Education in Heart
Management of hospitalised patients with heart
Cardiology, University Hospital
Hairmyres, Glasgow, UK
Correspondence to
Dr Robin A P Weir, Cardiology,
Hairmyres Hospital, East
Kilbride, UK;
​robin.​weir@​lanarkshire.​scot.​
nhs.​uk
Published Online First
27 February 2023
© Author(s) (or their
employer(s)) 2023. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Weir RAP. Heart
2023;109:959–965.
failure admitted to non-­cardiology services
Robin A P Weir ‍ ‍
INTRODUCTION
Heart failure (HF) is a clinical syndrome charac-
terised by typical symptoms and signs caused by a
structural and/or functional cardiac abnormality,
which results in reduced cardiac output and/or
elevated cardiac filling pressures. It is common,
with a prevalence of 1.6% within a population of
4 million UK residents, and accounts for nearly 5%
of acute medical hospital admissions.1 2 Guideline-­
based diagnostic pathways are in widespread use
for assessment of the breathless patient in order to
exclude or confirm HF, but despite these there is
considerable variability in criteria used to define
and diagnose this condition.3–5 This variability in
diagnosis is evident in both community and hospital
care, and even within different departments within
the hospital. This results in the potential for
underdiagnosis (or overdiagnosis) of HF, underuse
(or overuse) of guideline-­ directed pharmacolog-
ical therapies, underuse of appropriate implant-
able cardiac devices, variation in specialist team
involvement and follow-­ up after discharge back
into the community, which has an impact on patient
outcomes.6 The purpose of this article is to evaluate
how HF is diagnosed (and subcategorised) in the
hospital setting, and to review the management and
outcomes of patients with HF when cared for in
cardiology compared with non-­cardiology services.
HEART FAILURE DIAGNOSIS
With the notable exception of asymptomatic left
ventricular (LV) dysfunction, which is detected
when cardiac imaging is performed for indica-
tions other than symptoms of breathlessness and/
or signs of fluid retention (such as hypertension
assessment, screening of family members of a
genetic cardiomyopathy proband, serial monitoring
of patients undergoing cardiotoxic chemotherapy
regimens), HF is diagnosed by a combination
of clinical features and baseline investigations.
Natriuretic peptides feature prominently in Euro-
pean and American guidelines, although ranges of
normality, and thresholds for priority assessment,
vary somewhat between these governing bodies.3–5
The importance of clinical assessment cannot be
undervalued and is mandated in all guidelines, as
is the performance of routine bloodwork and the
undertaking of a 12-­lead ECG. In the patient with
suspected HF, B-­ type natriuretic peptide (BNP)
or N-­ terminal-­
pro-­BNP (NTproBNP) should be
measured, with further investigation guided by the
result (figure 1). For patients in whom the diag-
nosis is confirmed, further subcategorisation into
one of the three HF phenotypes—HF with reduced
LV ejection fraction (HFrEF), HF with mildly
Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720
Learning objectives
⇒ To review the diagnostic pathway for heart
failure and to appreciate the differences in
natriuretic peptide criteria used in primary
(community) and secondary (hospital) care.
⇒ To understand the negative impact on evidence-­
based treatment and clinical outcomes
(including mortality) of management of patients
with heart failure on non-­specialist services.
⇒ To appreciate the importance of specialist heart
failure team review in hospital and/or early
after discharge and its impact on heart failure
diagnosis, treatment, follow-­up and clinical
outcomes.
reduced LV ejection fraction (HFmrEF) or HF with
preserved LV ejection fraction (HFpEF)—is based
on echocardiographic appearances (table 1).
HEART FAILURE DIAGNOSIS IN HOSPITALISED
PATIENTS
Patients with HF in the hospital setting fall broadly
into two groups: those with known HF who are
then admitted (with HF decompensation or with
non-­HF-­related complaints) and those with de novo
HF, who are assessed in the emergency department
(ED) and are ultimately managed in cardiology or
non-­cardiology services (predominantly old-­ age
medicine, general medicine or occasionally surgical
wards). Diagnosis of de novo HF is made either in
ED (dependent on availability of diagnostic equip-
ment, most pertinently echocardiography and/or
lung ultrasound) or following admission to the unit
once baseline investigations have been completed.7
Natriuretic peptide sampling is not offered in all
EDs due to a combination of financial constraints,
concerns over excessive ordering (and overdiag-
nosis of HF in acutely unwell medical patients many
of whom will have non-­cardiac causes of natriuretic
peptide elevation) and perhaps underapprecia-
tion of their utility in patient triage. While there
is significant geographical variation, in general
around one-­third of EDs in Europe do not offer
this service.8 Diagnostic thresholds for acute HF in
the ED setting differ from those used in the chronic
HF (CHF) pathway. A study of 1586 patients
attending ED with possible acute HF identified a
BNP cut-­off of 100 ng/L as sufficiently specific and
sensitive to rule-­out HF, with a rule-­in cut-­off of
400 ng/L regardless of age.9 BNP concentrations
between 100 and 400 ng/L may not be helpful in
ruling in or ruling out acute HF.9 10 The recom-
mended NTproBNP rule-­ out threshold for acute
  959
 Education in Heart

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,
but while age-­specific rule-­in thresholds have been
proposed (due to non-­HF cardiac and non-­cardiac
causes of NTproBNP elevation), the European
Society of Cardiology (ESC) guideline uses a rule-­in
NTproBNP concentration ≥300 ng/L.3 10
There is no single test for diagnosing the HF
syndrome. Formal HF diagnosis in hospitalised
patients without known HF/LV dysfunction is
usually made following admission, after medical/
cardiology review and echocardiography, with or
without natriuretic peptide results dependent on
availability. Similar to natriuretic peptides in ED,
uptake of natriuretic peptide testing in hospital-
ised inpatients is patchy and not always available,
again with wide geographical variation.11 The
ESC guidelines recommend echocardiography as
the key investigation for cardiac function assess-
ment.3 There is no accepted national standard
in the UK, although the National Institute for
Health and Care Excellence acute HF guideline
recommends echocardiography in all new presen-
tations of acute HF.5 Data from the National
Institute for Cardiovascular Outcomes Research
National Heart Failure Audit (NHFA) 2020
show high uptake of ECG and echocardiography

Table 1 Diagnostic criteria for heart failure phenotypes

HFrEF HFmrEF HFpEF
Symptoms±signs Symptoms±signs Symptoms±signs
LVEF ≤40% LVEF 41%–49% LVEF ≥50%
–  – Cardiac structural and/or functional
abnormalities consistent with LV diastolic dysfunction/raised filling pressures, including elevated natriuretic peptides
HFmrEF, HF with mildly reduced LV ejection fraction; HFpEF, HF with preserved LV ejection fraction; HFrEF, HF with reduced LV ejection fraction; LV, left ventricular; LVEF, left
ventricular ejection fraction.

960 Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720

 Education in Heart

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
with possible HF in non-­ cardiology wards are
significantly less likely to undergo inpatient
echocardiography than those cared for in cardi-
ology. Echocardiography was performed in 94%
of patients with suspected HF in cardiology vs
83% in general medical services.12 In an Italian
study of 396 elderly (≥65 years) patients with
acute HF, echocardiography was undertaken in
93.4% of those who were managed in cardiology
services compared with 65.6% in general medical
units (p<0.001).13 A similar trend but with
overall much lower rate of echocardiography was
seen in an older population (≥75 years) of 261
patients with a discharge diagnosis of HF from
a London hospital; only 23.5% had an inpatient
echocardiogram, and again this was numeri-
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.

Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720 961

Education in Heart

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-­day 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.

962 Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720


BNP is associated with frailty even in the absence
of known cardiovascular disease, while in a study
of elderly patients with HF, higher NTproBNP
was associated with greater frailty and poorer
outcome.19 20 While guideline-­based HF diagnostic
and therapeutic pathways are used less frequently
in non-­cardiology services, applying such pathways
to frail multimorbid elderly patients may not always
be appropriate—symptom management, supported
discharge and holistic care may be more prescient
aspects of care for the patients and carers. In addi-
tion, overdiagnosis of HF in such patients can lead
to erroneous admission/outcome reporting and
mortality data.
EVIDENCE-BASED THERAPIES FOR
HOSPITALISED PATIENTS WITH HF
There are robust data that prove pharmacological
and device therapies reduce morbidity and mortality
in HFrEF, and recently sodium-­glucose cotransport-
er-­2 (SGLT2) inhibitors have been demonstrated to
improve outcomes in HFpEF, a condition for which
no previous drug class has shown benefit on major
clinical end points.21 22 SGLT2 inhibitor usage in
HF is too recent a development to be included in
any studies to date comparing cardiology and non-­
cardiology services, with most focusing on ACE
Key messages
⇒ Heart failure (HF) diagnosis is based on clinical symptoms and/or signs, ECG
and natriuretic peptides, with phenotypic subdivision by echocardiography
into HF with reduced LV ejection fraction, HF with mildly reduced LV ejection
fraction or HF with preserved LV ejection fraction.
⇒ B-­type natriuretic peptide and N-­terminal-­pro-­BNP rule-­in thresholds are
higher for hospitalised patients with acute HF than patients with community-­
based chronic HF.
⇒ Diagnostic tests including echocardiography are less likely to be offered to
patients on non-­cardiology units, a proportion of whom may be mislabelled
as having HF.
⇒ Non-­cardiology care of inpatients with HF is associated consistently with
less beta-­blocker prescription and lower rates of cardiac device implantation
(implantable cardioverter defibrillator/cardiac resynchronisation therapy).
⇒ HF specialist review, regardless of ward designation, is associated with
better HF treatment and improved survival, as is early outpatient cardiology
review.
⇒ Expansion of specialist hospital HF teams and increasing HF specialist nurse
capacity is essential in improving the outcomes of patients hospitalised with
HF.
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Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720
Education in Heart
inhibitors (ACEi)/angiotensin receptor blockers
(ARBs), beta-­ blockers and mineralocorticoid
receptor antagonists (MRAs) for the HFrEF patient
subgroup.
With the exception of a large retrospective survey
of patients enrolled in the Swedish HF Registry, the
majority of studies comparing demographics, treat-
ment and outcomes in patients with HF according
to inpatient specialty have modest sample sizes
which must be taken into account when interpreting
the findings (table 2).13 14 17 18 Patients with HF in
cardiology services in general tend to be younger
and more frequently male with higher prevalence
of ischaemic cardiomyopathy.13 17 The Swedish
registry data reveal compelling underprescription
of the recommended ‘triple therapy’ (at the time
of data collection) of beta-­blockers, ACEi/ARB and
MRA therapy; reduced beta-­ blocker prescription
in non-­cardiology services was consistent across all
studies (table 2).17 Device therapy prescription—not
included in all studies—was again more frequent in
cardiology-­managed patients with HF.17 18 Defibril-
lator therapy and beta-­ blockers have the stron-
gest evidence base for reducing sudden cardiac
(arrhythmic) death; that both are less likely to
be offered to patients with HF in non-­cardiology
services portends adverse outcome in these patients.
Angiotensin receptor neprilysin inhibitor
prescription is not recorded in currently available
studies examining patients with HF according
to base ward. These data will undoubtedly be
provided in future studies given the increase
in prescription of sacubitril-­ valsartan over the
last few years and are likely to show reduced
prescription in non-­cardiology wards both due to
lack of expertise among non-­cardiologists, and
evidence that symptomatic hypotension leading
to drug discontinuation is more common in the
elderly, who tend to be managed in general and
old age medical units.23
HF PHARMACOTHERAPY AND RENAL DECLINE
‘Acute kidney injury’, ‘sick-­day rules’ and ‘inter-
current illness’ are commonplace phrases, which
frequently lead to cessation of diuretics and renin-­
angiotensin-­aldosterone system inhibitors (RAASi)
in patients with HF. Declining renal function in
congested patients will often trigger reduction or
cessation of diuretic rather than a more appro-
priate increase, particularly on non-­ specialist
units. The life-­prolonging benefits of RAASi in
HFrEF in particular must be weighed against
the risk of (usually temporary) renal decline; the
British Society of Heart Failure and Renal Associ-
ation recommend no change to RAASi dose in HF
unless creatinine rises >30%, with (temporary)
cessation only if >50% (table 3).24 Congested
patients with declining renal function should
ideally be transferred to cardiology specialist care
units. Patients with HF undergoing non-­cardiac
surgery often have HF medications withheld and
not re-­introduced predischarge, exposing them to
higher risk of sudden death and progressive pump
963
Education in Heart
failure; prompt cardiology/HF nurse outpatient
care is essential for such patients.
DISCHARGE AND FOLLOW-UP OF PATIENTS
WITH HF
Median length of stay (LOS) for patients admitted
with HF has progressively declined over the last
5 years.12 LOS in medical services is consistently
shorter than in cardiology; by virtue of patient
population and comorbidity, average LOS in old age
medicine units is understandably longer.6 12 Regard-
less of specialty designation, cardiology specialist
care is associated with longer LOS (which for some
patients may actually be a marker of better care);
shorter admissions for patients with HF are associ-
ated with increased re-­admission rates and greater
mortality.12
Perhaps the most striking benefit of patients with
HF being managed in cardiology services is access
to specialist follow-­up with both cardiologists and
HF specialist nurses (figure 2).17 The magnitude
of this benefit varies between studies; among 396
patients with HF discharged from an Italian centre,
specialist follow-­up (defined as consultant cardiol-
ogist, consultant physician with an interest in HF
or HF specialist nurse) was sixfold higher when
discharged from cardiology compared with general
medicine (66.7% vs 11.9%, p<0.001).13 NHFA
data show similar trends, with cardiology follow-­up
in 45% of all HF admissions in England and HF
nurse follow-­up in 55%; these figures rise to 64%
and 66%, respectively when patients are discharged
from cardiology units.12 A retrospective observa-
tional survey of 2650 patients with HF evaluated
evidence-­ based secondary preventive medication
adherence (defined using a medication posses-
sion ratio with data from an electronic pharmacy
database) at discharge and follow-­up according to
base unit specialty.6 Compared with general medi-
cine, patients discharged from cardiology received
greater ACEi/ARB (OR 1.53 (95% 1.03 to 2.28))
and MRA (OR 1.77 (95% CI 1.24 to 2.51)) therapy.
Importantly, irrespective of inpatient specialty unit,
cardiology specialist review within 3 months of
discharge was associated with greater beta-­blocker
adherence (OR 1.46 (95% CI 1.09 to 1.97)).
Cardiology review while in hospital or early after
discharge increases prescription of evidence-­based
HF therapies.6 12
HF OUTCOMES—CARDIOLOGY VERSUS NON-
CARDIOLOGY SERVICES
HF management in cardiology units is associated
with greater use of diagnostic (and prognostic)
investigations, higher uptake of evidence-­ based
medical and device therapies and more frequent
access to specialist follow-­up care (figure 2). It is
unsurprising therefore that a mortality benefit
is observed. Review of inpatient data from the
~36 000 patients enrolled in the Swedish HF
Registry show non-­cardiology care to be associated
with higher inpatient mortality (3.9% vs 2.6%; HR
1.48 (95% CI 1.26 to 1.74), p<0.001) and 1-­year
964 Weir RAP. Heart 2023;109:959–965. doi:10.1136/heartjnl-2022-321720
mortality (29% vs 22%; HR 1.36 (95% CI 1.29 to
1.44), p<0.001) compared with cardiology care.17
First HF re-­hospitalisation was similar between the
two groups (~35% in both over 1 year). Mortality
trends similar to the Swedish HF study are observed
in several studies (table 4). While selection bias may
play some role in the lower mortality of patients
managed in cardiology, the most likely reason
for better outcome with cardiology specialist
care pertains to prescription of and adherence to
evidence-­based therapies.6
HF IN OTHER AREAS OF THE HOSPITAL
The majority of acute HF and CHF is managed on
cardiology, medical and geriatric units. Acute HF
may be managed on the high dependency unit or
intensive care unit. This is a very heterogeneous
population including acute myocardial infarctions,
acute valvular issues, cardiogenic shock of isch-
aemic or non-­ischaemic aetiology, sepsis with multi-
organ failure, etc. The management of such patients
differs from general admission unit management,
with greater emphasis on oxygenation, inotropic
support and mechanical circulatory support when
indicated and is outwith the scope of this paper.
HF may also present in cardiac device clinics—
patients with known HF attending for implantable
cardioverter defibrillator (ICD) or cardiac resyn-
chronisation therapy (CRT) review (often with
suboptimal HFrEF therapies prescribed) or brady-­
pacemaker patients who may have developed HF
over time, possibly consequent to excessive right
ventricular pacing. Vigilance from the cardiac
physiologists and clear communication with the
secondary care HF team is invaluable in this setting.
Review of patient’s medications when attending
for routine ICD or CRT generator replacement
procedures, and assessment of patients with HF
for upgrade to CRT at such times, is also strongly
encouraged.
CONCLUSIONS
HF is a common primary reason for hospital
admission, and a common comorbidity in hospi-
talised patients on many units of varying disci-
plines. While prognosis-­modifying treatments exist,
morbidity and mortality remain high. Early cardi-
ology specialist involvement in patient care, both as
inpatient and early after discharge, is strongly and
consistently associated with improved outcomes.
Centralising all patients with HF in cardiology
wards is altruistic but not feasible; expansion of HF
specialist nurses, development of hospital HF teams
and increased capacity for cardiology follow-­ up
is necessary to improve symptoms and reduce
mortality in patients hospitalised with HF.
Contributors This manuscript is my original work as sole author.
Funding The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not applicable.
 Education in Heart
Ethics approval Not applicable. of the ESC Working group on acute cardiac care. Eur Heart J
2012;33:2001–6.
Provenance and peer review Commissioned; internally peer
12 National Institute for Cardiovascular Outcomes Research (NICOR)
reviewed.
National Heart Failure Audit (NHFA). 2020. Available: www.nicor.​
Author note References which include a * are considered to be org.uk/wpcontent/uploads/2020/12/National-Heart-Failure-Audit-​
key references. 2020-FINAL.pdf
13 Orso F, Pratesi A, Herbst A, et al. Acute heart failure in the elderly:
ORCID iD setting related differences in clinical features and management. J
Robin A P Weir http://orcid.org/0000-0001-9895-2795 Geriatr Cardiol 2021;18:407–15.
14 Parmar KR, Xiu PY, Chowdhury MR, et al. In-­Hospital treatment
and outcomes of heart failure in specialist and non-­specialist
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