Latest Australian guidelines for heart failure management

The National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ) have developed new guidelines to assist clinicians in the care of adult patients with heart failure (HF). The guidelines are based on current evidence and replace the 2011 guidelines for the prevention, detection, and management of chronic heart failure.

The guidelines are published in the journals Heart, Lung and Circulation and Medical Journal of Australia.

KEY RECOMMENDATIONS

Prevention of heart failure

• Blood pressure and lipid-lowering according to published guidelines are recommended, to decrease the risk of cardiovascular events and the risk of developing HF.


• Sodium-glucose cotransporter 2 inhibitors are recommended in patients with type 2 diabetes mellitus associated with cardiovascular disease and insufficient glycaemic control despite metformin, to decrease the risk of cardiovascular events and decrease the risk of HF hospitalization.


• Angiotensin-converting enzyme (ACE) inhibitors are recommended in patients with left ventricular systolic dysfunction, to decrease the risk of developing HF.

Diagnosis of heart failure

• Plasma B-type natriuretic peptide (BNP) or N-terminal proBNP levels are recommended for diagnosis in patients with suspected HF when the diagnosis is uncertain.


• A transthoracic echocardiogram is recommended in patients with suspected HF, to improve diagnostic accuracy, and in patients with a new diagnosis of HF, to assess cardiac structure and function (including the measurement of LVEF), assist in classification and therefore guide management.

Management of heart failure

• The management of acute HF should be guided by the patient’s vital signs, oxygen saturation, and the presence or absence of congestion and hypoperfusion.


• Management includes intravenous diuretics in most patients accompanied by the selected use of oxygen therapy (if hypoxaemic), positive pressure ventilation, vasodilators, and inotropes.


• Effective long-term management of HF is key to decreasing hospitalization and improving survival.

Pharmacological management of chronic heart failure

• An ACE inhibitor is recommended in all patients with HFrEF associated with an LVEF ≤ 40%, unless contraindicated or not tolerated, to decrease mortality and decrease hospitalization.


• A β-blocker (specifically bisoprolol, carvedilol, controlled or extended release metoprolol or nebivolol) is recommended in all patients with HFrEF associated with an LVEF ≤ 40% unless contraindicated or not tolerated, and once stabilized with no or minimal clinical congestion on physical examination, to decrease mortality and decrease hospitalization.


• A mineralocorticoid receptor antagonist (MRA) is recommended in all patients with HFrEF associated with an LVEF ≤ 40% unless contraindicated or not tolerated, to decrease mortality and decrease hospitalization for HF.


• An angiotensin receptor blocker (ARB) is recommended in patients with HFrEF associated with an LVEF ≤ 40% if an ACE inhibitor is contraindicated or not tolerated, to decrease the combined endpoint of cardiovascular mortality and HF hospitalization.


• An angiotensin receptor neprilysin inhibitor (ARNI) is recommended as a replacement for an ACE inhibitor (with at least a 36-hour washout window) or an ARB in patients with HFrEF associated with an LVEF ≤ 40% despite receiving maximally tolerated or target doses of an ACE inhibitor (or ARB) and a β-blocker (unless contraindicated), with or without an MRA, to decrease mortality and decrease hospitalisation.


• Ivabradine should be considered in patients with HFrEF associated with an LVEF ≤ 35% and with a sinus rate ≥ 70 bpm, despite receiving maximally tolerated or target doses of an ACE inhibitor (or ARB) and a β-blocker (unless contraindicated), with or without an MRA, to decrease the combined endpoint of cardiovascular mortality and HF hospitalisation.


• A diuretic should be considered in patients with HF and clinical symptoms, or signs of congestion, to improve symptoms and manage congestion.


• Unless a reversible cause has been corrected, neurohormonal antagonists (ACE inhibitors or ARBs or ARNIs, β-blockers and MRAs) should be continued at target doses in patients with HF associated with a recovered or restored ejection fraction, to decrease the risk of recurrence.

Non-pharmacological management

• Referral to a multidisciplinary HF disease management program is recommended in patients with HF associated with high-risk features, to decrease mortality and rehospitalization.


• In areas where access to a face-to-face multidisciplinary HF disease management program after discharge is limited, patients should be followed up with a multidisciplinary telemonitoring or telephone support program.


• Nurse-led medication titration is recommended in patients diagnosed with HFrEF who have not achieved the maximum tolerated doses of ACE inhibitors, ARBs, ARNIs, β-blockers or MRAs, to decrease hospitalization.


• Regular performance of up to moderate intensity (ie, breathe faster but hold a conversation) continuous exercise is recommended in patients with stable chronic HF, particularly those with reduced LVEF, to improve physical functioning and quality of life and to decrease hospitalization.

Devices, surgery and percutaneous procedures

• Cardiac resynchronization therapy (CRT) is recommended in patients with HFrEF associated with sinus rhythm, an LVEF ≤ 35% and a QRS duration ≥ 150 ms despite optimal medical therapy, to decrease mortality, decrease hospitalization for HF, and improve symptoms.


• CRT should be considered in patients with HFrEF associated with sinus rhythm, an LVEF ≤ 35% and a QRS duration of 130–149 ms despite optimal medical therapy, to decrease mortality, decrease hospitalization for HF, and improve symptoms.


• CRT should be considered in patients with HFrEF associated with an LVEF of ≤ 50% accompanied by a high-grade atrioventricular block requiring pacing, to decrease hospitalization for HF.


• CRT is contraindicated in patients with a QRS duration < 130 ms, because of lack of efficacy and possible harm.


• An implantable cardioverter defibrillator (ICD) should be considered as a primary prevention indication in patients with HFrEF associated with ischaemic heart disease and an LVEF ≤ 35%, to decrease mortality.


• An ICD may be considered as a primary prevention indication in patients with HFrEF associated with dilated cardiomyopathy and an LVEF ≤ 35%, to decrease mortality.


• Coronary artery bypass graft surgery should be considered in patients with HFrEF associated with ischaemic heart disease and an LVEF ≤ 35% if they have surgically correctable coronary artery disease, to improve symptoms (eg, relief of angina and HF symptoms) and decrease morbidity and long-term mortality.


• Surgical aortic valve replacement is recommended in patients with severe aortic stenosis or severe aortic regurgitation and HF in the absence of major comorbidities or frailty, to improve symptoms and decrease mortality.


• Transcatheter aortic valve implantation should be considered in patients with severe aortic stenosis and HF at intermediate to high operative mortality risk, or considered inoperable for surgical aortic valve replacement, and who are deemed suitable for transcatheter aortic valve implantation following assessment by a heart team, to improve symptoms and decrease mortality.


• Referral to a specialist center for consideration of ventricular assist device implantation should be considered in patients with intractable, severe HF despite guideline-directed medical and pacemaker therapy, and who do not suffer from major comorbidities, to decrease mortality.


• Referral for heart transplant assessment should be considered in patients with HF associated with intractable New York Heart Association class III-IV symptoms who have exhausted all alternative therapies and who do not have overt contraindications, to decrease mortality.

Comorbidities in heart failure

• Pharmacological therapy aiming for a resting ventricular rate of 60–100 bpm should be considered in patients with HF associated with AF and a rapid ventricular response.


• Catheter ablation for AF (either paroxysmal or persistent) should be considered in patients with HFrEF associated with an LVEF ≤ 35%, who present with recurrent symptomatic AF, to decrease mortality and hospitalization for HF.


• Adaptive servo-ventilation is not recommended in patients with HFrEF and predominant central sleep apnoea because of increased all-cause and cardiovascular mortality.


• Erythropoietin should not be used routinely for the treatment of anemia in patients with HF, because of an increased risk of thromboembolic adverse events.


• In patients with HFrEF associated with persistent symptoms despite optimised therapy, iron studies should be performed and, if the patient is iron deficient (ie, ferritin < 100 μg/L, or ferritin 100–300 μg/L with transferrin saturation < 20%), intravenous iron should be considered, to improve symptoms and quality of life.

Palliative care in heart failure

• Referral to palliative care should be considered in patients with advanced HF to alleviate end-stage symptoms, improve quality of life and decrease rehospitalization. Involvement of palliative care should be considered early in the trajectory towards end-stage HF.

For more information follow the links: 10.5694/mja18.00647