Introduction

A robust and systematic approach is key to ensuring that people living with heart failure with preserved ejection fraction (HFpEF) receive a timely and accurate diagnosis and guideline-based therapies, avoiding their unnecessary deterioration and unplanned hospitalisation. Heart failure services and integrated care boards (ICBs) should work together to streamline inefficient heart failure pathways.

This pathway tool supports that and is for ICBs and other stakeholders responsible for planning and providing equitable service provision and care for those living with HFpEF.

Note: for the purposes of this tool, people living with heart failure with a mildly reduced ejection fraction (HFmrEF) should be considered as living with heart failure with reduced ejection fraction (HFrEF) and therefore are out of scope.

The tool aligns clinical practice for this patient group across healthcare providers in England with established guideline recommendations, to:

• provide high-quality standardised care
• optimise outcomes for all patients
• reduce unwarranted variation

It explains where the 2 Technology Appraisals for sodium-glucose co-transporter-2 inhibitors (SGLT2 inhibitors) published by the National Institute for Health and Care Excellence (NICE) for treating chronic heart failure with preserved or mildly reduced ejection fraction (TA929 and TA902) sit in the heart failure pathway.

This tool is not intended to override clinical judgement in individual cases.

Background

HFpEF accounts for about 40–50% of all heart failure diagnoses (Savarese, G et al 2017) and is associated with an older and multimorbid population. Given this, its prevalence is predicted to increase as the population continues to age and the incidence of co-morbidities escalates. It may also account for the increasing number of heart failure-related hospitalisations (National Cardiac Audit Programme, 2021).

However, service availability for HFpEF is variable across the NHS: a survey in 2017 showed that 40% of heart failure services only managed people living with HFrEF (Pumping Marvellous, 2018). Many patients with HFpEF who could benefit from being seen in heart failure clinics cannot access specialist heart failure care pathways. Instead, they are either remaining in secondary care or returning to their GP (GIRFT, 2021).

As a result, concerns have been raised around the unwarranted variation in the access people living with HFpEF have to specialists who can confidently make a diagnosis and subsequently code HFpEF in primary care records, particularly in areas where there is no locally commissioned service to manage HFpEF (historically due to lack of evidence for prognostic therapies to treat). Therefore, people with HFpEF may be denied guideline-based therapies and be unnecessarily readmitted into secondary care.

Other issues include:

• the use of open access echocardiography in the context of suspected heart failure, from providers that are not integrated with a local heart failure service
• difficultly non-specialists have in interpreting echocardiographic findings, for example from open access echocardiography reports
• variation in echocardiogram reports signposting the possibility of HFpEF to the referrer
• variation in seeking advice and guidance/referral to a heart failure service where an open access echocardiogram is suggestive of HFpEF
• suboptimal coding of heart failure subtype in clinical primary care records, with evidence that >70% of cases lack subtype codes (Bellanca L et al, 2023).

Principles

Diagnosis

HFpEF is characterised by:

• symptoms or signs of heart failure
• raised NT-proBNP
• echocardiographic findings including:
  • ejection fraction (EF) ≥50%
  • structural and/or functional changes that may include increased left ventricular filling pressure, left ventricular hypertrophy or atrial dilatation, and impaired left ventricular relaxation

Presentation in hospital

Many patients experience their first heart failure presentation during a hospital admission. As already mentioned, survey data from October 2017 to January 2018 showed that only 60% of teams managed all types of heart failure – that is, both patients living with HFrEF and those living with HFpEF, and 40% managed patients with HFrEF only (Pumping Marvellous, 2018). Hospitals should offer review for patients with all types of heart failure including HFpEF, such that an expedient formal diagnosis and management plan (with consideration of frailty) can be made.

Presentation in primary care

Where a new diagnosis of heart failure is suspected in primary care, such as from breathlessness, fatigue or oedema, NT-proBNP blood testing should be offered, as supported by our guidance Enhancing GP direct access to diagnostic tests for patients with suspected chronic obstructive pulmonary disease, asthma, or heart failure.

Those with a raised NT-proBNP should:

• not be offered an open-access echocardiogram from primary care unless the provider is fully integrated with the local acute heart failure service
• be referred to the local heart failure service for an echocardiogram and specialist review as per NICE guidelines

Echocardiogram abnormalities associated with HFpEF are non-specific. Therefore, if one or more is incidentally detected on an open access echocardiogram, the echocardiogram report should clearly state the possibility of HFpEF but that a formal heart failure diagnosis cannot be made without clinical validation (British Society of Echocardiography, 2024). The patient should first be clinically assessed for signs or symptoms of heart failure and, if present, an NT-proBNP test should be arranged as soon as clinically appropriate.

If NT-proBNP is elevated, the patient should be referred as per NICE guidelines either via advice and guidance or local pathways for confirmation by a heart failure specialist (see NICE pathway Chronic heart failure in adults: diagnosis and management). Specialists must be made aware of the presence of frailty (use clinical frailty score if aged over 65) and a care plan, current treatment and co-morbidities, including but not restricted to: high BMI, hypertension, chronic kidney disease, diabetes, coronary artery disease and valve disease.

Where GPs and community teams encounter patients who have been coded with HFpEF during a hospital admission but have not received a formal diagnosis and heart failure specialist review, a referral for confirmation of the diagnosis and heart failure specialist review should be considered to ensure patients receive guideline-directed medical therapy.

General practice teams can refer patients with uncertain symptoms that suggest either a respiratory condition or heart failure onto breathlessness pathways that several community diagnostic centres (on the FutureNHS platform, login required) are delivering, and guidance underpinning the delivery of the breathlessness pathway is available on the NHS England website. This pathway provides a combination of tests and can support GPs to diagnose and optimise uncertain COPD, asthma and heart failure referrals.

Management

This section aligns with NICE’s management scenario for confirmed heart failure with preserved ejection fraction.

Pharmacotherapy

Pharmacotherapy management should focus on:

1. congestion
2. SGLT2 inhibitors
3. concomitant diabetes
4. medication adjustment in the context of frailty
5. treatment of co-morbidities

See Appendix 1 for more details.

Self-management

People living with HFpEF should be offered and, where appropriate, signposted to lifestyle advice, tailored to different cultural backgrounds and language capabilities, and patient education resources such as My marvellous guide to heart failure with preserved ejection fraction: A patient’s story. Individualised consideration should be given to groups who face health inequalities, such as homeless people (Baggett TP et al, 2018), or barriers to medication adherence, communication and timely follow-up.

Annual review

Regular review is associated with improvement in quality of life and a reduction in the need for urgent hospitalisation. Once HFpEF, co-morbidities and lifestyle are optimised, and those living with frailty or in the last year of life have a Comprehensive Geriatric Assessment (CGA) and care plans in place, people living with HFpEF should be reviewed at least annually, as per NICE guideline NG106 (which recommends short monitoring intervals – days to 2 weeks – if the clinical condition or medication has changed and 6-monthly for people with stable heart failure) and the quality and outcomes framework.

At each review:

• coding integrity should be checked
• condition understanding should be reviewed
• symptoms and signs should be reviewed including assessment of blood pressure, cardiac rhythm and signs of congestion
• frailty or last year of life should be assessed for
• HFpEF and co-morbidities should be optimised, aligned to guideline-directed medical therapies but individualised in the case of frailty/last year of life
• side effects of medications should be considered, including postural symptoms and electrolyte disturbance
• mental health should be assessed
• lifestyle advice should be offered
• vaccinations should be offered
• cardiac rehabilitation should be offered

Review of existing cohort

There are significant prevalence and treatment gaps in heart failure. The prevalence gap is caused by true under-diagnosis as well as under-coding. All clinicians should be alert to the possibility of heart failure in their patients and primary care should ensure that people with heart failure are coded accurately (see Appendix 2).

Palliative care

It is vital that people living or dying with heart failure across the EF range have access to supportive palliative and end of life care. As already stated, patients living with HFpEF are often older and multi co-morbid [6], and have complex needs that are associated with increased hospital admissions (Pumping Marvellous, 2018). Heart failure patients should be proactively assessed at an early stage for severe frailty and last year of life.

Supportive palliative care should be offered alongside active treatment for HFpEF to improve quality of life and ensure people can be cared for and die in their preferred place wherever possible. However, given that only about 60% of services are commissioned for the full range of EF, there is significant concern that those with HFpEF but no heart failure specialist input in the community will also have little or no access to specialist palliative care services. 

NHS England’s Addressing palliative and end of life care needs for people living with heart failure: a revised framework for integrated care systems sets out the legal requirements for ICBs to provide palliative care as well as what good palliative and end of life care looks like in the context of people with any type of heart failure.

Further resources

• elearning for healthcare – Heart failure and heart valve disease
• UCL Partners – Proactive care framework for heart failure
• Primary Care Cardiovascular Society – Heart failure QI programme

References

1. Savarese G, Lund LH (2017). Global public health burden of heart failure. Cardiac Failure Review 3: 7-11.
2. National Cardiac Audit Programme. National Health Failure Audit (NHFA). 2021 summary report. NICOR and British Society for Heart Failure.
3. Pumping Marvellous. Heart failure nurse audit. Putting heart failure into context.
4. GIRFT (2021). Cardiology: GIRFT Programme National Specialty Report
5. Bellanca L, Linden S, Farmer R (2023). Incidence and prevalence of heart failure in England: a descriptive analysis of linked primary and secondary care data – the PULSE study. BMC Cardiovascular Disorders 23: article number 374.
6. British Society of Echocardiography (2024). Updated clinical indications and triage of echocardiography posters.
7. Baggett TP, Liauw SS, Hwang SW (2018). Cardiovascular disease and homelessness. Journal of the American College of Cardiologists 71 (22): 2585–2597.
8. NICE (2023). Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. Technology appraisal guidance [TA902].
9. NICE (2023). Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. Technology appraisal guidance [TA929].
10. Pumping Marvellous. Sick day rules.
11. NICE (2015). Type 2 diabetes in adults: management. NICE guideline [NG28].
12. Dalhousie University. Clinical Frailty Scale.
13. Butt JH, Jhund SP, Belohlavek J, de Boer RA, Chiang C-E, Desai AS, et al (2022). Efficacy and safety of dapagliflozin according to frailty in patients with heart failure: a prespecified analysis of the DELIVER trial. Circulation 146: 1210–1224.
14. NHS England (2023). Guidance note: virtual ward care for people with heart failure.

Appendix 1: pharmacotherapy management

1. Congestion:

• diuretics (preferably loop diuretics) should be used to reduce symptoms or signs of congestion
• diuretics should not be delayed for patients with oedema/fluid retention
• suggested starting dose:
  • diuretic naïve: furosemide 40mg once daily or bumetanide 1mg once daily
  • already prescribed loop diuretics: furosemide 40mg once daily or bumetanide 1mg once daily in addition to usual dose (for example, furosemide 40mg daily, increase to 80mg daily; bumetanide 1mg daily, increase to 2mg daily)
• check urea and electrolytes before (or up to date when bloods should be available within a reasonable timeframe) and after dose adjustment
• review response after maximum 1 week and increase the diuretic dose further if required
• ongoing diuretic management is required when the dose is increased during periods of congestion or decreased should the patient become dehydrated

2. Sodium-glucose co-transporter-2 (SGLT2) inhibitors:

• dapagliflozin 10mg daily or empagliflozin 10mg daily are recommended for the treatment of adults with HFpEF [8, 9]:
  • do not prescribe SGLT2 inhibitors in those at risk of diabetic ketoacidosis (risks include history of diabetic ketoacidosis, restricted dietary intake/ketogenic diet or dehydration, acute illness and undergoing major surgery)
  • advise all patients about sick day rules [10]

Dapagliflozin is approved for initiation in heart failure patients with a glomerular filtration rate (GFR) >15mL/min and empagliflozin is approved for initiation those with a GFR >20mL/min/1.73m².

3. Concomitant diabetes:

• all patients with concomitant Type 2 diabetes mellitus and chronic heart failure should be offered an SGLT2 inhibitor [11]. Before adding/switching to an SGLT2 inhibitor, check medications to control blood sugar and diabetic control. Dose adjustment of insulin or sulphonylureas may be required – see local guidelines for further advice
  • do not prescribe in people with Type 1 diabetes

4. Medication adjustment in the context of frailty:

• frailty should be proactively identified at an early stage. Use clinical frailty score in patients over the age of 65 [12]
• trial evidence showed that benefit of a SGLT2 inhibitor was consistent across the range of frailty studied, and quality of life improved early and was greater in patients with more severe frailty [13]
• patients with frailty or those who are in the last year of life should have a needs-based holistic assessment and individualised care plans, through shared decision-making, which may include advance care plans and preference to use a virtual ward [14] if required, and ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) considerations

5. Treatment of co-morbidities:

• good symptom control requires strict management of hypertension, atrial fibrillation, diabetes and weight reduction in obesity
• consider referral to an exercise-based cardiac rehabilitation programme for all people newly diagnosed with HFpEF
• assess for depression and anxiety
• offer vaccinations aligned to national programmes

Appendix 2: coding guidance

* Patients with an original HFrEF diagnosis with an improved ejection fraction – that is, more recent echo with EF >40% due to optimisation – should still be considered HFrEF as per original diagnosis, and must remain on their prognostic medications

From: Heart failure proactive care framework, UCL Partners (2023)

Appendix 3: acknowledgments

We would like to thank these colleagues for their expertise and knowledge in shaping this guidance:

• Dr Dawn Adamson, National Specialty Advisor, NHS England and Consultant Cardiologist, University Hospitals Coventry and Warwickshire NHS Trust
• Dr Lisa Anderson, Chair, British Society for Heart Failure and Consultant Cardiologist, St George’s University Hospitals NHS Foundation Trust
• Carys Barton, Chair Elect, British Society for Heart Failure and Nurse Consultant for Heart Failure, Imperial College Healthcare NHS Trust
• Professor Ahmet Fuat, GP with Special Interest in Cardiology and Honorary Professor of Primary Care Cardiology, Durham University
• Nick Hartshorne-Evans, Chief Executive, Pumping Marvellous Foundation
• Professor Paul Kalra, Consultant Cardiologist, Portsmouth Hospitals University NHS Trust
• Professsor Theresa McDonagh, Consultant Cardiologist and Clinical Lead for Heart Failure, King’s College Hospital NHS Foundation Trust and National Heart Failure Audit Clinical Lead, National Institute for Cardiovascular Outcomes Research (NICOR)
• Dr Jim Moore, Immediate Past President, Primary Care Cardiovascular Society, GP, Stoke Road Surgery and Primary Care Lead, West of England Integrated Cardiac Clinical Network
• Maria Paton, Co-Chair of Research and Audit, British Society for Echocardiography and Co-Lead for Cardiac Science Heart Failure Services, Leeds Teaching Hospitals NHS Trust
• Professor Raj Thakkar, President, Primary Care Cardiovascular Society, GP, Bourne End and Wooburn Green Medical Centre and Primary Care Cardiology Lead, Oxford and Thames Valley Health Innovation Network.

Publication reference: PRN01217