Primary Care Signals and Diagnostic Pathways Before Incident Heart Failure: A Systematic Scoping Review

IntroductionHeart failure may be preceded by non-specific symptoms or indicators recorded in primary care, although these records do not necessarily represent heart failure or missed diagnosis. We mapped quantitative evidence on prediagnostic signals, investigation, referral, diagnosis setting and outcomes.MethodsWe conducted a systematic scoping review of quantitative observational studies of incident or newly diagnosed adult heart failure that included a primary care, community or ambulatory first-contact component. Databases were searched from January 2000 to 1 May 2026. Two reviewers independently screened records, extracted data and assessed risk of bias using Joanna Briggs Institute tools. Heterogeneous findings were synthesised narratively and organised by dataset family.ResultsEleven reports were included as sources of evidence. Most were UK retrospective linked-record cohorts; six reports used overlapping national English data, and five used independent datasets from Portugal, other UK regions and the USA. Recorded symptoms or indicators before diagnosis occurred in 30.0% to 66.5% of patients. Among 80,824 English patients with prior indicators diagnosed in 2015-19, 12.5% had recorded natriuretic peptide testing, 19.8% echocardiography and 34.4% specialist referral in the six months before diagnosis. Hospital or acute-care diagnosis was common and was associated with poorer mortality, admission or cost outcomes. Repeat consultations and clinicians' responses to recurrence were rarely measured directly.ConclusionThe evidence describes recorded prediagnostic intervals and pathway gaps, not proven missed or avoidable diagnostic delay. It does not establish repeated or unresolved presentation as a clinical trigger. Primary studies should define recurrence, determine whether earlier records plausibly reflected heart failure, and adjudicate whether repeated presentation identifies preventable diagnostic opportunities.