GP Guidance (BNSSG)

Quick-reference guidance for summary statements on transthoracic echo reports for adult patients.

The objective is to help primary care physicians find the correct guidance quickly and without additional steps.

For GPs working in Bristol, North Somerset and South Gloucestershire ICB
▶Impaired Left Ventricular Systolic or Diastolic Function
For full up-to-date guidance, please see the following two resources:
Remedy - Heart Failure page: Click Here

BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
▶Suspected Heart Failure
▶"...impaired left ventricular systolic function" (EF <50%)
Alongside clinical signs of heart failure and elevated NT-proBNP (>400pg/ml) - this suggests:

Heart Failure with reduced Ejection Fraction (HFrEF)
In all cases:
Optimal medical management
BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
(Page 2: "Treatment Algorithm for LV Systolic Dysfunction")

+/- Referral to appropriate heart failure service
Remedy - Heart Failure page: Click Here
(scroll down to referral advice based on NT-proBNP level)
Technically, cases with EF 41-49% would be classed as Heart Failure with mid-range Ejection Fraction (HFmrEF) - but they are treated the same, so are grouped together here under HFrEF.
▶"...impaired left ventricular systolic function" (EF >50%)
Alongside clinical signs of heart failure and elevated NT-proBNP (>400pg/ml) - this suggests:

Heart Failure with preserved Ejection Fraction (HFpEF)
In all cases:
Optimal medical management
BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
(Page 3: "Treatment Algorithm for Preserved Ejection Fraction")

+/- Referral to appropriate heart failure service
Remedy - Heart Failure page: Click Here
(scroll down to referral advice based on NT-proBNP level)
▶"Impaired diastolic function" (EF >55%)
Alongside clinical signs of heart failure and elevated NT-proBNP (>400pg/ml) - this suggests:

Heart Failure with preserved Ejection Fraction (HFpEF)
In all cases:
Optimal medical management
BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
(Page 3: "Treatment Algorithm for Preserved Ejection Fraction")

+/- Referral to appropriate heart failure service
Remedy - Heart Failure page: Click Here
(scroll down to referral advice based on NT-proBNP level)
▶Normal systolic and diastolic function
This suggests the cause of symptoms and elevated BNP is not due to Heart Failure – other diagnoses should be considered.
▶Known Heart Failure
Routine follow-up imaging is not recommended for known heart failure.

Clinically stable with incidental finding of change in Ejection Fraction:
No action required unless change in clinical status

Significant change in clinical status despite optimal medical therapy:
Referral to the appropriate heart failure service.
Remedy - Heart Failure page: Click Here
(scroll down to “Patients with known heart failure”)
▶Incidental New Finding
Where echo has been performed for another reason and there is unexpected finding of left ventricular systolic and/or diastolic dysfunction.
In most cases:
Routine cardiology referral.

If severely impaired left ventricular systolic function (EF <35%):
Urgent cardiology referral.

For unclear cases, cardiology advice and guidance would likely be appropriate
▶Probability of Pulmonary Hypertension
For full up-to-date guidance, please see the following resource:
Remedy - Pulmonary Hypertension page: Click Here

Brief explainer:
In the most basic terms, elevated pulmonary artery pressures come about as a result of:
• Restriction of blood flow within the lungs (varied pathologies), or
• Restriction of blood flow out of the lungs (left-sided heart disease)

Estimates of the probability of pulmonary hypertension by transthoracic echo correlate poorly to gold standard measures of pulmonary pressures, so should always be considered alongside the clinical picture.
▶Low Probability of Pulmonary Hypertension

In all cases:
No action required.

▶Intermediate Probability of Pulmonary Hypertension
Known left-sided heart pathology:
In all cases: Optimal treatment of heart disease.
No further action required

Known pulmonary pathology:
In all cases: Optimal treatment of pulmonary disease.
No further action required

Unexplained dyspnoea with normal left heart:
Further investiation +/- referral to appropriate specialty
Please refer to Remedy - Pulmonary Hypertension page: Click Here
▶High Probability of Pulmonary Hypertension
Known left-sided heart pathology:
In all cases: Optimal treatment of heart disease.
No further action required

Known pulmonary pathology:
In all cases: Optimal treatment of pulmonary disease.
No further action required

Unexplained dyspnoea with normal left heart:
Further investiation +/- referral to appropriate specialty
Please refer to Remedy - Pulmonary Hypertension page: Click Here
▶Dilated Aorta
For full up-to-date guidance, please see the following resource:
Remedy - Aortopathy page: Click Here
▶New Finding of Dilated Aorta
▶Absolute diameter <40mm (root or proximal ascending aorta)
Asymptomatic patients with any of the following:
- Family history of aortic or vessel aneurysm/dissection.
- Bicuspid aortic valve.
- Age <60 with strong suspicion of underlying disease.
Routine valve clinic referral
(please see guidance on Remedy - Aortopathy page: Click Here)

Asymptomatic patients with none of the above:
No follow-up required
▶Absolute diameter >40mm (root or proximal ascending aorta)
Asymptomatic patients:
In all cases: Routine valve clinic referral
(please see guidance on Remedy - Aortopathy page: Click Here)

Safety netting - advise the patient that if they develop chest pain then they should call 999 and attend their local emergency department immediately.
▶Follow-up for Known Aortopathy

Follow-up for known aortopathy should be cardiologist-led in all cases.

▶Valve Disease
The guidance in this section is based primarily on the following resource, albeit with some local policy variations:
2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease Click Here
▶Aortic Valve
▶Sclerotic Aortic Valve
No routine follow-up

This describes an aortic valve with thickened and/or slightly restricted leaflets, but without any significant restriction to blood flow.
▶Aortic Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild aortic stenosis:
Trileaflet valve, non-dilated aorta: Repeat echo in 3 years
No cardiology referral required.

Trileaflet valve, aorta >40mm: Routine valve clinic referral
Please see Aortopathy section for referral urgency.

Bicuspid valve: Valve clinic referral
For referral urgency - please see Bicuspid Aortic Valve section.

Moderate aortic stenosis:
In all cases: Routine valve clinic referral

Severe aortic stenosis:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- New left ventricular systolic function (EF <55%) with no other cause and/or reducing ejection fraction on subsequent scans

Low-flow/Low-gradient aortic stenosis:
See Severe aortic stenosis (above)

This describes a valve which has either Moderate or Severe aortic stenosis, but it is not possible to differentiate between grades on resting echo due to low stroke volume and resulting low flow rates across the valve. Further testing will be required to determine severity.
▶Aortic Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild aortic regurgitation:
Trileaflet valve, non-dilated aorta: Repeat echo in 5 years
No cardiology referral required.

Trileaflet valve, aorta >40mm: Routine valve clinic referral
Please see Aortopathy section for referral urgency.

Bicuspid valve: Routine valve clinic referral
For referral urgency - please see Bicuspid Aortic Valve section.

Moderate aortic regurgitation:
In all cases: Routine valve clinic referral

Severe aortic regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Aortic root and/or proximal ascending aorta >40mm (by absolute values)
- Dilated LV and/or reducing ejection fraction on subsequent scans
▶Bicuspid Aortic Valve
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Severe aortic stenosis or regurgitation
- Aortic root and/or proximal ascending aorta >45mm (by absolute values)

Increased prevalence in 1st degree relatives - all immediate family members should be offered routine transthoracic echo for screening.
▶Mitral Valve
▶Mitral Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild mitral stenosis:
In all cases: Repeat echo in 3 years
No cardiology referral required.

Moderate mitral stenosis:
In all cases: Routine valve clinic referral
If new onset atrial fibrillation – please consider commencing Vitamin K Antagonist instead of DOAC (if no contraindications).

Severe mitral stenosis:
In all cases: Urgent valve clinic referral
If new onset atrial fibrillation – please consider commencing Vitamin K Antagonist instead of DOAC (if no contraindications).
▶Mitral Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild mitral regurgitation:
In most cases: No routine follow-up

Rheumatic valve/post-inflammatory process: Repeat echo in 3 years

Other anatomical abnormality: Routine valve clinic referral
(i.e. Mitral annular disjunction, mitral valve prolapse, carcinoid)

Moderate mitral regurgitation:
In all cases: Routine valve clinic referral

Severe mitral regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- New atrial fibrillation
- Dilated LV and/or ejection fraction <60%
- Estimated pulmonary artery systolic pressure >50mmHg and/or right ventricular impairment
- Indexed LA volume >60ml/m2 (by BSA)
▶Mitral Annular Dysjunction
This describes an abnormality of the mitral annulus which can result in arrythmia.
It is associated with mitral valve prolapse and mitral regurgitation.

In all cases cardiology review is required.

Please see Mitral Regurgitation section for referral urgency.
▶Tricuspid Valve
▶Tricuspid Stenosis
Vanishingly rare!

In all cases:
Routine valve clinic referral
▶Tricuspid Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild tricuspid regurgitation:
In most cases: No routine follow-up

Anatomical abnormality: Routine valve clinic referral
(i.e. Tricuspid valve prolapse, carcinoid, previous vegetation)

Moderate tricuspid regurgitation:
In most cases: No routine follow-up

Anatomical abnormality: Routine valve clinic referral
(i.e. Tricuspid valve prolapse, carcinoid, previous vegetation, pacing lead)

Severe tricuspid regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Estimated pulmonary artery systolic pressure >50mmHg and/or right ventricular impairment
▶Pulmonary Valve
▶Pulmonary Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Generally due to known congenital abnormality - followed up by the Adult Congenital Heart Disease (ACHD) service.

In most cases:
Routine Adult Congenital Heart Disease (ACHD) referral

If severe stenosis and any of the following features: Urgent ACHD referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Dilated and/or impaired right ventricle
- Estimated pulmonary artery systolic pressure >50mmHg
▶Pulmonary Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild pulmonary regurgitation:
In most cases: No routine follow-up

But, in rare cases of anatomical abnormality: Routine valve clinic referral
(i.e. Carcinoid, previous vegetation, previous valvuloplasty, pulmonary artery dilatation)

Moderate pulmonary regurgitation:
Generally due to known congenital abnormality - followed up by the Adult Congenital Heart Disease (ACHD) service.

In all cases: Routine Adult Congenital Heart Disease (ACHD) referral

Severe pulmonary regurgitation:
Generally due to known congenital abnormality - followed up by the Adult Congenital Heart Disease (ACHD) service.

In most cases: Routine Adult Congenital Heart Disease (ACHD) referral

If any of the following features: Urgent ACHD referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Dilated and/or impaired right ventricle
- Estimated pulmonary artery systolic pressure >50mmHg
▶Repaired or Replaced Valves
Mechanical Valve Replacements
Including:
- Mechanical aortic valve replacement (mAVR)
- Mechanical mitral valve replacement (mMVR)
- Mechanical tricupid valve replacement (mTVR)

In nearly all cases: No routine imaging surveillance required

Only if there is significant clinical change, or incidental finding of valve disfunction on other imaging would direct cardiology input be required.

Tissue Valve Replacements
Including:
- Tissue aortic valve replacement (bioAVR, TAVI)
- Tissue mitral valve replacement (bioMVR)
- Tissue tricupid valve replacement (bioTVR)
- Tissue pulmonary valve replacement (PPVI, Melody)

In all cases: Lifelong cardiologist-led follow-up

Surgical Valve Repairs
Including:
- Aortic valve repair (Ozaki)
- Mitral valve repair (including Mitral TEER)
- Tricuspid valve repair (including Tricuspid TEER)
- Pulmonary valves intervention (including pulmonary valvuloplasty)

In all cases: Lifelong cardiologist-led follow-up