What are the recommended monitoring parameters for patients on heart failure medications in primary care?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

For patients on heart failure medications in primary care, recommended monitoring parameters include both general clinical assessments and specific monitoring for individual drug classes .

  • General Monitoring for all Heart Failure Patients:
    • A clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status, and nutritional status .
    • A review of medication, including the need for changes and possible side effects .
    • An assessment of renal function .
    • Monitoring of symptoms and signs of heart failure, such as palpitations, shortness of breath, presence of oedema, and syncopal or presyncopal symptoms .
    • Checking the person's pulse rate and rhythm and examining the heart .
    • Consider monitoring N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels in people less than 75 years of age to guide optimum drug treatment, especially for those with a higher baseline NT-pro-BNP level (greater than 2114 pg/mL) .
    • The frequency of follow-up should be short (days to 2 weeks) if the person's clinical condition or drugs have changed, and at least every 6 months if the person's condition is stable .
  • Specific Medication Monitoring:
    • Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin-II Receptor Antagonists (AIIRAs/ARBs):
      • Measure serum sodium and potassium, and assess renal function, before and after starting the medication and after each dose increment .
      • Measure blood pressure after each dose increment .
      • Once the target or maximum tolerated dose is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell .
    • Beta-blockers:
      • Assess heart rate and clinical status after each titration .
      • Measure blood pressure before and after each dose increment .
    • Mineralocorticoid Receptor Antagonists (MRAs):
      • Measure serum sodium and potassium, and assess renal function, before and after starting the MRA and after each dose increment .
      • Measure blood pressure before and after each dose increment .
      • Once the target or maximum tolerated dose is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell .
      • Monitor closely for hyperkalaemia, especially in people with chronic kidney disease .
    • Digoxin:
      • Routine monitoring of serum digoxin concentrations is not recommended .
      • A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence .
      • The serum digoxin concentration should be interpreted in the clinical context, as toxicity may occur even within the 'therapeutic range' .
    • Amiodarone:
      • Offer liver and thyroid function tests, and a review of side effects, as part of their routine 6-monthly clinical review .
      • Review the need to continue the amiodarone prescription at the 6-monthly clinical review .

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