High risk groups 1–3

  • Diabetes, hypertension, CHD and dyslipidaemia
  • Smokers and those who drink alcohol above recommended limits
  • Sedentary lifestyle or obesity and overweight

Considerations in pregnancy1–3

  • Heart failure (HF) increases maternal and neonatal morbidity and mortality risk
  • HF may worsen as medicine is altered and fluid volume changes
  • Discuss ceasing HF medicines in patients with known cardiomyopathy with specialist

Urgent referral 1–3

  • Refer to the Primary Clinical Care Manual for increased or sudden onset of breathlessness or weight gain ≥ 2 kg in 3 days
  • Refer to the cardiologist for:
    • advanced HF or HFrEF not responding to optimal management therapies
    • HF with valvular heart disease, amyloidosis, CHD or cancer

1. What is HF? 1–5

  • The hearts inability to provide adequate circulation, commonly caused by CHD, hypertension and diabetes
  • Most commonly characterised by myocardial dysfunction which impairs the left ventricle to fill with or eject blood, particularly during physical activity
  • Manifests in congestive signs and symptoms during physical exertion or at rest as condition progresses. See Tables 1–2.

Table 1. Signs and symptoms of HF 3

More typical symptoms

More typical signs

  • Breathlessness (usually on exertion)
  • shortness of breath while lying flat or during sleep
  • Fatigue
  • Elevated jugular venous pressure
  • Hepatojugular reflux
  • Third heart sound
  • Laterally displaced apex beat

Less typical symptoms

Less specific signs

  • Nocturnal cough
  • Wheeze
  • Abdominal bloating
  • Anorexia
  • Confusion (elderly)
  • Depression
  • Palpitations
  • Dizziness
  • Fainting
  • Shortness of breath when leaning forward
  • Weight gain > 2 kg/wk
  • Weight loss (advanced HF)
  • Peripheral oedema (ankle, sacrum)
  • Pulmonary crackles
  • Pleural effusions
  • Cardiac murmur
  • Tachycardia
  • Tachypnoea
  • Cheyne–Stokes respiration
  • Ascites
  • HF is divided into 3 phenotypes based on left ventricular ejection fraction (LVEF):
    • reduced ejection fraction (HFrEF) ≤ 40% LVEF: the weakened ability of the left ventricle to contract and eject blood
    • mildly reduced ejection fraction (HFmrEF) 41–49% LVEF: the mildly weakened ability of the left ventricle to contract and eject blood
    • preserved ejection fraction (HFpEF) ≥ 50% LVEF: the left ventricle does not adequately fill due to structural or functional cardiac abnormalities resulting in poor stroke volume
  • The distinction between the phenotypes is relevant to the therapeutic approach
  • The simplest way to grade HF is based on severity of symptoms using the New York Heart Association (NYHA) Functional Classification system

Table 2. NYHA grading of symptoms in HF 1–3

NYHA grading

Clinical features

Class I

  • No limitations of ordinary physical activity

Class II

  • Slight limitation of ordinary physical activity
  • No symptoms at rest

Class III

  • Marked limitation of ordinary physical activity
  • No symptoms at rest

Class IV

  • Symptoms on any physical activity or at rest

Ordinary physical activity is a patient’s subjective opinion of their ability to exert themselves during activities of daily living

2. Diagnosis of HF 1–3

  • Requires presence of:
    • signs and symptoms. See Table 1.
    • objective evidence of structural abnormality or cardiac dysfunction. See Flowchart 1.
      • ECG for AF, Q waves, LV hypertrophy and widened QRS complexes
      • echocardiogram to assess LVEF
      • venous B-type natriuretic peptide (BNP or NT-proBNP) non-Medicare rebateable i.e. BNP > 35 pg/mL and NT-proBNP > 125 pg/mL
      • chest x-ray to exclude alternative causes of breathlessness (e.g. COPD) or to support evidence of HF (pulmonary congestion or cardiomegaly)
      • routine blood tests for comorbidities
  • Response to treatment helps determine diagnosis, prognosis and management
  • Consider early Advance Care Planning when diagnosis is made (class III–IV) so the patient can plan and retain control over their care and personal life as the condition progresses

3. Management of HF 1–3

  • Management goals are to reduce mortality, prevent recurrent hospitalisations and improve functional ability and quality of life by:
    • addressing Lifestyle modifications
    • identifying and addressing the following comorbidities in relation to Australian cardiovascular disease risk calculator
      • Diabetes
      • Hypertension
      • Coronary heart disease
      • Dyslipidaemia
    • optimal use of medicines

Flowchart 1. Diagnosing HF 1,2

Diagnosing HF

  1. Support patient self-management 1–3
    • Effective HF self-care results in better quality of life, lower readmission rates, and reduced mortality
    • Provide Resources 1–5 and discuss:
      • HF and its progression and prognosis, including death
      • fluid monitoring and dietary sodium intake
      • signs of worsening HF e.g. weight gain, breathlessness, lower extremity swelling
      • the need to seek timely access to health services
      • the need for patient involvement in management decisions
    • Provide home visits to support transition from discharge to the community to decrease mortality and re-hospitalisation
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
  2. Social-emotional support 1–3
    • See Social-emotional wellbeing
  3. Fluid management 1–3
    • Discuss symptoms of fluid overload including dyspnoea, oedema and bloating. See Resource 6.
    • Determine the patient’s ideal weight with no signs of overload after treatment with a diuretic (i.e. ‘dry’ or ‘euvolaemic’ weight)
    • Encourage the patient to keep a daily weight and fluid intake diary targeting their ideal weight and develop an action plan (Resources 7–8.) with the following information:
      • measure weight first thing in the morning post void i.e. “wake, wee, weigh, write”
      • a steady weight gain over a number of days indicates an episode of fluid retention; limit fluids to 1.5–2 litres/day to relieve symptoms
      • weight loss below the ideal weight indicates dehydration
      • high dietary sodium intake contributes to fluid overload and hospitalisation. Limit sodium intake if overloaded and refer to a dietitian. See Resource 8.
      • avoid alcohol. It contributes to fluid intake, increases body weight, alters metabolism of some HF medicines and impairs cardiac function
      • caffeine increases HR and BP, contributes to fluid intake and alters electrolyte levels if taking diuretics. Limit to 1–2 cups/day
      • seek medical attention for a weight gain > 2 kg in 3 days. The MO/NP may consider a change in diuretic dose
  4. Physical activity 1–3
    • Regular Physical activity and sleep for patients with HF leads to overall:
      • reduction in mortality and hospitalisation
      • improvement of physical functioning and quality of life
      • improvement of symptoms and neurohormonal abnormalities
  5. Cardiac rehabilitation 1–3,5
    • Cardiac rehabilitation:
      • is detailed in a discharge summary from the referring hospital
      • reduces hospitalisation by up to 56%
      • accelerates recovery
      • motivates lifestyle modification e.g. physical activity levels
      • improves adherence to medicines, social-emotional wellbeing and clinical management targets
    • When stable, refer and encourage all patients to attend a cardiac rehabilitation program especially Aboriginal and Torres Strait Islander people who:
      • are at higher risk of heart disease and repeat heart events
      • have specific cultural needs
      • participate in cardiac rehabilitation at lower rates than non-Indigenous people
    • An exercise program should be instigated by a physiotherapist or exercise physiologist for those with limited function according to clinical features:
      • NYHA class I or II symptoms–progress gradually to at least 30 minutes of physical activity (continuously or in 10 minute bouts) up to moderate intensity on most, if not all days of the week
      • NYHA class III symptoms–short intervals of low intensity activity, with frequent rest days
      • NYHA class IV symptoms–requires gentle mobilisation as symptoms allow
      • see Table 1.
    • See the National Cardiac Rehabilitation Program Directory for cardiac rehabilitation services in your region. See Resource 9.
  6. Diet and nutrition 1–3
    • Weight loss reduces HF symptoms and HF progression, and improves wellbeing
    • Anorexia and unintentional weight loss are common consequences in NYHA class III or IV. Intentional weight loss is not recommended in this class
    • Frequent small meals can reduce the risk of angina, dizziness, dyspnoea or bloating in severe HF
    • Refer to dietitian for:
      • constipation; common in HF due to gastrointestinal hypoperfusion
      • malnutrition, wasting (cardiac cachexia) and anaemia contributing to debilitating weakness, fatigue and poor prognosis
      • fluid overload requiring sodium restriction
    • See Diet and nutrition
  7. Smoking cessation 1
    • Smoking cessation decreases cardiovascular risks and HF progression
  8. Obstructive sleep apnoea (OSA) 1–3
    • Obesity and OSA are common in patients with HF
    • Accepted treatments for OSA in HF are:
      • weight loss in those with a BMI > 30. See Overweight and obesity (adult)
      • Smoking cessation
      • Alcohol reduction
      • CPAP therapy
    • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 10.
  9. Palliative care 1,2
    • Perform Advance Care Planning early and provide Palliative care to patients with NYHA class III (advanced) or IV symptoms not responding to interventions and death likely within 12 months
    • Assess impact of HF on activities of daily living, physical activity, employment, finances, family routines and emotional wellbeing

4. Medicines for HF

  1. Practice points 1–4,6
  • Support patients to continue taking medicines to avoid exacerbations
  • A pharmacist/MO/NP will review a patient on multiple or over the counter medicines
  • All patients whose LVEF improves after optimal medicine doses should continue regimen to prevent relapse of HF and LV dysfunction, even if asymptomatic
  • The following medicines have no benefit or are harmful in HFrEF:
    • diltiazem and verapamil
    • vitamins, nutritional supplements, and hormonal therapy
    • some antiarrhythmics
    • thiazolidinediones
    • NSAIDs
    • saxagliptin and alogliptin in those with type 2 diabetes or high CVD risk
  • Titration of medicines decreases mortality and hospitalisation when patient is:
    • diagnosed with HFrEF
    • stable and euvolaemic
    • supported by a specialist heart failure nurse/MO/NP
    • see Resource 11. for a medicine HF titration plan
  • See Flowchart 2. for pharmacological management of HF

Flowchart 2. Pharmacological management of HF 1–4

Pharmacological management of HF

Table 3. Medicines for comorbidities in HF 1–4

Hypertension

  • Most prevalent modifiable risk factor in two thirds of all HF patients
  • Avoid diltiazem, verapamil, and moxonidine in patients with HFrEF
  • ACEi, ARBs, ARNIs, some beta blockers, and MRAs all have blood pressure lowering effects, decreasing mortality and hospitalisation in those with HFrEF
  • Optimally treated HFrEF is rarely associated with Hypertension

Coronary heart disease and angina

  • Coronary heart disease is present in up to 50% of all HF patients, leading to increased functional limitation and risk of coronary events
  • For patients with HFrEF:
    • target maximally tolerated dose of beta blocker (unless contraindicated) and
    • ivabradine should be prescribed if HR is ≥ 70 bpm and LVEF ≤ 35%

Atrial fibrillation (AF)

  • All patients with Atrial fibrillation and HF (in particular HFrEF) should receive long term anticoagulation unless contraindicated. See CHA2DS2-VA
  • Digoxin may be useful to treat patients with HFrEF and AF with rapid ventricular rate where other medicines cannot be pursued

Diabetes

  • Metformin is safe at all stages of HF with preserved or stable moderately reduced renal function (eGFR > 30 mL/min)
  • SGLT2i (e.g. empagliflozin, dapagliflozin) recommended in HFrEF in addition to optimal doses of all other HF medicines regardless of diabetes status
  • Not recommended in patients with Diabetes and symptomatic HF:
    • thiazolidinediones (glitazones)
    • saxagliptin and alogliptin (DPP-4)

Chronic kidney disease (CKD)

  • Present in up to 60% of patients
  • Improvement in HF (reduction in renal venous hypertension and improvement in stroke volume) may improve renal function
  • Potassium binders can decrease the risk of recurrent hyperkalaemia in HF
  • See Chronic kidney disease

Hyponatraemia

  • Present in ≈ 20% HF patients and a predictor of recurrent hospitalisations and mortality
  • Two processes can result in hyponatremia requiring different therapeutic approaches:
    • volume overload with dilutional hyponatremia from congestion requiring fluid restriction and loop diuretics
    • hypovolemic hyponatremia from excessive use of natriuretics. Reconsider the need for diuretics

Table 4. Medicines for HF 1–4,6,7

*See LAM and PBS for medicine indications and restrictions

Angiotensin converting enzyme inhibitors (ACEi)

  • Do not use with ARB or ARNI
  • First line agent for HFrEF
  • Side effects include dry cough, hypotension, impaired renal function, hyperkalaemia, rarely angioedema (stop immediately). Initial asymptomatic hypotension or a rise in creatinine or K+ can occur. Monitor BP, UE, eGFR
  • Reduce high dose diuretics 24–48 hrs before starting ACEi

Ramipril start at 2.5 mg PO bd (to a max. 5 mg bd) consider lower starting dose if hypo/normotensive

Enalapril 2.5 mg PO daily (to max. 20 mg daily)

Lisinopril 2.5 mg PO daily (to max. 40 mg daily)

Perindopril arginine (or equivalent erbumine dose)  start at 2.5 mg PO daily (to a max. 10 mg daily)

Angiotensin II receptor blockers (ARB)

  • For ACEi or ARNI intolerant patients. Do not use with ACEi or ARNI
  • All else as per ACEi above

*Candesartan 4 mg PO daily (to max. 32 mg daily)

*Valsartan 40 mg PO bd (to max. 160 mg bd)

Irbesartan 75 mg PO daily (to a max. 300mg daily)

Telmisartan 40 mg PO daily (to a max. 80mg daily)

Beta blockers

  • Start low, go slow. Double dose every 2–4 weeks if stable
  • Ensure sitting systolic BP > 85 mm/Hg before starting
  • Begin only when the patient is clinically stable
  • Monitor BP and HR

Carvedilol start at 3.125 mg PO bd (< 85 kg to a max. 25 mg bd; > 85 kg to a max. 50 mg bd)

Metoprolol MR start at 23.75 mg PO daily (to a max. 190 mg daily)

Bisoprolol start at 1.25 mg PO daily (to a max. 10 mg daily)

*Nebivolol > 70 years age (limited data for < 70 years age) 1.25 mg PO daily. If tolerated, double dose every 1–2 weeks (to a max. 10 mg daily)

Mineralocorticoid receptor antagonists (MRA)

  • Life threatening hyperkalemia if used with ACEi or ARB in patient with renal impairment
  • For patients with sitting systolic BP > 85 mmHg
  • Avoid in patients with stage 4–5 CKD or K+ > 5 mmol/L
  • Monitor BP, UE, eGFR during initiation and up titration according to 5. Cycle of care

Spironolactone 25 mg PO daily (to a max. 50 mg daily after 8 weeks)

Angiotensin-receptor neprilysin inhibitor (ARNI)

  • Do not use with ARB or ACEi
  • Replace ACEi with an ARNI after a 36-hour washout period, in ambulatory patients with HFrEF, who remain symptomatic despite optimal doses of all other HF medicines, adequate BP and an eGFR > 30 mL/min/1.73m2
  • Ensure patient not on ARB monotherapy prior to commencing

Sacubitril with valsartan start at 24/26 mg PO bd (doubling dose every 2–4 weeks to a max. 97/103 mg bd)

Sodium-glucose co-transporter 2 inhibitors (SGLT2i)

  • In addition to optimal doses of all other HF medicines regardless of diabetes status:
    • SGLT2i is recommended with HFrEF
    • consider SGLT2i with HFmrEF and HFpEF

Dapagliflozin or Empagliflozin 10 mg PO daily

Diuretics

  • First line treatment of congestion to maintain euvolaemia
  • Monitor Wt, BP, UEC according to 5. Cycle of care
  • Avoid close to bed time to avoid sleep disruption

Furosemide 20–40 mg PO once a day or bd (to a max. 1 g in divided daily dose)

Bumetanide 0.5–1 mg PO once a day or bd (to a max. 4 g bd)

Digoxin

  • Consider for HFrEF with ongoing symptoms despite optimal doses of all other HF medicines
  • Monitor levels according to 5. Cycle of care
  • Therapeutic range is 0.5–0.8 microgs/L in HF. Levels > 1.2 microgs/L are toxic
  • Not recommended in advanced renal failure

Digoxinaccording to age, body weight and CrCl

  • CrCl 30–60 mL/min then 62.5–250 microgs PO daily
  • Avoid in CrCl < 30 mL/min. Consult specialist

Ivabradine

  • For HFrEF with LVEF ≤ 35% if in sinus rhythm and HR ≥ 70 bpm at rest despite optimal doses of all other HF medicines
  • Up-titrate beta-blocker to maximum tolerated doses before considering ivabradine

Ivabradine5 mg PO bd. Adjust dose after 2–4 weeks according to heart rate. Therapeutic range 2.5–7.5 mg PO bd

Hydralazine + isosorbide dinitrate combination

  • Consider in patients with HFrEF intolerant to ACEi/ARNI or Aboriginal and Torres Strait Islander or African-American people

Hydralazine 25 mg PO tds (to a max. 50–75 mg tds)

Isosorbide mononitrate SR 60mg daily (to max. 120mg daily)

5. Cycle of care

Cycle of care summary for HF

Action

Dx

Review frequency

Height

Once only

BMI

6 mthly

Weight

Daily for 2 wks then as clinically required

Waist circumference

3 mthly

Heart rate and rhythm

Each visit

Blood pressure

Each visit

Urinalysis

12 mthly

Fasting blood glucose 

12 mthly

Chest x-ray

At diagnosis and as clinically indicated

Thyroid function

12 mthly

ECG

Annually for QRS prolongation, conduction changes and AF

UEC and FBC

1 wk after starting or changing medicine. If significant fluid loss occurs check the next day. Otherwise 6 mthly

Iron studies (ferritin, TSAT)

6 mthly

eGFR

6 mthly

Digoxin level

If on high doses, elderly, female or renally impaired; 2 wks after starting or changing dose then 6 mthly

ECG

12 mthly

Social-emotional wellbeing

Each visit

Lifestyle modification

Each visit

Self management education

Each visit

Self-weight and fluid monitoring

Daily

Fluid management

Each visit

Physiotherapist, exercise physiologist

For cardiac rehabilitation, exercise program or home assessment for supports

Influenza, pneumococcal and COVID-19 vaccines

Recommended. See the Australian Immunisation Handbook for schedule

Dietitian

3 mthly

Medicine review

2 wks, mthly for 3 months then 6 mthly

Whenever there is a significant change to condition or medicine regime, refer for home medicine review

Dentist

12 mthly

MO/NP review

3 - 6 mthly

RN/IHW review

3 mthly

Cardiologist

As required

Palliation support

 

As required

Assess falls risk

As condition alters

6. References

7. Resources

  1. National Heart Foundation Heart Failure resources and Queensland Heart Failure Services
  2. Heart Support Australia resources
  3. Heart Foundation support
  4. Heartonline education and toolkits
  5. Understanding Heart Failure: A Practical Guide for all Australians (Information sheet) and Understanding Heart Failure: A Practical Guide for all Australians
  6. Information for fluid intake
  7. Living with Heart Failure diary 
  8. Reducing salt and nutrition with Heart Failure
  9. The National Cardiac Rehabilitation Program Directory and Queensland Heart Failure Services referrals and location
  10. The Epworth Sleepiness Scale and STOP-Bang questionnaire
  11. Heart failure medication optimisation plan

Last updated: September 2024

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