Case Study: Diagnosing Heart Failure in Primary Care

by | 2 Nov, 2025 | Blog

Heart failure is not always obvious. A subtle rise in NT-proBNP or a patient who “just feels tired” can easily be misattributed to age or comorbidity.
This short case highlights how structured interpretation of investigations — aligned with NICE NG106 (2024) and the ESC 2023 Heart Failure Guidelines  can make the difference between early intervention and a missed diagnosis.

The Case

A 68-year-old man presented to his GP with three months of exertional breathlessness, mild ankle swelling and fatigue.
Past history: hypertension and type 2 diabetes. On examination — bibasal crackles, mild pitting oedema, BP 128/78 mmHg, HR 88 bpm regular.

Investigations

Test Result Interpretation
NT-proBNP 820 pg/mL Above 400 → heart failure possible → echo within 6 weeks
ECG Sinus rhythm, LVH Hypertensive remodelling pattern
CXR Cardiomegaly + upper-lobe diversion Suggestive of pulmonary congestion
Clinical reasoning:
NT-proBNP between 400–2000 pg/mL should trigger echocardiography within 6 weeks. This level, combined with symptoms and CXR changes, supports a diagnosis of heart failure with reduced ejection fraction (HFrEF).

Management: The Four Pillars of HFrEF

Once confirmed, treatment should begin promptly. Current NICE and ESC guidance recommend a four-pillar approach — four disease-modifying therapies shown to reduce mortality and hospitalisation.

Pillar Example Mechanism & Key Point
1️⃣ ARNI / ACEi / ARB Sacubitril-valsartan, Ramipril RAAS inhibition → ↓ afterload, ↓ remodelling
2️⃣ Beta-blocker Bisoprolol, Carvedilol ↓ Sympathetic activity → improves EF, ↓ arrhythmias
3️⃣ MRA Spironolactone, Eplerenone Blocks aldosterone → ↓ fibrosis, ↓ remodelling
4️⃣ SGLT2 inhibitor Dapagliflozin, Empagliflozin Cardio-renal protection → ↓ admissions, ↑ QoL

Initiating all four pillars within the first month (as tolerated) significantly reduces mortality.
Diuretics relieve symptoms but do not alter long-term outcomes.

Professor’s Ahmet’s Tip:
“Think confirm → classify → combine. The sooner you layer the four pillars, the greater the survival benefit.”

 Key Takeaways

  • NT-proBNP is your gatekeeper — always investigate unexplained breathlessness.
  • Heart failure is both a clinical and biochemical diagnosis — confirm with echo.
  • Implement the four pillars early: ARNI/ACEi, Beta-blocker, MRA, SGLT2i.
  • Monitor renal function and potassium with every titration.

Next Step:
To explore titration schedules, safety monitoring, and case-based practice, read the full interactive module on our learning platform:

👉Watch out for our upcoming events to learn more: https://clinilink.co.uk/upcoming-events/

References