Forewords
Professor Martin Cowie
Professor of Cardiology, Imperial College London, and Consultant Cardiologist, Royal Brompton and Harefield NHS Foundation Trust
Despite a wealth of published evidence and clear guidance to the NHS, the speed of diagnosis of heart failure in the UK leaves a lot to be desired. Too often symptoms are misdiagnosed or are left to deteriorate to the extent that emergency hospital admission is required.1 This is unacceptable for patients and their families, and also for healthcare professionals. 
This new report highlights some major issues surrounding the contemporary diagnosis of heart failure. What struck me most were the patient stories: the chilling narratives around the fight to be correctly diagnosed and to start therapy, with all the anxiety that this provoked. We need to ask why these problems exist, and why there is so much variation across a so called “national” health service. Why is the implementation of simple guidelines taking so long? Why do women seem to get a particularly poor deal?2 What are the barriers that we need to pull down?
For many people with heart failure, we have effective therapies that not only improve symptoms and quality of life, but prolong life and reduce the need for emergency hospital admission. A rapid and accurate diagnosis is key to accessing such therapy and support. Recognising symptoms, taking a patient history and using natriuretic peptide testing (NT-proBNP) are all tools that can be used in primary and secondary care to identify heart failure.3 But although NT-proBNP is recommended by NICE guidelines for both acute and
chronic heart failure,4 in addition to European Society for Cardiology guidelines,3 use across the country remains patchy. This research found nearly one in five patients (18.9%) surveyed were not offered a blood test for heart failure at
any
point during their journey to a diagnosis.5

It has been estimated that access to simple blood tests in primary care could help deliver a 50% reduction in likely unnecessary echocardiograms and referrals, amounting to about £15,000 per month in just one population around an acute hospital.6 Earlier testing holds the potential to spare patients and families the trauma of a hospital admission, and reduce costs to the NHS.4 I remember publishing one of the first scientific papers on the value of using natriuretic peptide testing in primary care – more than 20 years ago.7 Let’s hope that at last we can bring such benefits to everyone who uses the NHS. We have the tools – let’s use them!
This new report highlights some major issues surrounding the contemporary diagnosis of heart failure. What struck me most were the patient stories: the chilling narratives around the fight to be correctly diagnosed and to start therapy, with all the anxiety that this provoked. We need to ask why these problems exist, and why there is so much variation across a so called “national” health service. Why is the implementation of simple guidelines taking so long? Why do women seem to get a particularly poor deal?2 What are the barriers that we need to pull down? For many people with heart failure, we have effective therapies that not only improve symptoms and quality of life, but prolong life and reduce the need for emergency hospital admission. A rapid and accurate diagnosis is key to accessing such therapy and support. Recognising symptoms, taking a patient history and using natriuretic peptide testing (NT-proBNP) are all tools that can be used in primary and secondary care to identify heart failure.3 But although NT-proBNP is recommended by NICE guidelines for both acute and chronic heart failure,4 in addition to European Society for Cardiology guidelines,5 use across the country remains patchy. This research found nearly one in five patients (18.9%) surveyed were not offered a blood test for heart failure at
any
point during their journey to a diagnosis.2 It has been estimated that access to simple blood tests in primary care could help deliver a 50% reduction in likely unnecessary echocardiograms and referrals, amounting to about £15,000 per month in just one population around an acute hospital.6 Earlier testing holds the potential to spare patients and families the trauma of a hospital admission, and reduce costs to the NHS.4 I remember publishing one of the first scientific papers on the value of using natriuretic peptide testing in primary care – more than 20 years ago.7 Let’s hope that at last we can bring such benefits to everyone who uses the NHS. We have the tools – let’s use them!
Nick Hartshorne-Evans
Chief Executive of
the Pumping Marvellous Foundation
A heart failure diagnosis changes your life forever. The difference between hearing those words from your GP or being rushed – petrified – into A&E after potentially years battling for the answer to your unresolved symptoms leaves an indelible mark – on your mental health, your finances and your ability to cope. We know this is not easy to hear either way, but receiving a diagnosis in a controlled manner can help people deal with the potential challenges they now face.
With reliable and cost-effective diagnostic innovations at our disposal, including a widely available, simple blood test, NT-proBNP, which can help to rule out heart failure,8 it is not good enough that three quarters (74.8%) of heart failure patients admitted in 2018/19 received their initial diagnosis in a hospital setting,2 and almost 50% of these are told they have heart failure in A&E.
2

Delays to diagnosis mean delays to treatment, which in turn means pressing pause on living the full life that heart failure patients can have and importantly deserve. The emotional impact of this is overwhelming. And the added layer of COVID-19 aggravates an already traumatic experience. More than
one third (38.4%) of patients have had their GP appointments cancelled as a result of service alterations and we also know that COVID-19 risks causing a 10% rise in heart failure, so there is an even greater sense of urgency.
9

We want to see a diagnostic pathway that works for both patients and healthcare professionals alike, and that works for all patients, regardless of age, gender or other factors. This is within our reach. GPs and cardiologists need more support to make a diagnosis by accessing the right intervention at the right time. The positive impact of this on patients and their families – both their physical and emotional wellbeing – will be transformative.
With reliable and cost-effective diagnostic innovations at our disposal, including a widely available, simple blood test, NT-proBNP, which can help to rule out heart failure,8 it is not good enough that three quarters (74.8%) of heart failure patients admitted in 2018/19 received their initial diagnosis in a hospital setting,2 and almost 50% of these are told they have heart failure in A&E.
2

Delays to diagnosis mean delays to treatment, which in turn means pressing pause on living the full life that heart failure patients can have and importantly deserve. The emotional impact of this is overwhelming. And the added layer of COVID-19 aggravates an already traumatic experience. More than one third (38.4%) of patients have had their GP appointments cancelled as a result of service alterations and we also know that COVID-19 risks causing a 10% rise in heart failure, so there is an even greater sense of urgency.9

We want to see a diagnostic pathway that works for both patients and healthcare professionals alike, and that works for all patients, regardless of age, gender or other factors. This is within our reach. GPs and cardiologists need more support to make a diagnosis by accessing the right intervention at the right time. The positive impact of this on patients and their families – both their physical and emotional wellbeing – will be transformative.