Table 1.

Triggers for Patient With Heart Failure Referral to a Specialist/Program^*

New onset HF (regardless of EF) for evaluation of etiology, guideline‐directed prescription of recommended therapies, and assistance in disease management. Chronic HF with high‐risk features, such as development of 1 or more of the following risk factors: Need for chronic IV inotropes Persistent New York Heart Association functional class III‐IV symptoms or congestion or profound fatigue Systolic blood pressure <90 mm Hg or symptomatic hypotension Creatinine >1.8 mg/dL or BUN >43 mg/dL Onset of atrial fibrillation or ventricular arrhythmias or repetitive implantable cardioverter defibrillator shocks Two or more emergency department visits or hospitalizations for worsening HF in prior 12 months Inability to tolerate optimal dose beta blockers and/or ACEI/ARB/ARNI and or aldosterone antagonists. Clinical deterioration as indicated by worsening edema requiring high dose diuretics, rising biomarkers (BNP, NT‐proBNP), worsened cardiopulmonary exercise testing, decompensated hemodynamics, end‐organ dysfunction, or evidence of progressive remodeling on imaging. High mortality risk using validated risk model for further assessment and consideration of advanced therapies.

ACEI indicates angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNI, angiotensin receptor‐neprilysin inhibitor; BNP, B‐type natriuretic peptide; BUN, blood urea nitrogen; EF, ejection fraction; HF, heart failure; ICD, implantable cardioverter defibrillator; LVEF, left ventricular ejection fraction; NT‐proBNP, N‐terminal pro‐B‐type natriuretic peptide; and NYHA, New York Heart Association.

^*Adapted from 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment. ⁹¹