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Figure 1 Heart failure (HF) diagnostic pathway. *Non-acute setting rule out <125 pg/ml. † non-acute setting rule out 35pg/ml. ACC, American
College of Cardiology; AHA, American Heart Association; BNP, B-type natriuretic peptide; ESC, European Society of Cardiology; HFmrEF, HF with mildly
reduced LV ejection fraction; HFpEF, HF with preserved LV ejection fraction; HFrEF, HF with reduced LV ejection fraction; LVEF, left ventricular ejection
fraction; NP, natriuretic peptides; NTproBNP, N-terminal-pro-BNP.
HF in this setting for all age groups is <300 ng/L, uptake of natriuretic peptide testing in hospital-
but while age-specific rule-in thresholds have been ised inpatients is patchy and not always available,
proposed (due to non-HF cardiac and non-cardiac again with wide geographical variation.11 The
causes of NTproBNP elevation), the European ESC guidelines recommend echocardiography as
Society of Cardiology (ESC) guideline uses a rule-in the key investigation for cardiac function assess-
NTproBNP concentration ≥300 ng/L.3 10 ment.3 There is no accepted national standard
There is no single test for diagnosing the HF in the UK, although the National Institute for
syndrome. Formal HF diagnosis in hospitalised Health and Care Excellence acute HF guideline
patients without known HF/LV dysfunction is recommends echocardiography in all new presen-
usually made following admission, after medical/ tations of acute HF.5 Data from the National
cardiology review and echocardiography, with or Institute for Cardiovascular Outcomes Research
without natriuretic peptide results dependent on National Heart Failure Audit (NHFA) 2020
availability. Similar to natriuretic peptides in ED, show high uptake of ECG and echocardiography
Figure 2 Specialist heart failure (HF) care and outcomes in patients hospitalised with HF (National Institute for Cardiovascular Outcomes Research
data 2018/2019).12 *Beta blocker, angiotensin converting enzyme inhibitor/angiotensin receptor blocker, mineralocorticoiod receptor antagonist.
HFrEF, HF with reduced LV ejection fraction.
across hospitals in England (figure 2).12 Patients 93.4% of those who were managed in cardiology
with possible HF in non- cardiology wards are services compared with 65.6% in general medical
significantly less likely to undergo inpatient units (p<0.001).13 A similar trend but with
echocardiography than those cared for in cardi- overall much lower rate of echocardiography was
ology. Echocardiography was performed in 94% seen in an older population (≥75 years) of 261
of patients with suspected HF in cardiology vs patients with a discharge diagnosis of HF from
83% in general medical services.12 In an Italian a London hospital; only 23.5% had an inpatient
study of 396 elderly (≥65 years) patients with echocardiogram, and again this was numeri-
acute HF, echocardiography was undertaken in cally more likely if managed under cardiology
Table 2 Patient demographics and treatment according to specialty (card=cardiology services; non-card=non-cardiology services)
Kapelios et al17 Orso et al13 Noad et al18 Parmar et al14
Card Non-card Card Non-card Card Non-card Card Non-card P
Ward designation (n=10 906) (n=8431) P value (n=61) (n=335) P value (n=108) (n=28) P value (n=36) (n=201) value
Age (year) 74.0 79.0 <0.001 81.0 85.3 <0.001 80.7 70.3 <0.001 79*
Male 69.6 66.6 <0.001 44.3 49.9 ns 77 43 <0.001 49*
β-Blocker 91.3 86.9 <0.001 76.5 65.0 ns 99.1 64.2 <0.001 63.9 42.8 <0.05
ACEi/ARB 85.1 81.8 <0.001 66.7 49.7 0.040 87.9 50.0 <0.001 52.8 67.1 ns
MRA 34.7 33.3 0.043 35.3 37.5 ns 68.5 39.3 <0.001 38.9 31.8 ns
Loop diuretic 84.7 84.9 ns 90.2 86.1 0.026 – – 77.8 84.6 ns
ICD/CRT 7.5 3.7 <0.001 – – 25.9 3.6 <0.001 – –
eGFR (mL/min/1.73 m2) 49.5 44.0 <0.001 48.5 52.6 ns – – – –
AF 55.8 57.0 0.004 46.2 45.8 ns – – 43.3 50.6 ns
T2DM 30.0 31.1 ns 32.8 29.1 0.049 – – 53.3 32.3 <0.05
*Total population data—no ward comparison given.
ACEi/ARB, ACE inhibitor/angiotensin receptor blocker; AF, atrial fibrillation; eGFR, estimated glomerular filtration rate; HTN, hypertension; ICD/CRT, implantable cardioverter
defibrillator/cardiac resynchronisation therapy; MRA, mineralocorticoid receptor antagonist; ns, not significant; T2DM, type two diabetes mellitus.
Table 3 Recommendations for renin-angiotensin-aldosterone system inhibitor continuation in heart failure with renal impairment
Recommendations for RAASi
Change in renal function from baseline HFpEF HFrEF
Serum creatinine rise by <30% Consider stopping ACEi/ARB/ARNI Continue (unless symptomatic hypotension)
Review MRA in context of fluid balance
Serum creatinine rise 30%–50% Stop RAASi Consider reducing dose and/or temporary withdrawal
Serum creatinine rise >50% Stop RAASi Temporary RAASi withdrawal
Severe renal dysfunction, for example, eGFR <20 mL/ Stop RAASi Stop RAASi if symptomatic uraemia regardless of baseline renal function
min/1.73 m2
*Assuming no other prognostic indication.
ACEi, ACE inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; eGFR, estimated glomerular filtration rate; HFpEF, HF with preserved LV
ejection fraction; HFrEF, HF with reduced LV ejection fraction; RAASi, renin-angiotensin-aldosterone system inhibitor.
(33.3% vs 22.4% in non-cardiology services).14 fraction (LVEF) was possible in only 27% (appro-
A frequent observation in all such comparison priate data unavailable in the remaining 73%),
studies, however, and reflected in the NHFA, is and HFpEF was confirmed in only half of those
that similar rates of echocardiography are seen with the required laboratory and echocardio-
when a specialist team is involved in a patient’s graphic measurements.15 Atrial fibrillation (AF),
care, irrespective of their base unit, underlining prevalent in up to around 40% of patients with
the importance of specialist HF teams operating HFpEF, can also confound the diagnosis as it is
within the hospital setting (figure 2). associated with elevated natriuretic peptides per
se, outwith the context of HF.16 Higher rule-in
thresholds for patients with HF symptoms and
DEMOGRAPHY OF HOSPITALISED PATIENTS
AF have been proposed.3 4
WITH HEART FAILURE
Studies comparing inpatients with HF according
Attempts to compare demographic data of
to specialty have tended to focus either on HFrEF
patients with HF according to base department
alone, or else general ‘HF’ without specifying
are hampered by variations in the accuracy of
phenotype.6 14 17 One study which did compare
the definition of HF. Given lack of widespread
HF phenotype according to hospital specialty
availability of natriuretic peptide testing, a signif-
unit showed that, among 396 elderly (≥65 years)
icant proportion of hospitalised patients with
patients admitted with HF, only ~15% were cared
suspected HF will not have been assessed using
for in cardiology, with the remainder divided
the guideline-recommended diagnostic pathways,
between old age and general medicine.13 HFpEF
and in many patients the diagnosis of HF will be
was the predominant phenotype in non-cardiology
a subjective clinical opinion. This is particularly
services (~51%) with HFmrEF accounting for
applicable to HFpEF. As in table 1, the diagnosis
~20% and HFrEF ~29%. In comparison, patients
of HFpEF requires evidence of a structural and/
with HF in cardiology units most commonly had
or functional cardiac abnormality in keeping with
HFrEF (~40%) or HFmrEF (~23%) and less
HF (including elevated natriuretic peptides), but
commonly HFpEF (~37%). Similar findings were
several patients with dyspnoea and/or lower limb
identified in a random sample survey of 249 hospi-
oedema with normal LV systolic function on echo
talised patients with HF, with a significantly higher
are labelled as HFpEF (or the more antiquated
proportion of patients with moderate-to-severe LV
term congestive cardiac failure (CCF), which
dysfunction admitted to cardiology services (72%
is still commonplace among patient comor-
vs 28%, p<0.001).18
bidity lists in medical clerk-ins), and once such
The average number of comorbidities at time of
a ‘diagnosis’ is attached to a patient it is very
diagnosis of HF is 5.4 .1 Patients with HF admitted
rarely rescinded. In a Polish study, application
to non-cardiology services tend to be older, frailer
of the ESC diagnostic criteria for HFpEF to a
and have a greater number of comorbidities than
retrospective review of clinical, laboratory and
those managed in cardiology, including a higher
echocardiographic data of 1848 patients hospi-
incidence of cognitive impairment.13 14 18 Elevated
talised with acute HF and preserved LV ejection
Table 4 Mortality of patients with heart failure according to specialty (card=cardiology services; non-card=non-cardiology services)
Noad et al18 NHFA12 Parmar et al14 Orso et al13
Card Non-card Card Non-card Card Non-card
Mortality (n=149) (n=100) P value Card Non-card P value (n=36) (n=201) P value (n=51) (n=308) P value
Inpatient 2 7 0.052 6.7 9.3 <0.05 0 12.9 <0.05 16.4 17.5 0.001
30-d ay 0.7 11 <0.001 – – – – – –
1-year 45 22.1 <0.001 25 35 <0.05 8.3 29.4 <0.01 – –
Data as percentages unless shown.
NHFA, National Heart Failure Audit.