Chronic heart failure in adults: diagnosis and management

  • NICE guideline
  • NG106
  • Published: 
  • Last updated: 
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Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people delivering care:

1.1 Team working in the management of heart failure

1.1.1

The specialist heart failure multidisciplinary team (MDT) should work in collaboration with the primary care team, and should include a:

  • lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis

  • specialist heart failure nurse

  • healthcare professional with expertise in specialist prescribing for heart failure, for example, a specialist heart failure pharmacist. [2018 amended 2025]

1.1.2

The specialist heart failure MDT should:

  • diagnose heart failure

  • give information to people with newly diagnosed heart failure (see the section on giving information to people with heart failure)

  • manage newly diagnosed, recently decompensated or advanced heart failure (New York Heart Association class III to IV)

  • optimise treatment

  • start new medicines that need specialist supervision

  • continue to manage heart failure after an interventional procedure such as implantation of a cardioverter defibrillator or cardiac resynchronisation device

  • manage heart failure that is not responding to treatment. [2018]

1.1.3

The specialist heart failure MDT should directly involve, or refer people to, other services, including rehabilitation, services for older people and palliative care services, as needed. [2018]

1.1.4

The primary care team should carry out the following, at all times, for people with heart failure, including during periods when the person is also receiving specialist heart failure care from the MDT:

  • ensure effective communication links between different care settings and clinical services involved in the person's care

  • lead a full review of the person's heart failure care, which may form part of a long-term conditions review

  • recall the person at least every 6 months and update the clinical record

  • ensure that changes to the clinical record are understood and agreed by the person with heart failure and shared with the specialist heart failure MDT

  • arrange access to specialist heart failure services if needed. [2018]

Care after an acute event

For recommendations on the diagnosis and management of acute heart failure, see NICE's guideline on acute heart failure.

1.1.5

Discharge people with heart failure from hospital when their clinical condition is stable, and a management plan is in place. Take into account the wishes of the person and their family or carers, and the level of care and support that can be provided in the community. [2003]

1.1.6

The primary care team should take over routine management of heart failure as soon as it has been stabilised and its management optimised. [2018]

Writing a care plan

1.1.7

The specialist heart failure MDT should write a summary for each person with heart failure that includes:

  • diagnosis and aetiology

  • medicines prescribed, monitoring of medicines, when medicines should be reviewed and any support the person needs to take the medicines

  • functional abilities and any social care needs

  • social circumstances, including carers' needs. [2018]

1.1.8

Use the summary as the basis of the person's care plan, which should include:

  • plans for managing the person's heart failure, including follow-up care, rehabilitation and access to social care

  • symptoms to look out for in case of deterioration

  • a process for any subsequent access to the specialist heart failure MDT if needed

  • contact details for

    • a named healthcare coordinator (usually a specialist heart failure nurse)

    • alternative local heart failure specialist care providers, for urgent care or review.

  • additional sources of information for people with heart failure. [2018]

1.1.9

Give a copy of the care plan to the person with heart failure, their family or carers if appropriate, and all health and social care professionals involved in their care. [2018]

1.2 Diagnosing heart failure

Symptoms, signs and investigations

1.2.1

Take a history and perform a clinical examination and tests to confirm the presence of heart failure. [2010]

1.2.2

Measure N-terminal pro-B-type natriuretic peptide (NT‑proBNP) in people with suspected heart failure. [2018]

1.2.3

Because very high levels of NT‑proBNP carry a poor prognosis, refer people with suspected heart failure and an NT‑proBNP level more than 2,000 nanogram per litre (236 picomole per litre) urgently, to have specialist assessment and transthoracic echocardiography within 2 weeks. [2018]

1.2.4

Refer people with suspected heart failure and an NT‑proBNP level between 400 and 2,000 nanogram per litre (47 to 236 pmol per litre) to have specialist assessment and transthoracic echocardiography within 6 weeks. [2018]

1.2.5

Be aware that:

  • an NT‑proBNP level of less than 400 nanogram per litre (47 pmol per litre) in an untreated person makes a diagnosis of heart failure less likely

  • the level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced and reduced ejection fraction. [2018, amended 2025]

1.2.6

Review alternative causes for symptoms of heart failure in people with NT-proBNP levels of less than 400 nanogram per litre. If there is still concern that the symptoms might be related to heart failure, discuss with a physician with subspeciality training in heart failure. [2018]

1.2.7

Be aware that:

  • obesity, African or African–Caribbean ethnic background, or treatment with the following can reduce levels of serum natriuretic peptides:

    • a diuretic

    • an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor-neprilysin inhibitor (ARNI) or angiotensin II receptor blocker (ARB)

    • a beta-blocker

    • a mineralocorticoid receptor antagonist (MRA)

  • high levels of serum natriuretic peptides can have causes other than heart failure (for example, pulmonary, renal, liver and systemic pathologies, sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver). [2010, amended 2025]

1.2.9

Use high‑resolution equipment operated by someone trained to the relevant professional standards to perform transthoracic echocardiography. Do not allow the need and demand for these investigations to compromise quality. [2003, amended 2018]

1.2.10

Ensure that those reporting echocardiography are experienced in doing so. [2003]

1.2.11

Think about alternative methods of imaging the heart (for example, radionuclide angiography [multigated acquisition scanning], cardiac MRI or transoesophageal echocardiography) if a poor image is produced by transthoracic echocardiography. [2003, amended 2018]

1.2.12

Perform an ECG and consider the following tests to evaluate possible aggravating factors or alternative diagnoses:

  • chest X-ray

  • blood tests:

    • renal function profile

    • thyroid function profile

    • liver function profile

    • lipid profile

    • glycosylated haemoglobin (HbA1c)

    • full blood count

  • urinalysis

  • peak flow or spirometry. [2010, amended 2018]

1.2.13

Try to exclude other disorders that may present in a similar manner. [2003]

1.2.14

When a diagnosis of heart failure has been made, assess severity, aetiology, precipitating factors, type of cardiac dysfunction and correctable causes. [2010]

Heart failure caused by valve disease

Reviewing existing diagnoses

1.2.16

Review the basis for a historical diagnosis of heart failure and manage care in accordance with this guideline only if the diagnosis is confirmed with cardiac imaging. [2003]

1.2.17

If heart failure is still suspected, but an underlying cardiac abnormality has not been identified, then refer to the specialist heart failure team. [2003]

1.3 Giving information to people with heart failure

1.3.1

Discuss the person's prognosis in a sensitive, open and honest manner. Be frank about the uncertainty in predicting the course of their heart failure. Revisit this discussion as the person's condition evolves. [2018]

First consultations for people with newly diagnosed heart failure

1.3.2

The specialist heart failure multidisciplinary team (MDT) should offer people with newly diagnosed heart failure an extended first consultation, followed by a second consultation to take place within 2 weeks if possible. At each consultation:

  • discuss the person's diagnosis and prognosis

  • explain heart failure terminology

  • discuss treatments

  • discuss the risk of sudden death, including any misconceptions about that risk

  • encourage the person and their family or carers to ask any questions they have. [2018]

1.4 Treating people with newly diagnosed and pre-existing heart failure with reduced ejection fraction

See recommendations 1.7.1 and 1.7.2 for guidance on how to introduce the medicines listed in recommendations 1.4.1, 1.4.3 and 1.4.4. See also the section on other treatments and advice for all types of heart failure.

Treatment combinations

1.4.1

Offer an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter-2 (SGLT2) inhibitor to people with heart failure with reduced ejection fraction. [2025]

1.4.2

For people on the maximum tolerated dose of each of the 4 medicines who continue to have symptoms of heart failure, consider switching the ACE inhibitor to an angiotensin receptor-neprilysin inhibitor (ARNI). [2025]

Alternative treatment combinations if certain medicines are not tolerated

1.4.3

For people with heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors (other than angioedema), offer an ARNI, beta-blocker, MRA and SGLT2 inhibitor. [2025]

1.4.4

For people with angioedema after taking an ACE inhibitor, or who have symptoms of intolerance to ARNIs:

  • offer a beta-blocker, MRA and SGLT2 inhibitor and

  • consider an ARB. [2025]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment combinations for heart failure with reduced ejection fraction.

Full details of the evidence and the committee's discussion are in evidence review A: medicines for heart failure with reduced ejection fraction.

Intravenous iron therapy

1.4.5

In people with heart failure with reduced ejection fraction, assess iron status and check for anaemia with all of the following blood tests:

  • transferrin saturation (TSAT)

  • serum ferritin

  • haemoglobin. [2025]

1.4.6

Consider iron sucrose, ferric carboxymaltose or ferric derisomaltose for people with heart failure with reduced ejection fraction and haemoglobin of less than 150 g per litre if they have iron deficiency defined as:

  • TSAT of less than 20% or

  • serum ferritin of less than 100 nanogram per ml. [2025]

1.4.7

If iron deficiency anaemia is identified, do not assume that it is related to the person's heart failure and think about investigating for alternative causes. [2025]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on IV iron therapy for heart failure with reduced ejection fraction.

Full details of the evidence and the committee's discussion are in evidence review C: IV iron therapy for heart failure.

Specialist treatment

Ivabradine
1.4.8

Ivabradine is recommended as an option in NICE technology appraisal guidance for treating heart failure with reduced ejection fraction. For full details, see the guidance on ivabradine (TA267, 2012).

Hydralazine in combination with nitrate
1.4.9

If ACE inhibitors, ARNIs and ARBs are not tolerated, seek specialist advice and consider hydralazine in combination with nitrate. [2010, amended 2025]

1.4.10

Seek specialist advice about whether to offer hydralazine in combination with nitrate (especially if the person is of African or Caribbean ethnicity and has moderate to severe heart failure [New York Heart Association class III/IV] with reduced ejection fraction). [2010]

Digoxin

For recommendations on digoxin for people with atrial fibrillation, see the section on rate and rhythm control in NICE's guideline on atrial fibrillation.

1.4.11

Offer digoxin to people with worsening or severe heart failure with reduced ejection fraction despite optimised treatment combinations as detailed in recommendations 1.4.1 to 1.4.4. Seek specialist advice before starting treatment. [2010, amended 2025]

Calcium-channel blockers
1.4.12

Avoid verapamil, diltiazem and short-acting dihydropyridine agents in people with heart failure with reduced ejection fraction. [2003, amended 2018]

1.5 Treating people with newly diagnosed and pre-existing heart failure with mildly reduced or preserved ejection fraction

Mildly reduced ejection fraction

See recommendations 1.7.1 and 1.7.2 for guidance on how to introduce the medicines listed in recommendations 1.5.1 to 1.5.3. See also the section on other treatments and advice for all types of heart failure.

1.5.1

Consider an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter-2 (SGLT2) inhibitor for treating heart failure with mildly reduced ejection fraction. See also recommendation 1.5.3. [2025]

1.5.2

For people who have symptoms of intolerance to ACE inhibitors, consider an angiotensin-receptor blocker (ARB), a beta-blocker, an MRA and an SGLT2 inhibitor. See also recommendation 1.5.3 [2025]

For a short explanation of why the committee made the 2025 recommendations and how they might affect practice, see the rationale and impact section on treatment combinations for heart failure with mildly reduced ejection fraction.

Full details of the evidence and the committee's discussion are in evidence review B: medicines for heart failure with mildly reduced ejection fraction.

Preserved ejection fraction

See recommendations 1.7.1 and 1.7.2 for guidance on how to introduce the medicines listed in recommendations 1.5.4 and 1.5.5. See also the section on other treatments and advice for all types of heart failure.

1.5.4

Consider an MRA and an sodium-glucose cotransporter-2 (SGLT2) inhibitor for treating heart failure with preserved ejection fraction. See also recommendation 1.5.5. [2025]

For a short explanation of why the committee made the 2025 recommendation and how it might affect practice, see the rationale and impact section on treatment combinations for heart failure with preserved ejection fraction.

Full details of the evidence and the committee's discussion are in evidence review D: MRA for heart failure with preserved ejection fraction.

1.6 Treating heart failure in people with chronic kidney disease

1.6.1

If the person's eGFR is 45 ml per minute per 1.73 m2 or less, consider lower starting doses and smaller dose increments for the medicine combinations covered by recommendations 1.4.1, 1.4.3, 1.4.4, and 1.5.1 to 1.5.5. [2018, amended 2025]

1.6.2

If the person's eGFR is less than 30 ml per minute per 1.73 m2, the specialist heart failure multidisciplinary team (MDT) should consider liaising with a renal physician. [2018, amended 2025]

1.7 Starting and monitoring medication use

Tailoring treatment

1.7.1

Use the person's medical history and findings from their clinical assessment, their frailty status, prognosis and preferences when deciding:

  • which specific medicines and medicine combinations to use (see recommendations 1.4.1, 1.4.3, 1.4.4 and 1.5.1 to 1.5.5)

  • the order and timing for introducing each medicine

  • the initial dose of each medicine and any subsequent dose increments

  • when and how to optimise the dose of each medicine.

    See also NICE's guideline on shared decision making. [2025]

1.7.2

Primary care prescribers should consider seeking advice from a heart failure specialist before starting someone on an angiotensin receptor-neprilysin inhibitor (ARNI). [2025]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on starting and monitoring medicine use.

Full details of the evidence and the committee's discussion are in evidence review A: medicines for heart failure with reduced ejection fraction.

ACE inhibitors, ARNIs, ARBs and MRAs

1.7.3

Before prescribing an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor-neprilysin inhibitor (ARNI), angiotensin II receptor blocker (ARB) or mineralocorticoid receptor antagonist (MRA), measure the person's renal function and electrolyte levels. [2025]

1.7.4

If the person is taking an ACE inhibitor, ARNI, ARB or MRA, measure their renal function and electrolyte levels:

  • 1 to 2 weeks after starting treatment

  • 1 to 2 weeks after each dose increment

  • every 3 to 6 months once the maximum tolerated dose has been established

  • any time renal function may be compromised. [2025]

1.7.5

If the person's serum creatinine level increases by more than 50% or their potassium concentration increases to more than 5.5 mmol per litre, follow local guidelines. [2025]

1.7.7

Measure the person's blood pressure, or ask the person to measure their own blood pressure, before and after each dose increment. [2025]

For a short explanation of why the committee made the 2025 recommendations and how they might affect practice, see the rationale and impact section on starting and monitoring medicine use.

Full details of the evidence and the committee's discussion are in the evidence reviews A: medicines for heart failure with reduced ejection fraction, B: medicines for heart failure with mildly reduced ejection fraction and D: MRA for heart failure with preserved ejection fraction.

Beta-blockers

1.7.9

Do not withhold treatment with a beta-blocker solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease. [2010]

1.7.10

Assess for heart rhythm, heart rate and conduction abnormalities using a 12-lead ECG before deciding whether to prescribe a beta-blocker. [2025]

1.7.11

Do not offer a beta-blocker to people with second-degree or third-degree heart block who do not have a pacemaker or to people with bradycardia (that is, a heart rate of less than 50 beats per minute). [2025]

1.7.12

Assess heart rate and clinical status after each dose increment. [2010]

1.7.13

For people with symptoms and bradycardia, consider repeating a 12-lead ECG after each dose increment. [2025]

For a short explanation of why the committee made the 2025 recommendations and how they might affect practice, see the rationale and impact section on starting and monitoring medicine use.

Full details of the evidence and the committee's discussion are in evidence review A: medicines for heart failure with reduced ejection fraction.

Digoxin

1.7.14

Do not routinely monitor serum digoxin concentrations. Be aware that 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. [2003]

1.7.15

Interpret the serum digoxin concentration in the clinical context as toxicity may occur even when the concentration is within the therapeutic range. [2003]

1.8 Clinical review

1.8.1

Monitor all people with heart failure. Provide:

  • 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 need for changes and possible side effects

  • an assessment of renal function

  • iron status and haemoglobin measurement.

    Note: This is a minimum. Provide further monitoring for people with comorbidities or co-prescribed medications. [2010, amended 2025]

1.8.2

Provide more detailed monitoring if the person has significant comorbidity or if their condition has deteriorated since the previous review. [2003]

1.8.3

Determine the frequency of monitoring based on the person's clinical status and the stability of their condition. If the person's clinical condition or medication has changed, use a short timeframe for monitoring (days to every 2 weeks). For stable people with proven heart failure, monitor at least every 6 months. [2003]

1.8.4

For people with heart failure who want to be involved in monitoring their condition, provide sufficient education and support from their healthcare professional to enable this to happen, with clear guidance on what to do in the event of deterioration. [2003]

People under 75 with normal renal function

1.8.5

For people aged under 75 in specialist care settings with heart failure with reduced ejection fraction and an estimated glomerular filtration rate (eGFR) more than 60 ml per minute per 1.73 m2, consider measuring N-terminal pro-B-type natriuretic peptide as part of optimising treatment. [2018]

1.9 Other treatments and advice for all types of heart failure

Diuretics

1.9.1

Use diuretics for the relief of congestive symptoms and fluid retention in people with heart failure and titrate (up and down) according to need using the lowest dose required. [2003]

Amiodarone

1.9.2

Make the decision to prescribe amiodarone in consultation with a specialist. [2003]

1.9.3

Review the need to continue the amiodarone prescription at the 6‑monthly clinical review. [2003, amended 2018]

1.9.4

Offer people taking amiodarone liver and thyroid function tests, and a review of side effects, as part of their routine 6‑monthly clinical review. [2003, amended 2018]

Anticoagulants

1.9.6

In people with heart failure in sinus rhythm, consider anticoagulation for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus. [2003]

Vaccinations

1.9.7

Offer people with heart failure an annual vaccination against influenza. [2003]

1.9.8

Offer people with heart failure vaccination against pneumococcal disease (only required once). [2003]

Contraception and pregnancy

1.9.9

For women, trans men and non-binary people of childbearing potential with heart failure, discuss contraception and pregnancy. If pregnancy is being contemplated or occurs, seek specialist advice. Subsequently, share specialist care between the cardiologist and obstetrician. [2003]

Salt and fluid restriction

1.9.10

Do not routinely advise people with heart failure to restrict their sodium or fluid consumption. Ask about salt and fluid consumption and, if needed, advise as follows:

  • restricting fluids for people with dilutional hyponatraemia

  • reducing intake for people with high levels of salt or fluid consumption.

    Continue to review the need to restrict salt or fluid. [2018]

1.9.11

Advise people with heart failure to avoid salt substitutes that contain potassium. [2018]

Smoking and alcohol

See NICE's guidance on smoking and tobacco and alcohol.

Air travel

1.9.12

Advise that air travel will be possible for most people with heart failure, depending on their clinical condition at the time of travel. [2003]

Driving

1.9.13

Ensure physicians are up to date with the latest Driver and Vehicle Licensing Agency (DVLA) guidelines. Check the DVLA website for regular updates. [2003]

1.10 Interventional procedures

Coronary revascularisation

Cardiac transplantation

1.10.2

Consider specialist referral for transplantation for people with severe refractory symptoms or refractory cardiogenic shock. [2003]

Implantable cardioverter defibrillators and cardiac resynchronisation therapy

1.10.4

When discussing implantation of a cardioverter defibrillator:

  • explain the risks, benefits and consequences of cardioverter defibrillator implantation, following the principles on shared decision making in NICE's guideline on shared decision making

  • ensure the person knows that the defibrillator function can be deactivated without affecting any cardiac resynchronisation or pacing, and reactivated later

  • explain the circumstances in which deactivation might be offered

  • discuss and dispel common misconceptions about the function of the device and the consequences of deactivation

  • provide the person and, if they wish, their family or carers, with written information covering the information discussed. [2018]

1.10.5

Review the benefits and potential harms of a cardioverter defibrillator remaining active in a person with heart failure:

  • at each 6‑monthly review of their heart failure care

  • whenever their care goals change

  • as part of advance care planning if it is thought they are nearing the end of life. [2018]

1.11 Cardiac rehabilitation

1.11.1

Offer people with heart failure a personalised, exercise-based cardiac rehabilitation programme. The programme:

  • should be preceded by an assessment to ensure that it is suitable for the person

  • should be provided in a format and setting (at home, in the community or in the hospital) that is easily accessible for the person

  • should include a psychological and educational component

  • may be incorporated within an existing cardiac rehabilitation programme

  • should be accompanied by information about support available from healthcare professionals when the person is doing the programme. [2018, amended 2025]

1.12 Palliative care

1.12.2

Do not use prognostic risk tools to determine whether to refer a person with heart failure to palliative care services. [2018]

1.12.3

If the symptoms of a person with heart failure are worsening despite optimal specialist treatment, discuss their palliative care needs with the specialist heart failure multidisciplinary team (MDT) and think about a needs assessment for palliative care. [2018]

1.12.4

Offer people with heart failure and their families or carers access to professionals with palliative care skills within the heart failure team. [2003]

Terms used in this guideline

Note: Heart failure is, by definition, symptomatic.

Heart failure with preserved ejection fraction

Heart failure with left ventricular ejection fraction of 50% or more, plus a structural issue in the heart including 2 or more of the following:

  • left atrial volume greater than 34 ml per m2 in sinus rhythm, or greater than 40 ml per m2 in atrial fibrillation

  • ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E:e' ratio) greater than 11

  • left ventricular hypertrophy, that is, wall thickness greater than 12 mm

  • pulmonary arterial pressure greater than 35 mmHg.

Heart failure with mildly reduced ejection fraction

Heart failure with left ventricular ejection fraction between 41% and 49%.

Heart failure with reduced ejection fraction

Heart failure with left ventricular ejection fraction of 40% or less.

Mineralocorticoid receptor antagonist

A medicine that antagonises the action of aldosterone at mineralocorticoid receptors.