Intended for healthcare professionals

Practice Rational Testing

Investigating suspected heart failure

BMJ 2013; 346 doi: (Published 24 April 2013) Cite this as: BMJ 2013;346:f2442
  1. Tushar Kotecha, cardiology specialist registrar,
  2. Kevin Fox, consultant cardiologist
  1. 1Charing Cross Hospital, Imperial Healthcare NHS Trust, London W6 8RF, UK
  1. Correspondence to: K Fox{at}

The authors explore the most appropriate initial investigations and referrals for use by doctors in primary care

Learning points

  • Patients with symptoms suggestive of heart failure who have had a myocardial infarction or have a raised B-type natriuretic peptide concentration should be referred to a cardiologist for further assessment

  • A normal 12 lead electrocardiogram and B-type natriuretic peptide <35 pg/mL (or N-terminal pro-B-type natriuretic peptide <125 pg/mL) have high negative predictive values for excluded heart failure in a non-acute setting

  • B-type natriuretic peptide >400 pg/mL or N-terminal pro-B-type natriuretic peptide >2000 pg/mL confers a poor prognosis, and such patients should be reviewed by a cardiologist within two weeks

  • Echocardiography remains the imaging modality of choice in confirming a diagnosis of heart failure

A 70 year old man presents to his general practitioner with a four week history of breathlessness on exertion. He currently takes bendroflumethiazide 2.5 mg daily for hypertension and uses inhalers for chronic obstructive pulmonary disease. He has no history of cardiac disease. His brother had a myocardial infarction in his 70s. The patient used to smoke 20 cigarettes a day but gave up smoking two years ago; he denied alcohol excess. On examination, his blood pressure was 150/95 mm Hg with a pulse of 90 beats/min. Heart sounds were normal and, on chest auscultation, he had bibasal inspiratory crepitations and scattered wheeze. His jugular venous pressure was not visible and he had mild bilateral ankle oedema.

What are the next investigations?

Breathlessness is a common presentation in general practice and emergency departments. The clinical diagnosis of heart failure can be challenging as signs and symptoms may be non-specific.1 In the United Kingdom the 2010 guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend that when heart failure is suspected, the initial investigations listed below are useful in primary care.2 …

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