Heart failure in 2026: diagnosis, NT-proBNP and foundational therapy (ESC 2026 vs NICE)
Diagnose heart failure with NT-proBNP to NICE thresholds, start the four pillars of HFrEF therapy, and understand what the 2026 ESC guideline changed — including the removal of HFmrEF — and what the AKT still expects.
Reviewed and kept current
Last editorial review: 28 September 2026 · Next scheduled refresh: March 2027.
Clinical vignette
Begin with the patient. Read the case, weigh the options, then work through the unit.
A 69-year-old woman was diagnosed with heart failure with reduced ejection fraction (LVEF 35%) eight months ago. A practice search of the heart-failure register finds that she takes ramipril 10 mg and bisoprolol 5 mg, but no MRA and no SGLT2 inhibitor. She lives alone in a rural village, two bus journeys from the hospital, and missed her last cardiology follow-up.
She remains in NYHA class II. Her blood pressure is 118/72 mmHg and heart rate 64 bpm. Her eGFR is 55 mL/min/1.73m² and potassium 4.4 mmol/L. She does not have diabetes.
Options to weigh
- Add an MRA (spironolactone or eplerenone), monitoring potassium and eGFR (NICE NG106).
- Add an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg); its benefit does not depend on diabetes (NICE NG106; NICE TA679).
- Up-titrate the beta-blocker towards the target dose: “start low, go slow” (NICE NG106).
- Consider seeking advice from a heart failure specialist before starting an ARNI (sacubitril–valsartan) (NICE NG106; NICE TA388).
England’s Cardiovascular Disease Modern Service Framework (July 2026) makes rapidly increasing the proportion of people with HFrEF on all four pillars a “treatment to target” priority; practices should expect searches for patients not on an SGLT2 inhibitor or MRA. NICE NG106 also notes that obesity and African or African–Caribbean family background lower NT-proBNP, so the same test can miss heart failure in some groups.
The Golden Triangle
Every condition has a Golden Triangle: what we know, what the evidence says, and what actually happens. Each apex is rated Red, Amber or Green. The Equinox, at the centre, is where all three meet in equal measure; the arrow shows the apex that must be drawn in to reach it.
Heart failure UK (NHS England)
| Apex | Rating | Why |
|---|---|---|
| Knowledge | Green | NT-proBNP, ECG and echocardiography diagnose it; NICE uses HFrEF ≤40%, HFmrEF 41–49% and HFpEF ≥50%. |
| Evidence | Green | NICE offers four pillars in HFrEF (NG106 rec 1.4.1); ESC 2026 gives SGLT2i and MRA in symptomatic HF at any LVEF (I, A). |
| Real-world | Red | 47% of heart failure is now diagnosed in hospital. Women and people in deprived areas wait up to five times longer for diagnosis (2000–21). |
Pull toward the Equinox — Real-world. Search registers for HFrEF patients not on all four pillars; read NT-proBNP below 400 ng/L with care in obesity, African–Caribbean background or on treatment.
Sources for this triangle
- NICE NG106. Chronic heart failure in adults: diagnosis and management. (Updated 3 September 2025)
- Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J 2026. (Published 28 August 2026)
- Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
- Lawson CA, et al. Health inequalities and trends in heart failure diagnosis in primary care in England, 2000–21: a national retrospective cohort data-linkage study. Lancet Prim Care 2025. (2025)
- CVDPREVENT data explorer and API (NHS Benchmarking Network / OHID). (Indicators to March 2026 (accessed 7 October 2026))
Reflect
Given the gap, what is your duty as the doctor — and how would you inform the patient of their access to care?
What this unit covers
Pocket-sized and self-contained: three AKT-style questions, the answers explained, an expanded discussion with hyperlinked guidance, a decision algorithm and a certificate.
By the end of this unit you will be able to
Five steps, in order
Answer first, then learn. Each section unlocks as you progress, and your progress is saved in this browser.
1Three single best answer questions
Commit to an answer for all three single best answer questions, then submit. Sections 2–4 open on submission; your certificate opens at 2/3 or better.
Question 1 of 3
A 74-year-old man presents with three months of exertional breathlessness and ankle swelling. He has hypertension and type 2 diabetes. His NT-proBNP is 2,600 ng/L. ECG shows sinus rhythm with left bundle branch block.
What is the most appropriate next step according to NICE?
Question 2 of 3
A 66-year-old woman has heart failure with reduced ejection fraction (LVEF 32%). She takes ramipril 10 mg daily, bisoprolol 10 mg daily and spironolactone 25 mg daily. She remains in NYHA class II. eGFR is 58 mL/min/1.73m² and potassium 4.6 mmol/L.
Which additional drug has the strongest evidence to reduce cardiovascular death and heart-failure hospitalisation?
Question 3 of 3
A 61-year-old man with exertional breathlessness has an echocardiogram showing LVEF 45%. His cardiologist’s letter quotes the 2026 European Society of Cardiology heart-failure guideline.
Under the 2026 ESC guideline, how is his heart failure classified?
2Answers explained
Question 1
Correct answer E. Refer for specialist assessment and transthoracic echocardiography within 2 weeks
NICE NG106: NT-proBNP above 2,000 ng/L → urgent referral for specialist assessment and transthoracic echocardiography within 2 weeks. Between 400 and 2,000 ng/L → within 6 weeks. Below 400 ng/L (untreated) makes heart failure less likely, but consider other causes.
A loop diuretic can be started for fluid overload while awaiting assessment, but it does not replace referral (option B). A normal chest X-ray does not exclude heart failure (option D).
Question 2
Correct answer E. Dapagliflozin
The four pillars (NICE NG106, updated 2025; ESC ‘foundational medical therapy’) are: ACE inhibitor/ARB or ARNI (sacubitril–valsartan), beta-blocker, MRA, and SGLT2 inhibitor (dapagliflozin or empagliflozin — NICE TA679 and TA773). She lacks only the SGLT2 inhibitor.
- Ivabradine needs sinus rhythm with heart rate ≥75 bpm and is a specialist add-on; digoxin improves symptoms but not mortality.
- Pioglitazone causes fluid retention and is contraindicated in heart failure; amlodipine is neutral (use only for other indications); verapamil and diltiazem should be avoided in HFrEF.
Question 3
Correct answer C. Heart failure with reduced ejection fraction (HFrEF)
The 2026 ESC guideline removed the HFmrEF category and now uses two phenotypes: HFrEF = LVEF <50% and HFpEF = LVEF ≥50%. The rationale is that patients with LVEF 41–49% share the pathophysiology of HFrEF and benefit from the same treatments.
3Expanded discussion, worked examples & guidance
1. Diagnosis in primary care (NICE NG106)
Suspected heart failure → take a history, examine, and measure NT-proBNP (plus ECG, bloods including renal function, FBC, TFTs, HbA1c, lipids and urine ACR, and consider a chest X-ray and spirometry).
| NT-proBNP | NICE action |
|---|---|
| >2,000 ng/L | Refer urgently: specialist assessment and echocardiography within 2 weeks |
| 400–2,000 ng/L | Refer: specialist assessment and echocardiography within 6 weeks |
| <400 ng/L (untreated patient) | Heart failure less likely; consider other diagnoses; re-test if concern persists |
NT-proBNP is raised by age over 70, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including PE), eGFR <60, sepsis, COPD, diabetes and cirrhosis. It is lowered by obesity, African or African–Caribbean family background, and treatment with diuretics, ACE inhibitors, ARBs, ARNIs, beta-blockers and MRAs. A “normal” result in an obese patient on treatment does not exclude heart failure.
The 2026 ESC guideline discusses age-adjusted rule-in thresholds (reported as ≥125 pg/mL under 50 years, ≥250 pg/mL at 50–74 and ≥500 pg/mL at 75 or over; pg/mL and ng/L are numerically equal). Use NICE thresholds in UK practice and in the AKT.
2. HFrEF: the four pillars
| Class | Examples | Key practical points |
|---|---|---|
| ACE inhibitor (or ARB if intolerant); ARNI on specialist advice | Ramipril; candesartan; sacubitril–valsartan (NICE TA388) | Check U&E at baseline, 1–2 weeks after each dose change; stop ACEi 36 hours before starting ARNI |
| Beta-blocker licensed for HF | Bisoprolol, carvedilol, nebivolol | “Start low, go slow”; offer even with COPD (not asthma); aim for target dose |
| MRA | Spironolactone, eplerenone | Monitor potassium and eGFR; gynaecomastia with spironolactone |
| SGLT2 inhibitor | Dapagliflozin 10 mg, empagliflozin 10 mg | Benefits irrespective of diabetes; sick-day rules; genital mycotic infection; rare euglycaemic DKA |
Both ESC (2023 focused update, reinforced in 2026) and NICE’s 2025 update of NG106 favour starting all four classes early and rapidly, rather than sequentially over months, with close monitoring. Local pathways define who initiates each drug.
Also: loop diuretics for congestion (symptom relief only); annual influenza, pneumococcal and COVID-19 vaccination; cardiac rehabilitation; review for IV iron if iron-deficient (specialist); ICD/CRT assessment; avoid NSAIDs, pioglitazone, non-dihydropyridine calcium-channel blockers (verapamil, diltiazem) and class I antiarrhythmics.
3. What changed in the 2026 ESC guideline
- Two phenotypes: HFrEF (LVEF <50%) and HFpEF (LVEF ≥50%); HFmrEF removed.
- Stages A–D: A = at risk (e.g. hypertension, diabetes, CKD, obesity) without structural heart disease; B = pre-heart failure (structural or functional abnormality, no symptoms); C = symptomatic HF; D = advanced HF. This moves the emphasis to prevention in primary care.
- “Decompensated” replaces “acute” heart failure.
- “Foundational medical therapy” = Class I therapies for the unselected population. HFrEF: beta-blocker + ACEi/ARNI/ARB + MRA + SGLT2i. HFpEF: MRA + SGLT2 inhibitor.
- GLP-1 receptor agonists (semaglutide or tirzepatide) Class IIa in symptomatic HF with LVEF ≥45% and BMI ≥30 kg/m², regardless of diabetes, to improve symptoms, exercise capacity and weight.
4. Links to the CVD Modern Service Framework (July 2026)
One of the framework’s “treatment to target” priorities is rapidly increasing the proportion of people with HFrEF on all four pillars. Practices and PCNs should expect searches for patients with HFrEF not on an SGLT2 inhibitor or MRA.
Worked example — searching the register
A PCN has 420 patients coded with HFrEF; 250 are on an SGLT2 inhibitor. After a pharmacist-led review, 340 are on one.
Answer. Uptake rises from 59.5% to 81.0% — an absolute increase of 21.5 percentage points. (Statistics links: Units 5 and 11.)
- NT-proBNP >2,000 → 2 weeks; 400–2,000 → 6 weeks.
- Pioglitazone, NSAIDs, verapamil and diltiazem are harmful in HFrEF.
- Digoxin is for symptom control or AF rate control, not mortality.
- After starting or increasing ACEi/ARB/MRA: check U&E in 1–2 weeks.
References and further reading
Guidance checked at the last editorial review (28 September 2026). Always use the current version.
- NICE NG106 — Chronic heart failure in adults: diagnosis and management
- 2026 ESC Guidelines for the management of heart failure (Eur Heart J, doi 10.1093/eurheartj/ehag100)
- ESC — Heart failure guidelines page
- NICE TA679 — Dapagliflozin for chronic heart failure with reduced ejection fraction
- NICE TA388 — Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
- NICE TA902 — Dapagliflozin for chronic heart failure with preserved or mildly reduced ejection fraction
- NICE TA929 — Empagliflozin for chronic heart failure with preserved or mildly reduced ejection fraction
- NICE CKS — Heart failure: chronic
- DHSC/NHS England — Cardiovascular disease modern service framework (July 2026)
4Decision algorithm
Suspected chronic heart failure in primary care
Start
Symptoms or signs of heart failure (breathlessness, orthopnoea, oedema, fatigue).
Action
History, examination, ECG, bloods and NT-proBNP.
Decision
Is NT-proBNP > 2,000 ng/L?
Decision
Is NT-proBNP 400–2,000 ng/L?
Decision
Echo shows LVEF ≤40% (NICE HFrEF; ESC 2026: LVEF < 50%)?
Outcome
For all: vaccinations, cardiac rehabilitation, avoid harmful drugs, and a care plan with sick-day and self-monitoring (weight) advice.
Revision summary; apply clinical judgement and local pathways.
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