Heart failure in primary care
The companion module to the Herts Heart Failure Masterclass: diagnosis and coding in 2026, the four pillars and structured up-titration, therapy across the ejection-fraction spectrum including finerenone (NICE TA1182), the morbidity around heart failure, the device exits, and how to run a CVRM-HF optimisation clinic that delivers HF009. About 60 minutes, for GPs, GP trainees, pharmacists, nurses, advanced clinical practitioners and physician associates. A 10-item knowledge check is marked on our learning platform; pass at 70% and a numbered, verifiable Certificate of CPD (1 hour) from New Vision University (UK) is issued to you.
Living Certificate · reviewed and kept current
Last editorial review: awaiting clinical sign-off · Next scheduled refresh: 12 months after sign-off.
The Golden Triangle for the topic taught here: fixed to the topic, and re-examined when its knowledge, evidence or real-world sources change.
Golden Triangle
Heart failure
Knowledge Green · Evidence Green · Real-world Red
Not yet at the Equinox · UK (NHS England) · as of 7 October 2026 · How the triangle works
A 68-year-old man with new breathlessness
Mr H, 68, a former smoker with hypertension and type 2 diabetes, books a routine appointment because he is breathless walking up the hill to the shops and has started sleeping on two pillows. His ankles are puffy by the evening. His GP finds a raised JVP, bibasal crackles and pitting oedema, and arranges an ECG (sinus rhythm, old anterior Q waves) and an NT-proBNP: 1,850 ng/L.
That value sits in the 400–2,000 ng/L band, so he is referred for specialist assessment and transthoracic echocardiography within 6 weeks (NICE NG106). Furosemide 40 mg relieves the congestion in the meantime. The echo reports LVEF 35% with an anterior wall-motion abnormality: heart failure with reduced ejection fraction, ischaemic in origin. The practice codes heart failure and left ventricular systolic dysfunction, so that HF009, which applies to patients with a current diagnosis of HFrEF, includes him.
At the first optimisation visit, once euvolaemic, he starts the four pillars in sequence over the first fortnight at low dose, in the order and at the pace that suit him: ramipril, bisoprolol, spironolactone and dapagliflozin. Sacubitril valsartan, after a 36-hour washout, is considered later only if he stays symptomatic on maximum tolerated doses. The PCN pharmacist titrates one agent at a time with U&E after each change, and in this illustrative case he is close to target doses by week six, less breathless, and counts towards HF009. The community heart-failure team meets him once, agrees the plan, and hands him back with a sick-day card and a weight chart. That journey, in six lessons, is this module.
By the end of this module you will be able to…
Diagnosis, classification and coding in 2026
The natriuretic-peptide pathway and its timeframes, the ejection-fraction classes, the NICE 2025 and ESC 2026 updates, and the codes that make a patient count.
The NT-proBNP pathway
Suspect heart failure from symptoms (breathlessness, orthopnoea, fatigue, ankle swelling) and signs (raised JVP, third heart sound, crackles, oedema), take a history that includes previous myocardial infarction, and measure NT-proBNP. NICE NG106 (updated September 2025) retains the diagnostic thresholds:
> 2,000 ng/L
Specialist assessment and transthoracic echocardiography within 2 weeks.
400–2,000 ng/L
Specialist assessment and echocardiography within 6 weeks.
< 400 ng/L
Heart failure is less likely in an untreated person; review alternative causes of the symptoms.
Confounders. NT-proBNP is lowered by obesity, African or African-Caribbean ethnic background, diuretics, ACE inhibitors, ARNIs, ARBs, beta-blockers and MRAs (NICE NG106 1.2.7), so a borderline value in a treated or obese patient does not exclude heart failure. NICE lists pulmonary, renal, liver and systemic pathologies, sepsis, COPD, diabetes and cirrhosis as causes of raised levels; age over 70 and atrial fibrillation also raise it (ESC guidance). Unlike BNP, NT-proBNP is not raised by sacubitril valsartan, so it remains interpretable on treatment.
Reading the ejection fraction
| Class | LVEF | What the report usually adds | What follows |
|---|---|---|---|
| HFrEF — reduced | ≤ 40% | Global or regional systolic impairment; often ischaemic | Four-pillar therapy; record the HFrEF category for HF009 |
| HFmrEF — mildly reduced | 41–49% | Mild systolic impairment | SGLT2 inhibitor (TA902, TA929); consider an ACE inhibitor, beta-blocker and MRA as well (NG106 1.5.1) |
| HFpEF — preserved | ≥ 50% | Symptoms plus at least two structural abnormalities on echo: left atrial volume above 34 mL/m² in sinus rhythm (above 40 in AF), E/e′ above 11, wall thickness above 12 mm, or pulmonary artery pressure above 35 mmHg (NICE NG106) | SGLT2 inhibitor; consider an MRA (NG106 1.5.5); finerenone is an option (TA1182); diuretic for congestion; treat the drivers and comorbidity |
NICE first recommended SGLT2 inhibitors for HFpEF and HFmrEF in TA902 and TA929 (2023); NG106 (September 2025) brought them into the guideline, added the option of an MRA and keeps these three bands, and TA1182 (August 2026) recommends finerenone. The 2026 ESC guideline removes HFmrEF (HFrEF is LVEF below 50%, HFpEF 50% or more) and adopts stages A–D; for UK coding, QOF and NICE pathways, follow NG106 and the echo report. The divergence is worked through at the masterclass.
Coding so that patients count
Two entries, not one. Code the heart-failure diagnosis and, where the ejection fraction is 40% or less, the reduced ejection fraction (HFrEF, left ventricular systolic dysfunction). In QOF 2026/27, HF008 (6 points) rewards confirming a new diagnosis by echocardiography or specialist assessment; HF009 (12 points, 20–50%) applies to patients with a current diagnosis of HFrEF, so record the ejection-fraction category as well as the heart-failure diagnosis. A patient whose HFrEF is uncoded is invisible to HF009 however well they are treated. Record a raised natriuretic peptide as a result, not a diagnosis. Heart failure is, by definition, symptomatic (NICE NG106), so do not code it in a patient without symptoms, even with a structural abnormality or a raised natriuretic peptide (see pre-heart failure in Lesson 4).
Checkpoint 1 · A 79-year-old woman on furosemide and ramipril, BMI 36, has an NT-proBNP of 380 ng/L. Is heart failure excluded?
No. Heart failure is less likely but not excluded: obesity, a loop diuretic and an ACE inhibitor all lower NT-proBNP. Review alternative causes and, if you are still concerned, discuss with a heart-failure specialist (NICE NG106 1.2.6) and arrange echocardiography by your local pathway. The 2-week and 6-week routes apply from 400 ng/L.
The four pillars and up-titration
The four classes NICE recommends, sacubitril valsartan done correctly, monitoring, sick-day rules, and what STRONG-HF taught us about speed.
HFrEF (LVEF ≤ 40%) management has consolidated into a four-pillar regimen. NICE NG106 (September 2025) recommends offering an ACE inhibitor, a beta-blocker, an MRA and an SGLT2 inhibitor to everyone with HFrEF (1.4.1). It sets no sequence: order, timing and dose steps are individualised, and one drug need not be optimised before the next is added (1.7.1). Starting all four early and up-titrating briskly is the ESC 2026 / STRONG-HF approach; ESC 2026 recommends up-titrating foundational therapy at least every 1–2 weeks (Class I C). NG106 1.7.2 says primary care prescribers should consider seeking advice from a heart failure specialist before starting an ARNI; TA388 says treatment should be started by a heart failure specialist, so follow your local pathway.
Pillar 1 · ACE inhibitor (ARNI where criteria are met)
An ACE inhibitor is first-line (NICE NG106 1.4.1; an ARB is considered only after ACE-inhibitor angioedema or ARNI intolerance, 1.4.4). Consider switching to sacubitril valsartan if the patient stays symptomatic on the maximum tolerated dose of all four medicines (1.4.2; TA388: NYHA II–IV, LVEF 35% or less, stable ACE inhibitor/ARB dose), or use it instead of an ACE inhibitor in ACE-inhibitor intolerance other than angioedema (1.4.3). Primary care prescribers should consider seeking specialist advice before starting (1.7.2); TA388 says specialist initiation, so follow your local pathway. The licensed start is 49/51 mg twice daily, doubled at 2–4 weeks towards 97/103 mg twice daily; start at 24/26 mg (doubling every 3–4 weeks) if not on an ACE inhibitor/ARB or on a low dose (below 10 mg enalapril equivalent), and consider it with systolic BP 100–110 mmHg, eGFR 30–60 or moderate hepatic impairment. Do not start if K⁺ is above 5.4 mmol/L or systolic BP is below 100 mmHg; it is contraindicated with a history of angioedema and with aliskiren in diabetes or eGFR below 60. Stop an ACE inhibitor at least 36 hours before the first dose (angioedema); no washout is needed from an ARB.
Pillar 2 · Beta-blocker licensed for heart failure
Bisoprolol or carvedilol; nebivolol is licensed only for stable mild-to-moderate heart failure in patients aged 70 or over. Check a 12-lead ECG first; do not start with second- or third-degree heart block (no pacemaker) or a heart rate below 50 bpm (NICE NG106 1.7.10–1.7.11). Start low once euvolaemic; double every 2–4 weeks as heart rate and blood pressure allow, reassessing heart rate and clinical status after each increment (1.7.12). Continue through decompensation unless there is cardiogenic shock. Mortality benefit in HFrEF.
Pillar 3 · Mineralocorticoid receptor antagonist
Spironolactone 25–50 mg or eplerenone 25–50 mg (RALES, EMPHASIS-HF). Start when K⁺ ≤ 5.0 mmol/L and eGFR ≥ 30 mL/min/1.73 m²; check U&E 1–2 weeks after starting and after each dose increase, then every 3–6 months once the maximum tolerated dose is established (NICE NG106 1.7.4).
Pillar 4 · SGLT2 inhibitor
Dapagliflozin 10 mg (NICE TA679) or empagliflozin 10 mg (TA773), no titration, diabetes status irrelevant. About a 26% relative reduction in cardiovascular death or heart-failure hospitalisation (DAPA-HF, EMPEROR-Reduced). Counsel on genital infection and ketoacidosis; pause during acute illness. NICE TA679 and TA773 (HFrEF) say to start on the advice of a heart failure specialist, and the TA929 rationale says the same for empagliflozin; TA902 and TA929 recommend them within their marketing authorisation, and where dapagliflozin and empagliflozin are both suitable for HFpEF or HFmrEF, use the least expensive (TA929 1.2).
Why speed matters: STRONG-HF
STRONG-HF (Mebazaa et al., Lancet 2022) randomised patients after a heart-failure admission to high-intensity care — rapid up-titration of guideline-directed therapy to full doses within two weeks, with four close safety visits — or usual care. It was stopped early for efficacy: fewer deaths or heart-failure readmissions at 180 days, with more hypotension and hyperkalaemia that were managed by the frequent checks. The lesson for primary care is that the follow-up schedule is the safety mechanism: titrate briskly, but see the patient.
Monitoring and the stop rules
| Finding | Action |
|---|---|
| Creatinine rise below 30% (eGFR fall below 25%) after starting or increasing an ACE inhibitor, ARB or ARNI | Do not change the dose; recheck in 1–2 weeks (NICE NG203 1.6.21–1.6.22). An early eGFR dip after an SGLT2 inhibitor is expected |
| Creatinine rise 30% or more (eGFR fall 25% or more) after starting or increasing a RAAS agent | Look for volume depletion, NSAIDs and renal artery disease; reduce or stop the RAAS agent if no other cause (NICE NG203 1.6.23). If creatinine rises by more than 50%, follow local guidelines (NG106 1.7.5) |
| eGFR 45 or below | Lower starting doses and smaller increments (NG106 1.6.1) |
| eGFR below 30 | The specialist heart-failure team should consider liaising with a renal physician (NG106 1.6.2) |
| K⁺ 5.0–5.5 mmol/L | Review potassium-raising drugs, potassium-containing salt substitutes (NG106 1.9.11) and diet; do not up-titrate and recheck within a week (ESC practical guidance or your local guideline; not an NG106 recommendation) |
| K⁺ > 5.5 mmol/L | Halve or hold the MRA (ESC practical guidance; NICE: follow local guidelines, NG106 1.7.5); recheck within 3 days if unexpected or unwell, within 14 days if expected and well; consider sodium zirconium cyclosilicate (TA1148, persistent K⁺ 5.5 or more) or patiromer (TA623, confirmed K⁺ 6.0 or more) to enable continued RAAS-inhibitor/MRA therapy (NG106 1.7.6) |
| K⁺ ≥ 6.0 mmol/L or ECG changes | Stop the MRA; same-day assessment |
| Symptomatic hypotension | Reduce the diuretic first if euvolaemic; then space the doses; reduce the ARNI/ACE inhibitor before the beta-blocker if the heart rate is controlled |
| Heart rate < 50 bpm or heart block | Halve the beta-blocker; ECG; review other rate-limiting drugs |
Sick-day rules. During vomiting, diarrhoea, fever with sweats or any illness with poor fluid intake, the patient pauses the diuretic, the ARNI/ACE inhibitor/ARB, the MRA and the SGLT2 inhibitor, and restarts within 24–48 hours of eating and drinking normally. The beta-blocker continues. Give it in writing. The SGLT2 inhibitor is omitted the day before and the day of elective surgery (UK perioperative consensus, Anaesthesia 2025) and withheld during acute illness, with blood ketones checked, because of the small risk of euglycaemic ketoacidosis.
Loop diuretics relieve congestion and keep the patient able to tolerate the pillars; they do not change prognosis. Use the lowest dose that keeps the patient at their dry weight, and teach daily weights with a 2 kg-in-3-days rule for calling the practice.
Checkpoint 2 · Two weeks after adding spironolactone 25 mg, K⁺ is 5.6 mmol/L and eGFR has fallen from 55 to 48. The patient is well. What do you do?
Reduce (halve) or temporarily hold the spironolactone per local guidance, review potassium-raising drugs, potassium-containing salt substitutes and dietary potassium, repeat U&E within 3 days, and plan a re-challenge at a lower dose once K⁺ is below 5.0 mmol/L — with sodium zirconium cyclosilicate (TA1148) if hyperkalaemia persists and limits RAAS therapy, so that the prognostic therapy is retained. The eGFR fall is within the expected range. Keep the other three pillars.
Across the ejection-fraction spectrum
HFmrEF and HFpEF after DELIVER, EMPEROR-Preserved and FINEARTS-HF; congestion, comorbidity, and obesity-related HFpEF.
For LVEF above 40% the regimen is anchored on an SGLT2 inhibitor: DELIVER (dapagliflozin) and EMPEROR-Preserved (empagliflozin) showed a reduction in cardiovascular death or heart-failure hospitalisation in HFmrEF and HFpEF, and NICE recommends both (dapagliflozin TA902; empagliflozin TA929). NICE therefore now offers disease-modifying therapy across the ejection-fraction spectrum, not diuretic symptom control alone.
What has evidence above 40%
An SGLT2 inhibitor (DELIVER, EMPEROR-Preserved; TA902, TA929) and an MRA (NG106 1.5.5: consider spironolactone or eplerenone; finerenone, TA1182). In HFmrEF, NG106 1.5.1 says to consider an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor. Spironolactone reduced heart-failure hospitalisation in TOPCAT without a significant primary effect. A loop diuretic for congestion. Blood-pressure control to target. Treatment of atrial fibrillation, ischaemia, obesity, MASLD, sleep apnoea and kidney disease.
What does not
Sacubitril valsartan (PARAGON-HF) and beta-blockers lack outcome benefit in HFpEF. Beta-blockers remain appropriate for rate control in atrial fibrillation or for angina.
Finerenone — FINEARTS-HF. NICE recommends finerenone as an option for symptomatic chronic HFmrEF and HFpEF (TA1182, August 2026; NG106 1.5.3, 1.5.6). It was the first MRA with a significant primary-outcome benefit in a dedicated trial in this population (Solomon et al., N Engl J Med 2024;391:1475–85; n = 6,001, LVEF 40% or more; rate ratio 0.84, 95% CI 0.74–0.95, for total worsening heart-failure events plus cardiovascular death; cardiovascular death alone was not significantly reduced, HR 0.93, 0.78–1.11). It has not been compared directly with spironolactone in this population. Use it instead of, not as well as, another MRA, and check K⁺ and eGFR before and after starting. Its separate indication in type 2 diabetes with chronic kidney disease is NICE TA877 (stage 3–4 CKD with ACR 3 mg/mmol or more and eGFR 25 or more, as an add-on to the highest tolerated ACE inhibitor/ARB and an SGLT2 inhibitor unless unsuitable).
Obesity-related HFpEF and the incretin therapies
In HFpEF with obesity, semaglutide 2.4 mg weekly (STEP-HFpEF, STEP-HFpEF DM) improved symptoms, physical limitation and exercise capacity, and tirzepatide (SUMMIT; Packer et al., N Engl J Med 2025;392:427–37) reduced the composite of cardiovascular death or worsening heart-failure events (HR 0.62, 95% CI 0.41–0.95) and improved health status. ESC 2026 gives semaglutide or tirzepatide a Class IIa recommendation for symptomatic heart failure with LVEF 45% or more and BMI 30 or more. Prescribe within the NICE obesity and diabetes technology appraisals (semaglutide TA875; tirzepatide TA1026, TA924), through the local weight-management pathway.
Checkpoint 3 · A 76-year-old woman with HFpEF (LVEF 58%), hypertension and a BMI of 34 is on ramipril and furosemide. What has disease-modifying evidence?
Add an SGLT2 inhibitor (dapagliflozin TA902 or empagliflozin TA929) and consider an MRA (NG106 1.5.5). Beta-blockers, sacubitril valsartan and digoxin do not have HFpEF outcome evidence. Optimise blood pressure, consider the weight-management pathway, and look for atrial fibrillation and sleep apnoea.
The morbidity around heart failure, and pre-heart failure
Atrial fibrillation, kidney disease, diabetes, frailty, iron deficiency, and the stage A–D framework that lets you act before the diagnosis.
Atrial fibrillation
Present in a third of patients and a common precipitant of decompensation. Anticoagulate on CHA₂DS₂-VASc (heart failure itself scores a point; NICE NG196), control rate with the beta-blocker (add digoxin if needed), and avoid diltiazem and verapamil in HFrEF. Refer for a rhythm strategy where AF and HFrEF coexist and the patient remains symptomatic.
Chronic kidney disease
One pathophysiology, two organs. The SGLT2 inhibitor treats both (KDIGO 2024: eGFR 20 or more with type 2 diabetes, or with ACR 20 mg/mmol or more, or with heart failure irrespective of albuminuria; suggested at eGFR 20–45 with lower albuminuria); accept the early eGFR dip; dose the MRA to potassium; below eGFR 45 start lower and increase in smaller steps (NG106 1.6.1); do not stop prognostic therapy for a stable eGFR of 30–45. Albuminuria is measured annually.
Type 2 diabetes
NICE NG28 (February 2026, 1.14.1) offers modified-release metformin plus an SGLT2 inhibitor in type 2 diabetes with heart failure; metformin continues while eGFR allows. Avoid pioglitazone (NG28: should be avoided in heart failure); saxagliptin carries a heart-failure warning in its SmPC and BNF. GLP-1 receptor agonists have not shown a heart-failure harm signal in cardiovascular outcome trials, but evidence in HFrEF is limited, so use caution; NG28 offers a DPP-4 inhibitor (not saxagliptin) as the next step.
Frailty and polypharmacy
Prognostic therapy still helps in older patients, but in frailty titrate more slowly, watch for postural hypotension and falls, review NSAIDs and anticholinergics, and ask what matters to the patient. Deprescribe the drugs that are not helping before adding the ones that are.
Iron deficiency
In heart failure, the ESC definition of iron deficiency is ferritin below 100 µg/L, or ferritin 100–299 µg/L with transferrin saturation below 20%. NICE NG106 (1.4.5–1.4.6) says to check TSAT, ferritin and haemoglobin in HFrEF and to consider intravenous iron if haemoglobin is below 150 g/L with TSAT below 20% or ferritin below 100 ng/mL; NICE does not cover HFmrEF or HFpEF. Check iron status in every new diagnosis and every patient who stays symptomatic. Intravenous iron (ferric carboxymaltose or ferric derisomaltose) improves symptoms, exercise capacity and quality of life (ESC Class I) and probably reduces heart-failure hospitalisation (ESC Class IIa; AFFIRM-AHF reduced total heart-failure hospitalisations, IRONMAN narrowly missed its primary endpoint; ESC 2023 focused update); neither reduced cardiovascular death. Oral iron is poorly absorbed and ineffective in this setting (IRONOUT-HF). Know your local community or day-case infusion route.
Pre-heart failure: the ACC/AHA stages
| Stage | Definition | What you do in primary care |
|---|---|---|
| A — at risk | Hypertension, diabetes, obesity, cardiotoxic exposure, family history; no structural disease, no symptoms | Treat the drivers; the CVRM clinic population |
| B — pre-heart failure | Structural disease, raised filling pressures or a raised natriuretic peptide without symptoms | Blood pressure to target, glycaemia and weight, an SGLT2 inhibitor where the diabetes or kidney indication applies, statin where indicated; do not code heart failure |
| C — symptomatic | Structural disease with current or previous symptoms | The pathway in Lessons 1–3; code and register |
| D — advanced | Marked symptoms despite optimal therapy; recurrent admissions | Advanced-heart-failure referral and palliative planning (Lesson 5) |
Checkpoint 4 · A 69-year-old man with HFrEF, NYHA III despite optimised pillars: haemoglobin 128 g/L, ferritin 180 µg/L, transferrin saturation 16%. Iron deficient?
Yes — ferritin 100–299 µg/L with transferrin saturation below 20% meets the ESC definition, and with haemoglobin below 150 g/L and TSAT below 20% he also meets NICE NG106 1.4.6. Arrange intravenous iron through the local pathway; oral iron will not work.
Device exits and specialist referral
Who needs cardiac resynchronisation or a defibrillator, the triggers for advanced heart failure, the community heart-failure team, and palliative needs.
Cardiac resynchronisation therapy (CRT)
NICE TA314 (LVEF 35% or less) sets ICD or CRT by QRS band (below 120, 120–149 and 150 ms or more), left bundle branch block and NYHA class; at 120–149 ms without LBBB the option is an ICD in NYHA class I–III (CRT-P in class IV). ESC guidance separately uses 130 and 150 ms thresholds and sinus rhythm, with the strongest evidence for LBBB with QRS ≥ 150 ms in sinus rhythm despite ≥ 3 months of optimal therapy.
Implantable cardioverter defibrillator (ICD)
Primary prevention: LVEF ≤ 35% on optimal therapy (NICE TA314 offers an ICD across NYHA I–III, by QRS band); the evidence is strongest in ischaemic cardiomyopathy (ESC). Secondary prevention after ventricular arrhythmia or resuscitated arrest. Combined CRT-D where both apply.
The practical message: once the pillars are optimised, repeat the echocardiogram at about three months, look at the ECG, and refer the device candidates. Many are missed because nobody re-measures the ejection fraction after treatment.
When to refer for advanced heart failure — I NEED HELP
Inotropes previously needed · NYHA III–IV or persistently raised natriuretic peptides · End-organ dysfunction (kidney, liver) · Ejection fraction below 20% or poor right-ventricular function · Defibrillator shocks · Hospitalisations more than once in a year · Excess fluid (oedema) despite escalating diuretics · Low blood pressure, high heart rate · Prognostic medication intolerance (progressive down-titration). Any one of these should prompt discussion with the heart-failure team or an advanced heart failure centre (ESC 2026 Table 15); the more present, the more urgent.
The community heart-failure team, escalation and palliative needs
The community heart-failure service takes new HFrEF diagnoses for titration where practices do not run their own clinic, manages decompensation at home or through the virtual ward, and recognises advancing disease. Refer early for worsening symptoms despite optimisation, recurrent admissions, or diuretic resistance. After a first admission, heart failure has a five-year survival comparable to many common cancers (Stewart et al., Eur J Heart Fail 2001;3:315–22). Open the conversation about what matters, record an advance care plan and a treatment escalation plan, consider ICD deactivation discussions, and involve palliative care alongside, not instead of, heart-failure care. Do not use prognostic scores to decide on palliative-care referral (NICE NG106 1.12.2); discuss palliative needs with the specialist team when symptoms worsen despite optimal treatment (1.12.3).
Cardiomyopathies not to miss. Cardiac amyloidosis: an older patient with LVH on echo but low QRS voltages, bilateral carpal tunnel syndrome, lumbar spinal stenosis, and intolerance of the pillars (hypotension on ACE inhibitors or beta-blockers) — request serum free light chains with serum and urine immunofixation (to exclude AL amyloid) and refer for bone scintigraphy. Hypertrophic and inherited cardiomyopathies: a family history of sudden death under 50, exertional syncope, or marked LVH without hypertension — refer to the inherited cardiac conditions service.
Checkpoint 5 · LVEF 30%, NYHA III, sinus rhythm, LBBB with QRS 160 ms after three months of optimised four-pillar therapy. Next step?
Refer for cardiac resynchronisation therapy (with a defibrillator if the ischaemic substrate and symptom class support it). This patient meets every criterion with the strongest evidence.
Running it: HF009 and the CVRM-HF optimisation clinic
The indicator, the searches that find the missing patients, a safe-titration protocol, and the national four-pillar ambition.
Three searches
A safe-titration protocol for the clinic
| Step | What happens |
|---|---|
| Before the first visit | Searches run; U&E, ferritin/TSAT, HbA1c, lipids, ECG within 3 months; home blood pressure and weight diary started |
| Visit 1 (GP or prescribing pharmacist, 20 minutes) | Confirm euvolaemia; check a 12-lead ECG, heart rate and rhythm before a beta-blocker; start any missing pillar at the lowest dose, in the order and at the pace that suit the patient (two at once if blood pressure, potassium, frailty and renal function allow; NICE NG106 1.7.1); if eGFR is 45 or below use lower starting doses and smaller increments, and if below 30 involve the specialist heart-failure team (1.6.1, 1.6.2); sick-day card; written plan |
| Every 1–2 weeks | U&E; blood pressure, heart rate, weight; one dose change per contact, telephone where safe; stop rules from Lesson 2 |
| By week 6–8 | Target or maximum tolerated doses; consider a switch to sacubitril valsartan if symptomatic on maximum tolerated therapy, with specialist advice and only if K⁺ is 5.4 mmol/L or below and systolic BP 100 mmHg or above; refer device candidates after the 3-month echocardiogram |
| Review at least every 6 months | NICE NG106 1.1.4, 1.8.3 (QOF HF007 needs one in 12 months): four pillars confirmed and coded; U&E; iron status; vaccinations; weight; functional class; advance care planning where appropriate |
The clinic is also where the wider cardiovascular-kidney-metabolic picture is handled — lipids, blood pressure, albuminuria, glycaemia, weight — and where lifestyle medicine, adherence and the community heart-failure routes keep people well between reviews. HF009 is the floor, not the target.
Practice task
Run searches 1 and 2 on your own system this week. Count the patients on the optimisation list by missing pillar, and the number of echo reports with LVSD and no code. Bring the two numbers to the masterclass workshop, or use them to open the clinic conversation with your clinical director. Record aggregate counts only in the reflection box below; it prints on your certificate. Do not include patient-identifiable information (names, NHS numbers, dates of birth or free-text clinical detail).
Checkpoint 6 · The clinical director asks for one search to report HF009 progress. Which?
Patients with a current diagnosis of HFrEF × each missing pillar, excluding those with a personalised care adjustment, contraindication or intolerance recorded, with the safety columns. Everything else follows from that list.
Ten items, marked on our learning platform
Answer all ten, add your details and reflection, and claim your certificate. Pass mark 70% (7 of 10). If you fall short you can read back and try again; your answers are kept.
How it works
Single-best-answer items in clinical-vignette format with five options. Your selections are saved in this browser until you mark them. Marking happens on learn.mdacumen.com, which records your answers and score against your learner record, issues the certificate and makes it verifiable; nothing in this page contains the answers.
Loading the knowledge check from learn.mdacumen.com…
Your certificate details
The name and e-mail address you enter here create your learner record on learn.mdacumen.com and appear on the certificate and its verify page.
Reflection — for your CPD portfolio
Two short entries of at least 20 characters each. They are stored with your certificate record and printed on the certificate. Do not include patient-identifiable information (names, NHS numbers, dates of birth or free-text clinical detail); record aggregate counts only.
New Vision University (UK)
Acumen Focus · CVRM-HF Foundation series · delivered by MD Acumen Ltd
This certifies that
Your name will appear here
has completed
Acumen Focus F4 · Heart failure in primary care
the masterclass companion module, including its 10-item knowledge check
Authored by Prof Rajesh Varma · MD Acumen Ltd · mdacumen.com
CPD authorised by Prof Rajesh Varma, Convenor for CPD, New Vision University (UK)
Signed against: NICE NG106 (updated September 2025; minor changes October 2025, December 2025 and September 2026) · NICE TA388, TA679/TA773, TA902/TA929, TA1182, TA1148, TA623, TA877, TA314, TA875/TA924/TA1026 · NICE NG28, NG196, NG203 · ESC heart failure guideline 2021, 2023 focused update, 2026 · KDIGO 2024 · QOF 2026/27 (HF007, HF008, HF009) · DHSC/NHS England cardiovascular disease modern service framework (July 2026)
The certificate fills in once you pass the knowledge check. It is numbered and recorded on learn.mdacumen.com, so anyone can verify it.
What a Living Certificate is
A conventional certificate records that on a given date you passed a course that was correct on that date, and then it quietly ages. A Living Certificate ties the certificate to the currency of the content it certifies: it carries a certificate number, the module version, the guideline set the module was signed against, the signer and the date. When a cornerstone guideline changes, the module is updated and re-signed, and learners who opted in receive a short update assessment; passing it re-dates the certificate in their record, while a certificate that is not refreshed still stands as a dated record whose verify page shows when the content was superseded.
Keep learning
F4 is the fourth module of the CVRM-HF Foundation series (F1 cardiometabolic risk · F2 lipids · F3 type 2 diabetes · F4 heart failure · F5 kidney disease · F6 obesity and MASLD) and the first to be published. Complete all six for the series certificate (6 CPD); the series counts as recognised prior learning for the Certificate of Advanced Studies in CVRM-HF.
Key sources
The principal sources are listed below; the trials cited are named in the text. Where several licensed agents in a class exist they are presented even-handedly per their NICE technology appraisals.
CAS Programmes · Legal & Regulatory · enquiry@mdacumen.com
© 2026 MD Acumen Ltd · Registered in England and Wales · Company no. 16538952 · ICO registration ZC105897