rules. eGFR at 2–4 weeks. ↓CV death/worsening HF 26% (DAPA-HF).

Symptoms → Furosemide — symptom control only, NO mortality benefit. Extra dose per written plan if ≥2kg/3days. U&Es after every dose change.

⚠ HFpEF UPDATED (NG106, Sept 2025): consider an MRA AND an SGLT2i — the MRA is the new part. Read it as "consider", not "offer": the HFpEF evidence is for symptoms/hospitalisation rather than a clear mortality signal. ACEi/BB still need their own indication (HTN, AF rate, post-MI). ⛔ BB only when euvolaemic.

Drug modifications by comorbidity / contraindication

Asthma → avoid BB. Ivabradine is specialist-led (TA267: sinus rhythm, HR ≥75, LVEF ≤35%). ACEi/MRA/SGLT2i still OK.

CKD eGFR <30 → specialist input. Avoid MRA. Reduce ACEi dose. SGLT2i: do not initiate if eGFR <15 (dapagliflozin SPC); do not stop for eGFR decline alone. Apixaban if AF coexists.

K⁺ >5.0 → do not start MRA; on treatment act per K⁺ thresholds. Caution with ACEi up-titration. Recheck U&Es urgently. Sodium zirconium cyclosilicate (confirmed K⁺ ≥5.5) may be started in primary care (NICE TA1148); patiromer from ≥6.0 (TA623).

ACEi cough → switch to ARB (candesartan). Same renal + cardiac protection. Do NOT give ACEi + ARB together.

Post-MI → Eplerenone preferred over spironolactone (EPHESUS trial). Start 3–14 days post-MI.

Gynaecomastia on spiro → switch to eplerenone. Same mortality benefit, no anti-androgenic SE. Do NOT stop the MRA class.

DM → SGLT2i dual benefit (HF outcomes + HbA1c). Metformin safe if eGFR >30. Sick day rules essential.

Still symptomatic on all four pillars, LVEF ≤35% → consider ARNI switch (TA388; HF-specialist advice). Sacubitril-valsartan ↓mortality 20% vs enalapril (PARADIGM-HF). 36h washout from ACEi first.

⚠ 5 — Safety Netting & Follow-Up

Follow-up schedule — NICE NG106

1

1–2 weeks after drug start/change: U&Es + K⁺ + BP + HR. Weight. Symptom response. Titration plan.

2

2 weeks post-hospital discharge: specialist HF team follow-up (NICE CG187). Medications · BNP trend · Weight · HF nurse link · Adherence.

3

Every 2–4 weeks during titration: Up-titrate each pillar to target dose. U&Es after each change. Target: ACEi full dose, BB HR 50–70, spiro 50mg, SGLT2i 10mg.

4

3–6 months specialist: Repeat echo if EF borderline. ICD/CRT if EF ≤35%. BNP trend. NYHA reassessment. ACP if NYHA III–IV.

5

Structured review at least 6-monthly (QS9): NYHA · Ferritin/TSAT · U&E+ACR · HbA1c · Vaccinations · Medication review · Psychosocial · ACP update · Cardiac rehab

📌 Written HF action plan reduces hospitalisations 30–40%. Sick day rules card essential. Digoxin toxicity = nausea + yellow halos + bradycardia → 999.

🔬 6 — Monitoring & Safety

Drug	Test	Timing	Action threshold
ACEi / ARB / ARNI	U&E + K⁺ + eGFR	1–2 weeks post each change	K⁺ 5.5–5.9 → stop K⁺-raisers, recheck, adjust per SPC; ≥6.0 → urgent. Cr ↑>50% (heart failure monitoring, NG106) → local protocol + heart failure team advice; smaller stable rise expected.
MRA (spiro/eplere)	K⁺ + eGFR + Na⁺	1–2 weeks post each change	K⁺ 5.5–5.9 → reduce or withhold per SPC/local protocol; ≥6.0 → stop + urgent. eGFR <30 → stop + seek advice. Then every 3–6 months.
Loop diuretic	Na⁺ + K⁺ + eGFR	1–2 weeks post change	K⁺ <3.5 → supplement or reduce loop. Na⁺ <130 → stop urgently. Daily weight self-monitoring by patient.
SGLT2i	eGFR	2–4 weeks post-start	Do not stop for eGFR decline alone; seek advice if eGFR <15 or on dialysis. Withhold on sick days (vomiting, surgery, fasting). No routine glucose monitoring needed in non-DM.
Digoxin	Level + K⁺ + U&E	Every 6 months	Level >1.0 ng/mL → reduce dose. K⁺ <3.5 → urgent correction (loop diuretics lower K⁺ → toxicity). Toxicity: nausea + yellow vision + bradycardia.
Beta-blocker	HR + BP	Before each dose increase	HR <50 → ECG, review rate-limiting drugs, reduce BB last. Symptomatic hypotension → reduce diuretic first; asymptomatic low BP needs no action. Target HR 50–70 in sinus rhythm.
All HF patients	NYHA + weight + BP/HR	Every contact; review at least 6-monthly	BNP is not a routine serial monitor. NYHA deterioration → escalate drugs, consider ICD/CRT/ACP. Weight ↑ >2kg/3days → action plan.

999 red flags: Acute pulmonary oedema · Cardiogenic shock (SBP <90, cold/oliguric) · ACS precipitating HF · Haemodynamically unstable VT/AF · NYHA IV rapidly worsening

🛡️ Safeguarding: Cognitive impairment from low CO (capacity for drug decisions) · Carer burden · Medication mismanagement · Depression (PHQ-9) · ACP for NYHA III–IV · Social isolation (missed decompensation)

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow — with Domain Scoring

0–2 min

Open & ICE

"I can see from the letter you've been having breathlessness over the past few weeks..."

"Tell me in your own words how this has been affecting your day-to-day life."

"What does the term 'heart failure' mean to you? What are you most frightened of?"

Relating to OthersGlobal Skills

✗ Asking info in letter · Closed Qs first · Not addressing "heart failure" fear

2–5 min

Safety Screen

"Before anything else — is your breathing manageable right now, or is it getting rapidly worse?"

Name red flags aloud: acute dyspnoea · chest pain · palpitations · syncope

NSAID screen — ibuprofen is a major precipitant

Precipitant: infection? missed meds? excess salt? new AF?

TasksGlobal Skills

✗ Missing AKI / cardiogenic shock signs · Not naming red flags aloud

5–7 min

Context & Risk

NYHA class from function: "What can you manage now vs 3 months ago?"

Precipitant: NSAID · missed meds · AF · infection · salt/fluid

Psychosocial: lives alone? carer? mood? driving? ACP?

Medications: NSAID, CCB, glitazone — must be found and stopped

TasksRelating to Others

✗ No NYHA assessment · Missed NSAID · No psychosocial context

7–10 min

Explain & Negotiate

"'Heart failure' is a terrible name — it doesn't mean your heart is about to stop. Think of it like a pump that's lost some of its squeeze."

"Today I'll start a tablet to clear the fluid and make breathing easier. The protective tablets we'll add once we have the scan result, so we get the right ones for you."

Address wife's death / prognosis fear directly and honestly

TasksRelating to Others

✗ Starting ACEi/BB/MRA before echo · Not addressing death fear · Jargon

10–12 min

Plan & Close

"If breathing gets suddenly much worse at rest — call 999. Not the surgery."

"Weigh yourself every morning. ≥2kg in 3 days — take the extra water tablet written in your plan and ring us."

Sick day rules for SGLT2i · ACP if appropriate · Driving (ICD?) · Mood screen · "Anything else?"

TasksRelating to OthersGlobal Skills

✗ No weight plan · No sick day rules · No psychosocial · Vague safety-net · No close question

🔴🟠🟢 RAG Scoring — All 3 Domains

Tasks Domain

🟢

BNP pathway + echo urgency correct · 4 pillars named · SGLT2i all EF types · U&Es post drug changes · Weight action plan · Sick day rules · Mandatory 2-week post-discharge review

🟠

Drug plan reasonable but SGLT2i missed · Echo urgency threshold not applied correctly · Weight plan mentioned but not explained · Post-discharge review not mentioned

🔴

Starts ACEi/BB/MRA before echo confirmed · Starts BB in acute decompensation · No SGLT2i · No safety-net · No follow-up plan

Relating to Others

🟢

Expectation addressed first · "HF" explained as pump/squeeze · Wife's death fear addressed honestly · ICE throughout · Psychosocial (ACP, mood, driving, isolation) · Closes with "anything else?"

🟠

ICE at start but not revisited · Wife acknowledged but not explored · Some psychosocial · Closes without checking for more concerns

🔴

Jumps to drug regimen · "Heart failure" not explained · Wife's death not named · No ICE · No psychosocial · No ACP consideration

Global Skills

🟢

Reads letter first · Open Q leads · Progresses efficiently · Data gathering complete by 6–7 min · Clear language · Responsive to patient cues · Recognises NSAID as precipitant

🟠

Some structure but overruns; some jargon; misses one key cue (NSAID or isolation or low mood)

🔴

Asks info from letter · Rigid tick-box · Jargon throughout · Data gathering not complete · Misses NSAID precipitant entirely

💬 Key Phrases — ICE, Diagnosis & Plan

💭 Ideas

"What does the term 'heart failure' mean to you? Has anyone explained what's actually happening with your heart?"

😟 Concerns — address wife's death

"You mentioned your wife had heart failure — I can only imagine how frightening that must be for you now. What specifically are you most afraid of?"

🎯 Expectations

"Were you hoping I could reassure you this isn't heart failure — or were you hoping for a plan to tackle it head-on? Let me know what would feel most helpful today."

🗣️ Lay diagnosis — pump analogy

"Heart failure is a terrible name — it doesn't mean your heart has stopped or is about to. Think of it like a pump that's lost some of its squeeze. It can't push blood as forcefully, so fluid backs up — that's why you're breathless and swollen."

💊 Plan — today vs after echo

"Today I'll start a tablet to clear the fluid and help your breathing within a few days. The protective tablets — the ones that really strengthen the heart long-term — we'll add once the scan tells us exactly what type of heart problem this is, so we can tailor them to you."

✅ Closing

"Weigh yourself every morning. If breathing gets suddenly much worse — call 999. I'll personally review you in 2 weeks. Is there anything else worrying you that we haven't talked about today?"

🚫 9 Danger Zones — Instant Deductions

✗

Asking info already in referral letter
→ "I can see from the letter your breathlessness has been worsening..."

✗

Starting ACEi/BB/MRA before echo
→ Furosemide for symptoms only — wait for echo to confirm phenotype

✗

Starting BB in acute decompensation
→ BB only when euvolaemic — initiation in fluid overload worsens HF

✗

Not mentioning SGLT2i for all EF types
→ SGLT2i (dapagliflozin) now indicated in HFrEF AND HFpEF AND HFmrEF

✗

Missing NSAID as precipitant
→ Always ask about ibuprofen/naproxen — major decompensation cause

✗

Not addressing "heart failure" fear
→ Explain: pump/squeeze analogy. Address wife's death directly.

✗

No weight monitoring / action plan
→ "Weigh every morning — ≥2kg in 3 days, take the extra water tablet we've written down for you and call us"

✗

No sick day rules for SGLT2i/diuretics
→ Mandatory patient education — withhold in vomiting/surgery/fasting

✗

No ACP / depression / isolation screen
→ PHQ-9 in HF. ACP from NYHA III. "Is there support at home for you?"

💊 Drug Quick-Pick (post-echo)

HFrEF (EF ≤40%) — Pillar 1

→

ACEi/ARB/ARNI

U&Es 1–2wks

HFrEF — Pillar 2 (euvolaemic only)

→

Bisoprolol

HR target 50–70

HFrEF — Pillar 3 (K⁺ <5.0)

→

Spironolactone

K⁺ ≥5.5 → per SPC

ALL HF phenotypes — Pillar 4

→

SGLT2i (Dapa)

Sick day rules

Symptoms / fluid overload

→

Furosemide

No mortality benefit

⛔ No ACEi/BB/MRA before echo · BB only when euvolaemic · SGLT2i for ALL EF types

Red Flags in Heart Failure — act before continuing

Safeguarding Considerations — HF Context

🏠 Carer Stress & Domestic Situation

👴 Cognitive Impairment & Consent

💊 Medication Safety

😔 Depression, Isolation & End of Life

💼 Work & Activities

💑 Relationships & Sexuality

😰 Mood & Mental Health

🏠 Home & Independence

🔮 Prognosis & End of Life

💰 Financial Impact

999 or Same-Day Hospital

Same-Day Assessment / Days

Primary Care Management

Validate the fear

Explain with honesty

Negotiate the plan

Driving

Work & Benefits

Relationships & Sexuality

Mental Health

Advance Care Planning

Financial & Practical

Within 2 weeks of initiating treatment

Within 2 weeks of hospital discharge

Every 2–4 weeks during drug titration

3–6 months: specialist HF clinic review

Structured review at least 6-monthly (QS9) — all HF patients

Memory rule for HF monitoring

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting is especially important in HF

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked

Psychosocial + bonus details