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Complex syndrome where efficiency of pump is impaired - structurally or functionally
most commonly from Coronary artery disease and often previous MI
may have reduced or preserved LV ejection volume

incidence increases with age - average age at diagnosis - 76
30-40% die within 1 year of diagnosis, then mortality is <10%/yr

Need accurate diagnosis (review history and ensure all Ix complete)
''Suspected HF without Hx of MI'' - measure BNP (or Nterminal-proBNP) 
- if >400pg/ml (>2000) refer 2WW echo and specialist opinion , if 100-400 (400-2000) refer 6WW for same
''Suspected HF with Hx MI'' - refer 2ww for echo and specialist opinion 

//BNP// - if high - poor prognosis
Reduce BNP - Obesity, ACE, ARB, BB, diuretic, spironolactone
High BNP - LVH. ischaemia, tachyc, hypoxaemias (egPE), eGFR <60, COPD, sepsis, diabetes, cirrhosis, >70

//Echo//
Transthoracic 2D doppler echo for valve disease, sys and dias function of LV and intracardiac shunt
(if poor images consider trans-oesophageal or cardiac MRI or radionuclide angiography)
shows if LV systolic function is impaired or preserved

Preserved LV function
Lifestyle advice and Mx co-morbid conditions
Diuretic for Sx relief if needed

//Advice//
stop smoking
stop alcohol if alcohol related
annual flu jab
air travel and sex are OK as to condition
cardiac rehab programme is impt if stable and no other precluding condition, should include psych and education and be tailored to pt ability 

//Drugs//
ACEi and BB (if LV systolic function is impaired) for all at closest to max dose poss
then with specialist advice, add Spironolactone (esp if recent MI) or ARB (may cause angioedema) or Hydralazine with Nitrates (esp if afro-caribean or intolerant to ACE/ARB)
Diuretic may help Sx but doesn't change prognosis so other drugs 1st 
In elderly there is more tolerance to drugs and inc need to monitour for SE
If young and female remember to discuss pregnancy

//Monitour//
U/E, eGFR (6/12 if stable else more)
clinical assess - fluid status, cardiac rythum, functional capacity, nutrition and cognition
medication - SE and effectiveness
NOT routine CXR or ECG but do if Sx change

//Specialist for ...//
initial diagnosis and if Mx becomes difficult
or if cause is valve disease,
?biventricular pacemaker (cardiac resynchronisation)
Coronary revascularisation if refractory angina
Transplant if severe refractory and young
Palliative care should be discussed when appropriate