Most acute presentations are due to patients with chronic heart failure suffering an acute decompensation ( 65%), while the remainder are new presentations of acute heart failure ( 35%). Patients identified in the community with heart failure have breathlessness as their most common complaint. However, patients often consult their doctor with multiple non-specific symptoms such as fatigue, or with symptoms in the context of other long-term co-morbidities which can make the recognition of heart failure more challenging 45 . 2.2 Clinical context Around 920,000 people in the UK today have been diagnosed with heart failure 74 . Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 77 years.While around 1 in 35 people aged 65 74 years has heart failure, this increases to about 1 in 15 of those aged 75 84 years, and to just over 1 in 7 in those aged above 85 years. Less data exists about heart failure in younger age groups but there is increasing recognition that this condition affects a proportion of patients aged less than 65 years 371 . The prevalence of heart failure is rising overall despite improvements in care through a combination of improved survival of people with ischaemic heart disease, more effective treatments for heart failure, and the effects of population ageing 74 .The recent rise in the prevalence of heart failure with preserved left ventricular ejection fraction parallels the rise in the prevalence of obesity and allied co-morbidities of hypertension, and diabetes mellitus 166, 353 . The most common cause of heart failure in the UK is coronary artery disease. Other heart failure admissions are often associated with atrial fibrillation or heart valve disease as well with presentations of cardiomyopathies and myocarditis. 