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Guide: Heart Failure Guideline Update

On 1 August 2018, updated guidelines for prevention, detection and management of heart failure were released by the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand.1 These guidelines replace the 2011 guidelines for the prevention, detection and management of chronic heart failure in Australia.2 Here, we provide a brief overview of how GPs should diagnose, classify and manage HF.

Diagnosis

  • A new diagnostic algorithm to guide workup of patients with suspected heart failure
    This new diagnostic algorithm contains information about:
    • Recommended tests to confirm heart failure
    • Role of plasma B-type natriuretic peptide (BNP)/N-terminal proBNP (NT ProBNP) testing.

Classification and investigation

  • Heart failure is now classified using a left ventricular ejection fraction (LVEF) threshold of 50%
    An LVEF of <50% is considered heart failure with reduced ejection fraction (HFrEF), and an LVEF of ≥50% is considered heart failure with preserved ejection fraction (HFpEF).1
  • No separate ‘mid-range’ category for patients with ejection fraction of 40-50%1
  • Red flags which indicate a need for urgent evaluation and specialist referral
    A list of signs, symptoms and test results is now available to indicate when early referral is recommended for patients with heart failure in the community. These are:1
    Symptoms
    • Orthopnoea
    • Paroxysmal nocturnal dyspnoea
    • Syncope
    • Ischaemic chest pain.

    Signs

    • Tachycardia (heart rate > 100 bpm)
    • Bradycardia (heart rate < 40 bpm)
    • Hypotension (systolic blood pressure < 90 mmHg)
    • Hypoxaemia
    • Gallop rhythm
    • Significant heart murmur.

    Investigations

    • Evidence of ischaemia or infarction on 12-lead electrocardiogram
    • Pulmonary oedema on chest x-ray
    • Raised cardiac troponin level
    • Moderate or severe valvular heart disease on echocardiography
    • Left ventricular ejection fraction ≤ 40%
    • Ischaemia on stress testing.

Pharmacological management

  • Medications recommended in all patients with HFrEF
    ACE inhibitors, beta blockers and MRAs recommended in all patients with a LVEF≤40%
    ACE inhibitors, beta blockers and MRAs may be considered in patients with a LVEF 41-49%
  • Additional guidance on optimising treatment
    While it is important to aim for the target doses of these medicines that showed benefit in RCTs, this should not be to the exclusion of starting other drugs that have been shown to decrease mortality in patients with HFrEF.1
  • New treatment option for patients with persistent HFrEF: ARNI
    For persistent HFrEF associated with an LVEF ≤40% despite receiving maximally tolerated or target doses of an ACE inhibitor (or ARB) and beta blocker (unless contraindicated), ARNI is now recommended as a replacement for an ACE inhibitor (or ARB), with or without an MRA, to decrease mortality and decrease hospitalisation.1
    Ensure a ≥36 hr washout window for an ACE inhibitor when switching to an ARNI, and note that patients are not required to be taking an MRA in order to commence treatment with an ARNI.1
  • Ivabradine - additional guidance on patient population
    The recommended population for ivabradine treatment has been updated to:
    • Include an LVEF of ≤35%, to reflect clinical trial evidence1
    • Include previous treatment with maximally tolerated or target doses of an ACE inhibitor (or ARB) and a beta blocker (unless contraindicated), with or without an MRA1
    • Remove the requirement for recent heart failure hospitalisation1,2
  • For patients with recovered ejection fraction: continue treatment to decrease risk of recurrence
    In patients with heart failure associated with a recovered or restored ejection fraction (≥50%), ACE inhibitors, ARBs or ARNIs, beta blockers and MRAs should be continued at target doses unless a reversible cause has been corrected.1

Non-pharmacological management

Multidisciplinary management of patients with heart failure New recommendations include:1

  • Referral to a multidisciplinary heart failure disease management program
    This is recommended for patients with heart failure associated with high risk features to reduce all-cause mortality and rehospitalisation.1
  • Telemonitoring and telephone support
    For high risk heart failure patients living in areas with limited access to face-to-face services after discharge, multidisciplinary telemonitoring or telephone support program should be used for follow-up.1
  • Nurse-led medication titration clinics
    This is recommended for patients with HFrEF who have not achieved maximum tolerated doses of ACE inhibitors, ARBs, ARNIs, beta blockers or MRAs, to decrease hospitalisation.1

Other updates

Further updates to the guidelines are included for prevention, management, devices, surgery and percutaneous procedures, and palliative care. There are 2 new sections relating to “nutraceuticals” and cardiotoxicity.

Key resources

  1. The full 2018 heart failure guideline: National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for prevention, detection, and management of heart failure in Australia 2018.
    Read more about the changes:
    Prevention:
    • Section 4.1: Pharmacological prevention of heart failure

    Diagnosis and investigation:

    • Section 3.3: Classification and Table 3: Diagnostic criteria for HFrEF and HFpEF
    • Section 3.3.3: Ejection fraction 40-50%
    • Section 5.2: Diagnostic investigations for heart failure and Figure 2: Diagnostic workup of a patient with suspected heart failure
    • Section 5.2: Diagnostic investigations for heart failure and Table 4: BNP and NT-proBNP diagnostic cut-off values
    • Section 5.2.2: Assessment of aetiology
    • Section 5.2.3: Risk stratification and prognosis
    • Section 5.1.3: Requirement for more urgent evaluation or referral

    Management

    • Figure 3: Management of patients with heart failure and reduced ejection fraction
    • 5.2.4: Diagnostic tests to guide therapy in heart failure

    Pharmacological management

    • Section 7.1.2.3: Angiotensin Receptor Neprilysin Inhibitor
    • Section 7.1.2.4: Ivabradine
    • Section 7.1.2.7: Nutraceuticals
    • Section 12: Treatment of heart failure with recovered ejection fraction

    Non-pharmacological management

    • Section 8.2: Models of care to improve evidence-based practice

    Chemotherapy-related cardiotoxicity and heart failure

    • Section 11: Chemotherapy-related cardiotoxicity and heart failure

    Devices, surgery and percutaneous procedures

    • Section 9: Devices, surgery and percutaneous procedures

    Palliative care in heart failure

    • Section 14: Palliative care in heart failure
  2. Guideline summary: National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for prevention, detection, and management of heart failure in Australia 2018 - Guideline Summary. Med J Aust, 2 August 2018.

References

  1. Atherton et al. National Heart Foundation of Australia and Cardiac Society of Australian and New Zealand: Guidelines for the prevention, detection and management of heart failure in Australia 2018. Heart and Lung Circulation 2018; 27(10): 1123-1208.
  2. National Heart Foundation of Australia and Cardiac Society of Australian and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection and management of heart failure in Australia: Updated October 2011. National Heart Foundation of Australia, 2011.
  3. Ponikowski et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC), developed with the special contribution of the Heart Failure Association of ESC. European Society of Cardiology, 2016.

This guide was produced by ThinkGP, and sponsored by Novartis.