Heart failure: taking an active role

Early diagnosis of heart failure and effective management keeps people out of hospital and helps them live better, longer lives.

Heart failure: taking an active role

Key points

  • Heart failure affects 480,000 Australians and is associated with high rates of hospitalisation and mortality. Only 50% of people with heart failure are alive 5 years after diagnosis.
  • GPs are ideally placed to diagnose people with heart failure and provide effective treatments that reduce hospitalisations and save lives.
  • An echocardiogram is the single most important investigation in heart failure to confirm the diagnosis and classify heart failure as reduced or preserved ejection fraction (HFrEF or HFpEF) to guide management.
  • ACE inhibitors, heart failure beta blockers and mineralocorticoid receptor antagonists (MRAs) have all been shown to improve prognosis for people with HFrEF, reducing all-cause mortality by 56% over 1–3 years when a medicine from each class is taken in combination at target doses.
  • Start heart failure medicines at low doses and gradually up-titrate one at a time to target or maximum tolerated doses, usually doubled every 2–4 weeks.
  • People with heart failure can gain substantial benefit from education, self-management including action plans, and referrals such as multidisciplinary services and Home Medicines Reviews (HMRs).
 

Focus on heart failure

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How much do you regard heart failure as a condition that needs your attention? Do you have a degree of resignation that there’s not much you can do about it for your patients? Experts advise and evidence shows however, that GPs are ideally placed to identify their patients with heart failure, provide effective life-saving therapy and be the gatekeepers to coordinated patient-centred care. 

Read the full article

 

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

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These guidelines have been developed by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.

They provide guidance for health professionals across all disciplines, including in primary care, on clinical care for people living with heart failure based on current evidence and informed by other international guidelines and local clinical expertise.

Read the full guidelines

 
 

Australian Prescriber

Management of heart failure with preserved ejection fraction

Emma Gard, Shane Nanayakkara, David Kaye, Harry Gibbs
Aust Prescr 2020;43:12–17

Heart failure with preserved ejection fraction (HFpEF) is a highly heterogenous disease. Conventional therapies used in heart failure with reduced ejection fraction (HFrEF) are yet to show a mortality benefit for HFpEF. There is emerging evidence that treatment should be tailored to the individual’s associated comorbidities. Key treatment objectives include control of hypertension and fluid balance.

Read the full article | Hear the podcast

For your patients

NPS MedicineWise

This action plan helps people to identify the most important parts of their heart failure self-management to focus on and put into practice now.

Heart failure: more than just your heart

Date published : 23 February 2021

This factsheet provides information about heart failure, what it means for daily life and provides 5 questions to ask GPs.

Heart failure: What you need to know

Date published : 23 February 2021

Heart Foundation 

  • Living well with heart failure
    This booklet provides information about what heart failure is, its symptoms, self-management strategies and pharmacological management.
  • Heart failure
    This video series provides information about what is heart failure, pharmacological management, psychological health and self-management.
  • Take action within 24 hours
    This action plan encourages people to call the doctor, nurse or health worker within 24 hours if they experience certain symptoms.
  • My fluid plan
    This action plan helps people record and plan their daily fluid intake.
  • Healthy weight action plan
    This action plan helps people to learn more about maintaining a healthy weight and put a plan into practice.
  • Physical activity action plan
    This action plan helps people determine how ready they are to be physically active and put a plan into practice.
  • Get started with more physical activity
    This webpage provides information about doing physical activity and finding a Heart Foundation Walking Group.

Heart Online

Queensland Health

Veterans’ MATES

  • Veterans' Advice: Taking steps to live well with heart failure
    This brochure provides guidance and practical advice for veterans living with heart failure including ‘talk to your GP about planning your care’, ‘do your daily checks’ and other steps regarding physical activity, fluid, salt and alcohol intake, quitting smoking and vaccinations.
 

For your Aboriginal and Torres Strait Islander patients

At NPS MedicineWise, we acknowledge the Aboriginal and Torres Strait Islander peoples as the traditional owners of the lands across Australia. We pay our respects to their Elders past, present and emerging. 

  • Weak heart
    This video, produced by St Vincent’s Hospital Heart Health and the Heart Foundation, provides Aboriginal and Torres Strait Islander people with information about heart failure and its self-management.
  • Physical activity and heart failure: Helping your heart by being active
    This booklet by Queensland Health provides Aboriginal and Torres Strait Islander peoples with information and practical guidance about heart failure and physical activity (exercise).
 

Resources in community languages

The Heart Foundation has a selection of heart health information brochures in a range of languages. You can find brochures on:

  • Living well with chronic heart failure information sheet
  • Living with heart failure:  information to make you feel better
 

Clinical resources and tools

Heart Foundation

Veterans’ MATES

Queensland Health

  • Heart Failure Medication Titration Plan
    This plan provides health professionals with monitoring recommendations, information on medicines up-titration, a problem-solving guide and a printable plan to use with patients.

Practice gaps and patient experience

Reference

Summary

Howlett et al, 2018

Clinical practices and attitudes regarding the diagnosis and management of heart failure: findings from the CORE Needs Assessment Survey

This survey was completed by 346 GPs, cardiologists and nurses who manage patients with heart failure in six countries: Australia, Austria, Canada, Spain, Sweden and the UK.

Results revealed multiple gaps over the spectrum of care, including:

  • diagnosis (low recognition of the signs and symptoms of heart failure and limited use of diagnostic tests)
  • treatment planning (underuse of recommended medicines and sub-therapeutic dosing)
  • treatment monitoring and adjustment (lack of adherence to recommendations)
  • long-term management (low confidence in providing patient education)

Al-Omary et al, 2018

Mortality and readmission following hospitalisation for heart failure in Australia: A systematic review and meta-analysis

The first systematic review and meta-analysis of all-cause readmission and all-cause mortality for patients hospitalised with heart failure in Australia. Studies included were heart failure hospitalisations in Australia published between January 1990 and May 2016.

The statistical analysis used a random effects model to pool proportions across the 13 included studies, which were 3 randomised controlled trials (RCTs) and 10 cohort studies.

Results:

  • The pooled estimated 30-day and 1-year all-cause mortality were 8% and 25% respectively.
  • The pooled estimated 30-day and 1-year all-cause readmission rates were 20% and 56% respectively.

The authors advised that ‘urgent action is needed to reduce the human and financial costs associated with such high mortality and readmission rates.’

Jeon et al, 2010

The experience of living with chronic heart failure: a narrative review of qualitative studies

A narrative review of 30 qualitative studies, mainly from the US and Sweden, of the experience of people living with heart failure, written by Australian-based authors. While published in 2010 (and focusing on research from 1990–2008), the general flavour is still considered to accurately reflect the experience of people today.

It found the most prominent impacts of heart failure on a person’s everyday life includes social isolation, living in fear and losing a sense of control.

 

Diagnosis

Reference

Summary

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Chapter 5 provides a detailed description of the process of differential diagnosis for heart failure, including the Diagnostic Workup algorithm (Page 1145, Figure 2).

5.1 Dyspnoea, which includes a patient history and cardiorespiratory physical examination and blood tests, and Table 6

Table 7: Red flags

5.2 Diagnostic investigations for heart failure, which include blood tests and:

  • 5.2.1.1 12-lead ECG
  • 5.2.1.2 Chest X-rays
  • 5.2.1.3 B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide (BNP or NT proBNP)
  • 5.2.1.4 Echocardiogram
  • 5.2.2 Assessment of aetiology
  • 5.2.4 Diagnostic tests to guide therapy in heart failure

Parsons et al, 2020.

The epidemiology of heart failure in the general Australian community - study of heart failure in the Australian primary carE setting (SHAPE): methods

The SHAPE study is a retrospective cohort epidemiological study based on analysis of non-identifiable medical records of 1.12 million active patients at 43 Australian general practices in 2013–18.

Results for active patients included:

  • 15,468 were classified as having ‘definite heart failure (HF)’, based on having a formal HF diagnosis, HF terms recorded as text in the notes and HF-specific medication
  • only 19.5% of patients identified as definite HF had a HF diagnosis recorded in the diagnosis section of their medical records; 52.4% had a diagnostic term recorded as free text in the consultation notes; 26.7% were identified based on HF-specific medication
  • classification of heart failure as either HFrEF (heart failure with reduced ejection fraction) or HFpEF (heart failure with preserved ejection fraction) was only found in 19 records
  • the age-standardised prevalence of combined ‘definite’ and ‘probable’ HF (the latter defined by medical record data such as ≥40 to < 50% ejection fraction or typical signs and symptoms, and either use of diuretics or more) was 2.199% (95% CIs: 2.168–2.23%)

De Pasquale and Audehm, 2019

Diagnosis of heart failure

This article, published in Medicine Today, is written for a GP audience.

It is accessible via a subscription or once-only payment.

It provides an easy-to-read overview of the diagnosis of heart failure, largely based on the Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.

 

Pharmacological management

Reference

Summary

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Chapter 7 provides a detailed description of the pharmacological management of heart failure, including the HFrEF Management algorithm (Page 1155, Figure 3).

7.1 Heart failure with reduced ejection fraction (HFrEF) (pages 1154 to 1161) includes medicines recommended for:

All patients

  • Angiotensin converting enzyme inhibitors (ACEI)
  • Heart failure beta blockers
  • Mineralocorticoid receptor antagonists (MRAs)

Selected patients

  • Diuretics
  • Angiotensin receptor blockers (ARBs)
  • Angiotensin receptor neprilysin inhibitors (ARNIs)
  • Ivabradine
  • Hydralazine plus nitrates
  • Digoxin
  • Nutraceuticals

    7.2 Heart failure with preserved ejection fraction (HFpEF), which is a much briefer section (half a page) including 5 points of practical advice.

    Burnett et al, 2017

    Thirty years of evidence on the efficacy of drug treatments for chronic heart failure with reduced ejection fraction: A network meta-analysis

    This meta-analysis of 57 included randomized controlled trials (RCTs) found hazard ratios for medicines including ACEI, ARB, ARNI, heart failure beta blocker and MRA, either alone or in combinations of two or three versus prescribed to target doses versus placebo for all-cause mortality and 95% confidence intervals for patients with HFrEF (presented in Figure 5).

    The meta-analysis highlighted that the combination of an ACEI + heart failure beta blocker + MRA for patients with HFrEF had a 56% reduction in all-cause mortality compared to placebo: (hazard ratio 0.44 [95% CI 0.26 to 0.66]).

    This compared, for example, to 17% for ACEI alone and 43% for ACEI + heart failure beta blocker.

    Sindone and Driscoll, 2019

    How to optimise therapy for heart failure with reduced ejection fraction

    This article, published in Medicine Today, is written for a GP audience. It is accessible via a subscription or once-only payment.

    It provides an easy to read overview of pharmacotherapy and device therapies that improve the prognosis for patients with heart failure with reduced ejection fraction (HFrEF).

    It is largely based on the Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.

     

    Education, self-management, referrals and non-pharmacological management

    Reference

    Summary

    National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

    Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

    Chapter 8 provides a detailed description of non-pharmacological management for heart failure. The main takeaways are the ‘Recommendations’ and ‘Practice Advice’:

    8.1 Systems of Care to Reduce Rehospitalisation

    8.2. Models of Care to Improve Evidence-Based Practice

    This section includes guidance on:

    • multidisciplinary heart failure disease management programs
    • nurse-led titration
    • non-pharmacological heart failure management and multimorbidity

    8.3. Frequency of Follow-up

    8.4. Self-management

    This section includes self-monitoring education (see Practice advice)

    8.5. Fluid Restriction and Daily Weighing

    8.6. Sodium Intake

    Note that the guidance for heart failure applies the sodium intake guidance for the whole Australian population. If sodium intake is > 2 g/day for a specific patient, then intervention is recommended to reduce intake for that patient.

    8.7. Exercise Training and Heart Failure

    Jonkman et al, 2016

    Do self-management interventions work in patients with heart failure? An individual patient data meta-analysis

    An individual patient data meta-analysis of 20 included RCTs assessing the effectiveness of self-management interventions for people living with heart failure.

    It found reduced risk of time to the combined endpoint of heart failure-related hospitalisation or all-cause death (HR 0.80; 95% CI, 0.71 to 0.89) and time to heart failure-related hospitalization alone (HR 0.80; 95% CI 0.69 to 0.92).

    The Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018 state that this meta-analysis shows that ‘self-management interventions significantly prolonged the time patients spent out of hospital and stayed alive.’