Heart failure learning module 2: diagnosis

Released1 November 2017     Expires: 01 November 2019      Programme:

NPs and guidelines for specialist referral

The diagnosis of heart failure can only be fully established by specialist assessment coupled with appropriate imaging, most commonly echocardiography.

Measurement of blood concentrations of NPs is recommended by the National Institute for Health and Care Excellence (NICE) in all patients with suspected heart failure. It can be used to guide appropriateness of referral, and to increase the speed with which referrals are seen by specialists.

NICE guidance for chronic heart failure gives detailed guidance on thresholds of NP concentration to guide referral.6

  • Patients in whom heart failure is suspected and who have a history of prior myocardial infarction (MI) do not require NP testing, but rather should be referred for specialist assessment and should be seen within two weeks of referral as the likelihood of significant myocardial dysfunction is high.
  • Patients without prior history of MI should be referred according to the guidance (table 3).
Table 3. NICE guidance and NP results
Table 3. NICE guidance and NP results

The European Society of Cardiology Heart Failure Guidelines 2016 have lower serum NP thresholds for referral for echocardiography: BNP >35 pg/mL and NTproBNP >125 pg/mL.5

A normal NT-proBNP excludes the diagnosis of heart failure without the need for an echocardiogram. Essential initial investigations include a 12-lead electrocardiogram (ECG) and laboratory tests (see below).5 Other diagnostic tests are generally only required if the diagnosis remains unclear.

HeFNEF versus HeFREF

Heart failure is a clinical diagnosis based on symptoms and signs combined with echocardiographic evidence of impaired systolic or diastolic function and raised NPs (figure 2).

Heart failure learning module 2 - Figure 2. Diagnostic algorithm for heart failure
Figure 2. Diagnostic algorithm for heart failure

The distinction between heart failure with a normal ejection fraction (HeFNEF) and heart failure with a reduced ejection fraction (HeFREF) at diagnosis changes management. While there are several evidence-based drug and device treatments for HeFREF, no treatment for patients with HeFNEF has shown convincing outcome benefit in randomised controlled trials. Symptomatic relief with diuretics and treatment of co-morbidities are the best treatment strategies for these patients.


All rights reserved. No part of this programme may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers, Medinews (Cardiology) Limited.

It shall not, by way of trade or otherwise, be lent, re-sold, hired or otherwise circulated without the publisher’s prior consent.

Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs becomes necessary. The editors/authors/contributors and the publishers have taken care to ensure that the information given in this text is accurate and up to date. Readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice.

Healthcare professionals should consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews (Cardiology) Limited cannot accept responsibility for any errors in prescribing which may occur.