Why prompt investigation and treatment of heart failure matter — and what happens when they don’t occur
Heart failure means the heart is not pumping blood as well as it should. It does not mean that the heart has stopped working, but that support is needed to help it work better. Left unchecked, heart failure causes breathlessness, swollen legs, overwhelming fatigue, and most importantly, progressive damage to the heart and other organs.
UK and European guidelines are clear: when heart failure is suspected, patients should have a simple blood test (to check BNP protein levels – higher levels of BNP in the blood can be a sign that the heart is not working as it should) followed by an urgent echocardiogram (an ultrasound of the heart) and specialist review, with the highest‑risk results seen within two weeks.
Early specialist input and a structured pathway improve outcomes and shorten hospital stays. Timely diagnosis opens the door to treatments that reduce deaths and hospitalisations.
Heart failure can be put into different categories depending on ejection fraction. Ejection fraction is a measure of the amount of blood squeezed out of the main chamber of the heart with each beat. It is measured as a percentage and over 50% is considered normal. Ejection fraction is measured from an echocardiogram. For those whose heart is not pumping strongly enough (known as heart failure with reduced ejection fraction), starting the right treatments quickly can make a big difference. Medicines such as ACE inhibitors or ARNIs, beta‑blockers, mineralocorticoid receptor blockers, and SGLT2 inhibitors are proven to help people live longer and feel better. Current guidance stresses that these key treatments should be started as soon as possible, including right after a hospital stay for heart failure. Even for those whose heart pumping strength is normal but who still have heart failure (heart failure with preserved ejection fraction), newer treatments, especially SGLT2 inhibitors, and careful management of other health conditions are starting to improve outcomes too.
Unfortunately, delays are common and harmful. People can have symptoms for months yet are only diagnosed after an emergency hospital admission. Heart failure can be missed by GPs because, in its early stages, it rarely presents with dramatic or clear‑cut symptoms. Many people experience breathlessness, tiredness, or ankle swelling, but these issues are so common that they are easily attributed to far less serious conditions such as chest infections, asthma, anxiety, or simply the effects of ageing. Patients may report these symptoms for months or even years before a GP considers heart failure as a possible cause, which means opportunities for early diagnosis are frequently lost.
Another major reason that heart failure slips through the net is that the key tests recommended by national guidelines are not consistently carried out in primary care. The BNP protein blood test should be the first step in confirming suspected heart failure, yet often GPs do not arrange it. Even fewer patients are referred for an echocardiogram for a more definitive diagnosis. Depending on the symptoms the patient has, this can amount to a breach of duty of care owed by the GP to the patient and be the basis for a clinical negligence claim. It will be deemed negligent if no responsible body of GPs would have failed to suspect heart failure and arrange blood testing to investigate it. NICE guidelines state that NT-proBNP testing should be the first-line investigation in patients with symptoms suggestive of heart failure and the blood test is then the gateway to urgent echocardiography and specialist review if elevated. If a patient presents with classic features of possible heart failure and the GP fails to arrange any diagnostic testing at all, the court may well see that as falling below a reasonable standard of care. This is particularly true in cases where symptoms progress, where the patient re‑attends multiple times, or where other clues (for example abnormal examination findings or high risk history such as previous cardiac arrest) were present but not acted on. In that situation, the failure to order a simple and widely accessible blood test is often considered a breach of duty of care, because competent GPs would order it and NICE guidance strengthens that argument.
The causative impact of such breaches of duty of care is typically clear. Delayed diagnosis means delayed treatment, and that raises the chances of fluid overload, kidney injury, emergency admissions, and death. People may suffer preventable hospitalisations, strokes or rhythm disturbances, worsening heart or kidney function, and loss of independence. Studies of real‑world pathways highlight missed opportunities for blood testing, specialist assessment, and rehabilitation – each a moment where deterioration may have been avoided.
In the case of AJB v MK (2022), the claimant, a seventy-one-year-old man, received damages for injuries he suffered following a failure by his GP to suspect a progressive cardiac issue and to refer him for specialist cardiology investigations. The claimant had a history of shortness of breath, lethargy, chest pain, and cough. He suffered acute heart failure, requiring significant emergency surgery. Subsequently he brought a claim alleging that his GP had failed to fully and properly consider his underlying symptoms of fatigue and shortness of breath, to elicit a full history of the symptoms, to undertake a full and proper clinical assessment including a physical examination, blood testing and auscultation of the heart, and then to refer for a cardiological review and treatment in a timely manner. It was the claimant’s case that with proper GP care, he would have been referred and investigated earlier. While he would still have required surgery, he would have had it earlier and in a planned and measured way, avoiding the urgency that transpired. He would have avoided continuing to suffer from his worsening symptoms for a further year, and the distress and anxiety that caused him, as well as the acute heart failure that catalysed the emergency hospital admission.
Alison Johnson, partner in the medical negligence team at Penningtons Manches Cooper, comments: “When GPs fail to recognise symptoms that may signal heart failure, patients can be left dangerously undiagnosed. A GP is not necessarily going to be able to reach a firm diagnosis of a cardiology issue, or indeed be expected to, but an appropriate assessment should be undertaken, to include blood testing, so that it can be established whether heart failure is a potential cause of symptoms and a cardiology referral is required.”