When should I consider referring a patient with heart failure to a specialist for further evaluation or management?

You should consider referring a patient with heart failure to a specialist multidisciplinary heart failure team or cardiology service for further evaluation or management in several key situations ¹.

• Refer if the patient has severe heart failure (New York Heart Association [NYHA] class IV) ¹.
• Refer if heart failure does not respond to treatment in primary care or can no longer be managed in the home setting ¹.
• If there is no response to diuretic therapy for fluid overload, refer the person to a specialist for further advice on management ¹.

• Refer if the patient has a left ventricular ejection fraction of 35% or less ¹.
• For suspected heart failure, refer urgently within 2 weeks if the N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is above 2,000 ng/L (236 pmol/L) for specialist assessment and transthoracic echocardiography ¹,².
• Refer within 6 weeks if the NT-proBNP level is between 400 and 2,000 ng/L (47–236 pmol/L) for specialist assessment and transthoracic echocardiography ¹,².
• If NT-proBNP levels are below 400 ng/L but symptoms of heart failure persist, discuss with a physician with subspecialty training in heart failure ².

• Refer people with heart failure resulting from valvular heart disease for specialist assessment and advice ¹,².
• If the patient experiences syncope or presyncope (unless clearly due to postural hypotension), refer to a cardiologist, especially if they have a reduced ejection fraction, as this may indicate ventricular tachycardia ¹.

• Refer women with heart failure and reduced ejection fraction (HF-REF) who are planning a pregnancy for specialist pre-conceptual advice ¹.
• Refer women who are pregnant for specialist management ¹.
• Consider referral for a person with heart failure and a comorbidity such as chronic kidney disease or chronic obstructive pulmonary disease ¹.