These recommendations reflect those made by the National Institute for Health and Clinical Excellence (NICE) in their guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010], as well as guidelines from the Scottish Intercollegiate Guidelines Network [SIGN, 2007] and are consistent with recommendations in European specialist society guidelines [European Society of Cardiology, 2008].

Specialist

• NICE defines the term 'specialist' as a physician with sub-speciality interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care, and palliative care) in the care of individual persons.

Echocardiography

• Echocardiography can exclude significant valve disease, assess systolic and diastolic function, and detect intracardiac shunts.
• The most important measure of ventricular function provided by echocardiography in people with heart failure is left ventricular ejection fraction (LVEF).
• Cut-off values vary, but an LVEF of 45–50% or greater is usually considered to be normal.
• In most people with heart failure, left ventricular systolic function will be impaired and LVEF will be reduced.
• In people with preserved ejection fraction, echocardiography shows normal or only mildly abnormal left ventricular systolic function (LVEF >= 45–50%), and there may be evidence of diastolic dysfunction (abnormal left ventricular relaxation or diastolic stiffness) [European Society of Cardiology, 2008].

Referral

• NICE recommends referral for specialist assessment for confirmation of the diagnosis, because the diagnosis should not be based on the results of echocardiography alone and it is important to identify the type and severity of the abnormality responsible for heart failure.
• NICE recommends urgent referral (within 2 weeks) for people with high natriuretic peptide levels or who have had a myocardial infarction, because they have a worse prognosis (high chance of mortality) and a high probability of having heart failure.
• Good evidence supports the use of B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide tests to exclude heart failure; normal levels make a diagnosis of heart failure unlikely. However, natriuretic peptide levels can be reduced by obesity or certain drug treatments (aldosterone antagonists, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, beta-blockers, and diuretics), and this should be considered when interpreting values.
• The availability of tests for natriuretic peptide vary from area to area. It was estimated that in 2008, only one third of primary care trusts had access to natriuretic peptide testing, although it is thought that this number has increased [British Heart Foundation, 2008b]. CKS recommends that when heart failure is suspected and it is not possible to measure natriuretic peptide levels, use the results from electrocardiography (ECG) to decide whether to refer the person for specialist assessment and echocardiography. A normal ECG can help to rule out the diagnosis of heart failure [Mant et al, 2009]. However, if the ECG is normal and there is still a strong clinical suspicion of heart failure, CKS recommends that specialist assessment should be considered (about 1 in 10 people with heart failure have a normal ECG [European Society of Cardiology, 2008]).