Intended for healthcare professionals

Practice Clinical updates

Non-acute heart failure management in primary care

BMJ 2024; 385 doi: (Published 05 April 2024) Cite this as: BMJ 2024;385:e077057
  1. Rachel Roskvist, senior lecturer1,
  2. Kyle Eggleton, senior lecturer1,
  3. Bruce Arroll, professor1,
  4. Ralph Stewart, adjunct clinical professor2
  1. 1Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
  2. 2Department of Medicine, School of Medicine, University of Auckland, New Zealand
  1. Correspondence to: B Arroll bruce.arroll{at}

What you need to know

  • Heart failure should be considered in any patient presenting with breathlessness in primary care

  • B-type natriuretic peptide (BNP) is an important initial test for heart failure, with a negative result usefully ruling out the condition

  • Heart failure encompasses various causes, many of which have specific treatment options

Heart failure is prevalent worldwide, impacts quality of life, and is associated with high morbidity and mortality. Global prevalence estimates indicate that 1-2% of adults in the developed world have known heart failure.12 In the UK alone, almost one million people have diagnosed heart failure, placing a substantial demand on specialist cardiology services.3 Heart failure often presents in primary care, where many patients have risk factors and long term treatments are usually indicated even after symptoms have improved. This update focuses on recent evidence and changes to heart failure clinical practice guidelines, emphasising aspects most relevant to primary care.

Stages and classes of heart failure

A universal definition and novel classification system for heart failure was proposed in 2021 by the Heart Failure Society of America (HFSA), Heart Failure Association of the European Society of Cardiology (HFA-ESC), and Japanese Heart Failure Society (JHFS), and the system has been included in the recent American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) guidelines.45 This four-stage classification system recognises two pre-heart failure stages without symptoms (stages A “at risk” and B “pre-heart failure”) and two symptomatic stages encompassing the clinical syndrome of heart failure (stages C “symptomatic” and D “advanced”) (box 1).45 Most guideline-directed pharmacological treatments target stages C and D, but they may also be indicated in asymptomatic patients to reduce the risk of progression to symptomatic heart failure. The New York Heart Association (NYHA) functional classification system complements this staging system and is applied to stages C …

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