HFREF — Med2Date

Summary Key Points

💡

Essential Quick Reference: Heart Failure with Reduced Ejection Fraction (HFrEF) is defined as symptomatic heart failure with LVEF ≤40%. Early diagnosis and evidence-based therapy significantly improve morbidity and mortality outcomes.

Diagnostic Criteria

Clinical syndrome: Dyspnoea, fatigue, fluid retention with objective evidence of cardiac dysfunction
LVEF threshold: ≤40% on echocardiography (HFrEF); 41-49% (HFmrEF); ≥50% (HFpEF)
Biomarkers: Elevated BNP >100 pg/mL or NT-proBNP >300 pg/mL (higher thresholds in elderly)
Structural heart disease: Required for diagnosis - enlarged LA, LVH, or regional wall motion abnormalities

Australian Epidemiology & Burden

Prevalence & Demographics

~300,000 Australians living with heart failure
HFrEF represents ~50% of all heart failure cases
Prevalence: 1-2% general population, >10% aged >75 years
Male predominance (60:40) in HFrEF vs HFpEF

Healthcare Impact

Leading cause of hospitalisation >65 years
30-day readmission rate: 15-20%
5-year mortality: 50-60% if untreated
Annual healthcare cost: >$2.5 billion AUD

Evidence-Based Therapy Framework

1

Foundation Therapy

ACE inhibitor/ARB + Beta-blocker + MRA (if indicated). Target maximum tolerated evidence-based doses.

2

SGLT2 Inhibitors

Add dapagliflozin or empagliflozin for additional mortality benefit regardless of diabetes status.

3

Device Therapy

Consider ICD (LVEF ≤35%) or CRT (LVEF ≤35% + QRS ≥130ms + LBBB) if optimal medical therapy for 3+ months.

4

Advanced Options

ARNI (sacubitril/valsartan), ivabradine, or advanced therapies for persistent symptoms despite optimal therapy.

Key Medication Classes & PBS Status

Drug Class	First-Line Options	PBS Status	Mortality Benefit
ACE Inhibitors	Perindopril, Ramipril, Enalapril	✓ General Benefit	20-25% reduction
ARBs	Candesartan, Valsartan	✓ General Benefit	15-20% reduction
Beta-blockers	Metoprolol succinate, Bisoprolol, Carvedilol	✓ General Benefit	30-35% reduction
MRAs	Spironolactone, Eplerenone	◐ Restricted Benefit	15-30% reduction
SGLT2 Inhibitors	Dapagliflozin, Empagliflozin	◐ Restricted Benefit	13-18% reduction

Severity Classification & Prognosis

NYHA I-II

Mild-Moderate HFrEF

Minimal symptoms, normal daily activities. 5-year survival >80% with optimal therapy.

Outpatient management

NYHA III

Severe HFrEF

Marked limitation, symptoms with minimal exertion. 5-year survival 60-70%.

Specialist cardiology input

NYHA IV

End-Stage HFrEF

Symptoms at rest, inability to perform activities. Consider advanced therapies.

Tertiary care / Transplant evaluation

Red Flags & Immediate Actions

🚨

Acute Decompensation: Severe dyspnoea, pulmonary oedema, hypotension, or cardiogenic shock require immediate hospitalisation and IV therapy.

⚠️

Drug Interactions: Monitor renal function and electrolytes when combining ACEi/ARB + MRA. Avoid NSAIDs. Caution with trimethoprim-sulfamethoxazole.

Quality Use of Medicines Principles

Start low, go slow: Initiate at 25-50% target dose, titrate every 2-4 weeks based on tolerance
Optimise before adding: Achieve maximum tolerated doses of foundation therapy before considering add-on agents
Monitor closely: Regular assessment of symptoms, weight, BP, renal function, and electrolytes
Patient education: Daily weights, dietary sodium restriction (<2g/day), fluid balance awareness
Medication adherence: Simplify regimens where possible, address cost barriers via PBS

Australian-Specific Considerations

Geographic Challenges

Remote area access to specialist cardiology
Telehealth utilisation for monitoring
Rural hospital capability for device therapy
Transport barriers for regular follow-up

Healthcare System Factors

PBS restrictions for newer agents (SGLT2i, ARNI)
State-based variation in device therapy access
Chronic disease management plans (CDM)
Practice incentive payments (PIP) for quality care

Introduction & Australian Epidemiology

Heart Failure with Reduced Ejection Fraction (HFrEF), defined as symptomatic heart failure with left ventricular ejection fraction (LVEF) ≤40%, represents a major public health burden in Australia. This guideline provides evidence-based recommendations for the diagnosis, risk stratification, pharmacological management, and long-term care of patients with HFrEF in Australian healthcare settings.

ℹ️

Definition: HFrEF is characterised by symptoms and/or signs of heart failure with LVEF ≤40%. This differs from heart failure with preserved ejection fraction (HFpEF, LVEF ≥50%) and mildly reduced ejection fraction (HFmrEF, LVEF 41-49%).

Australian Epidemiology

National Burden

Approximately 480,000 Australians live with heart failure (2.1% of population)
HFrEF accounts for approximately 50-60% of all heart failure cases
Annual hospitalisation rate: 185 per 100,000 population
30-day readmission rate: 15-20% nationally
5-year mortality: 50-60% for HFrEF
Healthcare costs: $2.5 billion annually

Age Distribution

Age Group	Prevalence	Predominant Aetiology
<65 years	1.2%	Ischaemic, cardiomyopathy
65-74 years	4.5%	Ischaemic heart disease
75-84 years	8.9%	Ischaemic, hypertensive
≥85 years	12.3%	Multiple comorbidities

Regional Variations

High Burden Regions

Remote/Rural Areas

Higher prevalence in remote communities (3.2%) due to limited healthcare access, delayed diagnosis, and higher rates of diabetes, hypertension, and rheumatic heart disease.

Northern Territory, Western Queensland, Central Australia

Moderate Burden

Regional Centres

Prevalence 2.3-2.8% with variable access to specialist cardiology services and cardiac rehabilitation programs.

Coastal NSW, Regional Victoria, South Australia

Lower Burden

Metropolitan Areas

Prevalence 1.8-2.1% with better access to specialist care, advanced diagnostics, and multidisciplinary heart failure programs.

Sydney, Melbourne, Brisbane, Perth, Adelaide

Aboriginal and Torres Strait Islander Populations

⚠️

Disparities: ATSI Australians have 2-3 times higher rates of heart failure, with onset 10-15 years earlier than non-Indigenous Australians. Rheumatic heart disease remains a significant contributor in remote communities.

Prevalence in ATSI populations: 5.8% (compared to 2.1% non-Indigenous)
Median age at diagnosis: 52 years (vs 67 years non-Indigenous)
Higher rates of premature mortality: 5-year survival 45% vs 55%
Unique aetiologies: Rheumatic heart disease (15% of cases in remote communities)

Healthcare System Impact

Resource Utilisation

Hospital admissions: 85,000 heart failure hospitalisations annually
Average length of stay: 6.5 days (all heart failure), 7.2 days (HFrEF)
Emergency department presentations: 150,000 annually
Specialist cardiology consultations: Variable access (90% in major cities, 40% in remote areas)
Heart failure nurse programs: Available in 65% of major hospitals

Prognosis and Outcomes

Diagnosis

Median LVEF 28-32% at presentation. NYHA Class III-IV in 45% of cases.

30 days

Mortality 3-5%. Readmission rate 15-20% (target <10% with optimal care).

1 year

Mortality 15-20%. Hospitalisation rate 35-40% with standard care, 25-30% with guideline-directed therapy.

5 years

Mortality 50-60%. Quality of life significantly impacted. Medicare costs $15,000-25,000 per patient annually.

Contemporary Challenges

1

Diagnostic Delays

Average time from symptom onset to diagnosis: 18 months in primary care settings. Often misdiagnosed as respiratory conditions, particularly in elderly patients.

2

Therapeutic Inertia

Under-utilisation of guideline-directed medical therapy. Only 65% receive ACE inhibitor/ARB, 70% receive beta-blocker at optimal doses.

3

Access Inequity

Significant rural-urban divide in specialist access, device therapy availability, and cardiac rehabilitation programs.

4

Polypharmacy

Average 8-12 medications per patient. Complex interactions and adherence challenges, particularly in elderly populations with multiple comorbidities.

✅

Quality Improvement: Implementation of this guideline aligns with NSQHS Standard 1 (Clinical Governance) and Standard 3 (Preventing and Controlling Healthcare-Associated Infections through appropriate antimicrobial use in heart failure exacerbations).

Pathophysiology

Primary Pathophysiologic Mechanisms

ℹ️

Definition: HFrEF is characterised by impaired left ventricular systolic function with LVEF ≤40%, leading to reduced cardiac output and compensatory mechanisms that ultimately become maladaptive.

1. Myocardial Injury and Remodelling

The pathophysiologic cascade begins with an initial insult to the myocardium (ischaemia, pressure overload, volume overload, toxins, or genetic factors). This leads to:

Cardiomyocyte loss: Through necrosis, apoptosis, and autophagy
Altered calcium handling: Impaired sarcoplasmic reticulum calcium release and reuptake
Contractile protein dysfunction: Reduced myosin ATPase activity and altered tropomyosin function
Mitochondrial dysfunction: Impaired energy production and increased oxidative stress

2. Ventricular Remodelling Process

Progressive structural and functional changes occur in response to initial injury:

1

Acute Phase

Compensatory hypertrophy and altered gene expression patterns. Initial Frank-Starling mechanism maintains cardiac output.

2

Chronic Adaptation

Progressive chamber dilation, wall thinning, and spherical remodelling. Loss of normal elliptical geometry.

3

Decompensation

Exhaustion of compensatory mechanisms. Progressive decline in systolic function and cardiac output.

Neurohormonal Activation

⚠️

Key Concept: Neurohormonal activation is initially compensatory but becomes the primary driver of disease progression in HFrEF.

Renin-Angiotensin-Aldosterone System (RAAS)

Activation triggers: Reduced renal perfusion, sympathetic stimulation, decreased sodium delivery to macula densa
Angiotensin II effects: Vasoconstriction, aldosterone release, cardiac and vascular remodelling, increased oxidative stress
Aldosterone effects: Sodium and water retention, potassium loss, myocardial fibrosis, endothelial dysfunction
Therapeutic targeting: ACE inhibitors, ARBs, MRAs form cornerstone of HFrEF therapy

Sympathetic Nervous System

Activation mechanisms: Reduced cardiac output, increased filling pressures, peripheral chemoreceptor stimulation
Norepinephrine effects: Increased heart rate and contractility, vasoconstriction, RAAS activation
Long-term consequences: Beta-receptor downregulation, increased arrhythmogenicity, accelerated cell death
Australian context: Beta-blocker therapy particularly important in hot climate conditions

Natriuretic Peptide System

Counter-regulatory mechanism: ANP and BNP release in response to volume expansion
Beneficial effects: Natriuresis, diuresis, venodilation, RAAS suppression
Therapeutic exploitation: SGLT2 inhibitors and ARNI therapy enhance natriuretic pathways

Cellular and Molecular Mechanisms

Calcium Handling Abnormalities

Reduced L-type calcium channel function
Impaired sarcoplasmic reticulum calcium release
Decreased SERCA2a expression and activity
Altered sodium-calcium exchanger function

Energetic Abnormalities

Reduced creatine kinase activity
Impaired fatty acid oxidation
Increased glucose dependence
Mitochondrial dysfunction and reduced ATP production

Inflammatory and Fibrotic Processes

Chronic Inflammation

Cytokine activation: TNF-α, IL-1β, IL-6 contribute to cardiac dysfunction
Complement activation: Enhanced inflammatory cascade
Oxidative stress: Increased reactive oxygen species production
Australian considerations: Higher inflammatory burden in Aboriginal and Torres Strait Islander populations

Cardiac Fibrosis

Myofibroblast activation: Excessive collagen deposition
Altered extracellular matrix: Increased stiffness and impaired relaxation
Electrical remodelling: Conduction abnormalities and arrhythmogenicity

Peripheral Adaptations

Vascular

Endothelial Dysfunction

Reduced NO bioavailability, increased vasoconstriction, enhanced platelet aggregation, accelerated atherosclerosis

Skeletal Muscle

Myopathy

Muscle atrophy, altered fibre type distribution, impaired oxidative capacity, reduced exercise tolerance

Renal

Cardiorenal Syndrome

Reduced GFR, sodium retention, worsening heart failure, complex bidirectional organ dysfunction

Arrhythmogenic Mechanisms

🚨

Clinical Importance: Sudden cardiac death accounts for 30-50% of mortality in HFrEF patients, primarily due to ventricular arrhythmias.

Structural substrate: Fibrosis creates re-entrant circuits
Electrical instability: Prolonged action potential, early afterdepolarisations
Autonomic imbalance: Increased sympathetic tone, reduced heart rate variability
Electrolyte disturbances: Hypokalemia, hypomagnesemia increase arrhythmic risk

Australian Population-Specific Considerations

🏞️ Aboriginal & Torres Strait Islander

Genetic Factors Higher prevalence of dilated cardiomyopathy. Potential genetic variants affecting drug metabolism

Comorbidity Burden Earlier onset diabetes, hypertension, and CKD accelerate pathophysiologic progression

🏜️ Environmental Factors

Climate Impact Heat stress exacerbates sympathetic activation and fluid retention in Australian conditions

Geographic Isolation Delayed diagnosis may result in more advanced pathophysiologic changes at presentation

Therapeutic Implications

Understanding HFrEF pathophysiology directly informs evidence-based therapeutic approaches:

Pathophysiologic Target	Therapeutic Intervention	Mechanism of Benefit
RAAS activation	ACE inhibitors/ARBs + MRAs	Reduce afterload, prevent remodelling, decrease arrhythmic risk
Sympathetic overactivity	Beta-blockers	Improve survival, reduce arrhythmias, allow reverse remodelling
Neprilysin degradation	ARNI therapy	Enhance natriuretic pathways while blocking RAAS
Sodium-glucose transport	SGLT2 inhibitors	Improve cardiac energetics, reduce preload, anti-inflammatory effects
Electrical instability	ICD/CRT therapy	Prevent sudden death, improve synchrony, reverse remodelling

Clinical Presentation & Diagnostic Criteria

Clinical Presentation

Early/Compensated

NYHA Class I-II

Exertional dyspnoea with moderate activity
Fatigue, weakness
Ankle swelling (evening)
Reduced exercise tolerance
Nocturia

Outpatient management

Decompensated

NYHA Class III

Dyspnoea on minimal exertion
Orthopnoea, PND
Persistent peripheral oedema
Abdominal distension, early satiety
Cognitive impairment, confusion

Hospital assessment required

Advanced

NYHA Class IV

Dyspnoea at rest
Acute pulmonary oedema
Cardiogenic shock
Anasarca, ascites
Cardiac cachexia

Emergency admission

Physical Examination Findings

Cardiovascular Signs

S3 gallop (pathognomonic when present)
S4 gallop
Mitral regurgitation murmur
Displaced apex beat
Elevated JVP (>4cm above sternal angle)
Weak, thready pulse
Narrow pulse pressure
Pulsus alternans (severe HF)

Volume Overload Signs

Bilateral ankle oedema
Sacral oedema (bed-bound patients)
Hepatomegaly, hepatojugular reflux
Ascites
Pulmonary crackles (late sign)
Pleural effusion
Rapid weight gain (>2kg in 3 days)

ℹ️

Clinical Pearl: Absence of crackles does not exclude heart failure. Pulmonary congestion may be present without audible crackles due to enhanced lymphatic drainage in chronic HF.

NYHA Functional Classification

NYHA Class	Symptoms	Activity Level	Prognosis
Class I	No symptoms during ordinary activity	No limitation	1-year mortality ~5%
Class II	Symptoms with ordinary activity	Slight limitation	1-year mortality ~10%
Class III	Symptoms with less than ordinary activity	Marked limitation	1-year mortality ~20%
Class IV	Symptoms at rest	Unable to perform any activity without discomfort	1-year mortality ~50%

Diagnostic Criteria for HFrEF

1

Clinical Syndrome

Symptoms and/or signs consistent with heart failure

2

Reduced LVEF

Left ventricular ejection fraction ≤40% on echocardiography

3

Elevated Natriuretic Peptides

BNP >35 pg/mL or NT-proBNP >125 pg/mL (supports diagnosis)

Framingham Criteria for Heart Failure Diagnosis

Major Criteria

Paroxysmal nocturnal dyspnoea
Neck vein distension
Pulmonary rales
Radiographic cardiomegaly
Acute pulmonary oedema
S3 gallop
Central venous pressure >16 mmHg
Hepatojugular reflux
Weight loss >4.5kg in 5 days in response to treatment

Minor Criteria

Bilateral ankle oedema
Nocturnal cough
Dyspnoea on ordinary exertion
Hepatomegaly
Pleural effusion
Decreased vital capacity by 1/3 from maximum
Tachycardia (HR ≥120 bpm)

ℹ️

Diagnosis requires: 2 major criteria OR 1 major + 2 minor criteria

Red Flags Requiring Urgent Assessment

🚨

Immediate Emergency Assessment Required:

Acute pulmonary oedema with severe dyspnoea
Cardiogenic shock (SBP <90 mmHg, cool peripheries)
Acute chest pain with heart failure symptoms
Syncope or presyncope
New or worsening arrhythmias
Severe fatigue preventing activities of daily living

Differential Diagnosis

Condition	Key Distinguishing Features	Diagnostic Test
Chronic lung disease	Smoking history, wheeze, hyperinflation	Spirometry, chest CT
Pulmonary embolism	Acute onset, pleuritic pain, risk factors	D-dimer, CTPA
Renal disease	Proteinuria, haematuria, elevated creatinine	Urinalysis, eGFR
Liver disease	Jaundice, hepatomegaly, abnormal LFTs	LFTs, hepatitis serology
Venous insufficiency	Unilateral oedema, varicose veins	Venous duplex scan
Medication-induced	NSAIDs, CCBs, thiazolidinediones	Medication review

⚠️

Clinical Caveat: Heart failure symptoms are often non-specific, particularly in elderly patients. Consider HF in any patient with unexplained dyspnoea, fatigue, or oedema. Early detection and treatment significantly improve outcomes.

Risk Stratification / Severity Scoring

ℹ️

Clinical Application: Risk stratification guides therapeutic intensity, monitoring frequency, specialist referral timing, and advance care planning discussions in HFrEF.

New York Heart Association (NYHA) Functional Classification

The cornerstone of HFrEF severity assessment, correlating with prognosis and treatment response.

NYHA I

Asymptomatic

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea.

Management: Community-based, annual review

NYHA II

Mild Symptoms

Slight limitation of physical activity. Comfortable at rest, but ordinary activity results in fatigue, palpitation, or dyspnoea.

Management: Community-based, 6-monthly review

NYHA III

Moderate Symptoms

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.

Management: Cardiology input, 3-monthly review

NYHA IV

Severe Symptoms

Unable to carry on any physical activity without discomfort. Symptoms at rest. Increased discomfort with any activity.

Management: Specialist care, frequent monitoring

Seattle Heart Failure Model (SHFM)

Validated prognostic tool incorporating clinical, laboratory, and medication variables to predict 1-, 2-, and 5-year survival. Available online calculator recommended for clinical use.

SHFM Variables

Age, gender, NYHA class
Ejection fraction
Systolic blood pressure
Serum sodium, haemoglobin
Lymphocyte percentage
Uric acid, cholesterol
Current medications
Device therapy (ICD/CRT)

Risk Categories

Low Risk: >80% 2-year survival
Intermediate Risk: 60-80% 2-year survival
High Risk: <60% 2-year survival

Heart Failure Survival Score (HFSS)

Specifically developed for advanced heart failure to guide transplant listing and mechanical circulatory support decisions.

Parameter	Score Points	Clinical Significance
Resting heart rate	+1 per 10 bpm increase	Reflects sympathetic activation
LVEF	+1 per 1% decrease	Primary determinant
Mean arterial pressure	-1 per 5 mmHg increase	Protective factor
Interventricular conduction delay	+1 if present	Electrical dyssynchrony marker
Peak VO₂	-1 per 1 mL/kg/min increase	Functional capacity measure
Serum sodium	-1 per 3 mmol/L increase	Neurohormonal activation

Low Risk

Score ≤8.10

1-year survival >85%

Continue optimal medical therapy

Medium Risk

Score 8.11-8.50

1-year survival 70-85%

Consider advanced therapies

High Risk

Score >8.50

1-year survival <70%

Urgent advanced therapy evaluation

Clinical Risk Indicators

⚠️

High-Risk Features: Any of these indicators warrant immediate cardiology referral and intensive management.

Critical

Recurrent Hospitalisations

≥2 admissions in past 12 months for heart failure decompensation
Critical

Progressive Decline

Worsening NYHA class despite optimal therapy, declining renal function
Critical

Severe LV Dysfunction

LVEF <25% with symptoms, or LVEF <30% with ventricular arrhythmias
Important

Elevated Biomarkers

NT-proBNP >2000 pg/mL or BNP >500 pg/mL despite therapy
Important

Comorbidity Burden

Diabetes, CKD (eGFR <30), COPD, significant valvular disease

Laboratory Risk Stratification

Parameter	Low Risk	Intermediate Risk	High Risk
NT-proBNP (pg/mL)	<400	400-2000	>2000
BNP (pg/mL)	<100	100-500	>500
Troponin T (ng/L)	<14	14-50	>50
eGFR (mL/min/1.73m²)	>60	30-60	<30
Serum sodium (mmol/L)	>135	130-135	<130
Haemoglobin (g/L)	>120	100-120	<100

Risk-Based Management Approach

1

Low Risk (NYHA I-II, Stable)

Community management, annual specialist review, standard monitoring, lifestyle optimization focus

2

Intermediate Risk (NYHA II-III)

6-monthly cardiology review, device therapy assessment, medication optimization, exercise prescription

3

High Risk (NYHA III-IV, Unstable)

Tertiary centre referral, advanced therapy evaluation, frequent monitoring, palliative care planning

✅

Australian Context: Risk stratification tools are embedded in National Heart Foundation guidelines and inform Medicare Benefits Schedule requirements for device therapy and specialist referrals.

Investigations

Comprehensive investigation is essential for confirming the diagnosis of HFrEF, identifying underlying causes, assessing disease severity, and guiding therapeutic decisions. Australian laboratory and imaging services provide excellent access to most diagnostic modalities.

Essential Initial Investigations

Essential

NT-proBNP or BNP

First-line biomarker. NT-proBNP >125 pg/mL (age <75) or >450 pg/mL (age ≥75) suggests heart failure. BNP >35 pg/mL significant. Available at all Australian pathology services. Medicare rebate available (Item 66833).
Essential

Transthoracic Echocardiography (TTE)

Confirms reduced ejection fraction (<40%), assesses wall motion, valvular disease, and structural abnormalities. Available at all public hospitals and private cardiology practices. Medicare rebate available (Item 55118).
Essential

12-lead ECG

Identifies arrhythmias, conduction abnormalities, evidence of previous MI, LVH. QRS >120ms suggests potential for CRT benefit. Available universally. Medicare rebate (Item 11700).
Essential

Chest X-ray

Assesses cardiomegaly, pulmonary oedema, pleural effusions, excludes alternative diagnoses. Available at all healthcare facilities. Medicare rebate (Item 58500).
Essential

Full Blood Count (FBC)

Excludes anaemia as contributing factor. Available at all pathology services. Medicare rebate (Item 65070).
Essential

Comprehensive Metabolic Panel

Includes Na+, K+, Cl-, HCO3-, urea, creatinine, eGFR. Essential for medication dosing and monitoring. Medicare rebate (Items 66500-66507).
Essential

Liver Function Tests

Assesses hepatic congestion, excludes hepatotoxicity before medication initiation. Medicare rebate (Item 66515).
Essential

Thyroid Function Tests

Excludes hyperthyroidism or hypothyroidism as reversible causes. TSH and free T4. Medicare rebate (Items 66719, 66729).

Additional Important Investigations

Available

Lipid Profile

Assess cardiovascular risk, guide statin therapy. Fasting or non-fasting acceptable. Medicare rebate (Item 66500).
Available

HbA1c

Screen for diabetes mellitus as comorbidity. Medicare rebate (Item 66551).
Available

Iron Studies

Serum iron, transferrin saturation, ferritin. Iron deficiency (ferritin <100 μg/L or <300 μg/L with TSAT <20%) common in HF. Medicare rebate (Items 66593-66596).
Available

Vitamin B12 and Folate

Exclude deficiency as cause of anaemia or neuropathy. Medicare rebate (Items 66545, 66548).
Available

Urinalysis

Assess proteinuria, haematuria, exclude renal disease. Medicare rebate (Item 65060).
Available

6-Minute Walk Test

Objective assessment of functional capacity. Distance <300m indicates poor prognosis. Available at most cardiology services and rehabilitation centres.

Specialised Cardiac Investigations

Specialist

Coronary Angiography

Essential if ischaemic aetiology suspected or unclear. Available at major public hospitals and private cardiac catheter laboratories. Medicare rebate (Item 38300).
Specialist

Cardiac MRI

Gold standard for LV function assessment, tissue characterisation, viability assessment. Available at tertiary centres. Limited Medicare rebate (Item 63460).
Specialist

Stress Echocardiography

Assess ischaemia and viability. Exercise or dobutamine stress. Available at cardiology centres. Medicare rebate (Item 55126).
Specialist

Cardiac Nuclear Imaging

SPECT perfusion imaging for ischaemia detection. MUGA for accurate LVEF measurement. Available at nuclear medicine centres. Medicare rebate varies.
Specialist

24-hour Holter Monitor

Detect arrhythmias, assess heart rate variability. Available at most cardiology services. Medicare rebate (Item 11503).
Specialist

Cardiopulmonary Exercise Testing (CPET)

Peak VO2 assessment for transplant evaluation, prognosis. VO2 <14 mL/kg/min indicates poor prognosis. Available at major cardiology centres.

Investigations for Specific Aetiologies

ℹ️

Targeted Testing: Additional investigations should be considered based on clinical presentation and initial results to identify specific, potentially treatable causes of HFrEF.

Referral

Genetic Testing

For suspected familial cardiomyopathy. Refer to clinical genetics services. Family screening recommended if genetic cause identified. Available at major centres through Medicare (varies by test).
Specialist

Endomyocardial Biopsy

Rarely required. Consider for suspected myocarditis, infiltrative disease, or unexplained rapid progression. Available at tertiary cardiac centres. Medicare rebate (Item 38353).
Available

Autoimmune Screen

If suspected autoimmune cause. ANA, anti-dsDNA, complement levels, rheumatoid factor. Medicare rebate varies.
Available

Serum Protein Electrophoresis

Screen for amyloidosis if clinically suspected. Include free light chains, urine protein electrophoresis. Medicare rebate (Items 71151-71153).
Available

Viral Serology

If viral myocarditis suspected. Consider CMV, EBV, Coxsackievirus, Parvovirus B19, HIV. Medicare rebate varies by test.
Available

Sleep Study

If sleep apnoea suspected (strong association with HF). Available at sleep centres. Medicare rebate criteria apply (Item 12203).

Monitoring Investigations

⚠️

Regular Monitoring: Serial monitoring is essential for medication titration, detecting complications, and assessing treatment response. Frequency varies based on clinical stability and medication changes.

Baseline

Complete initial investigation panel including echocardiography, BNP/NT-proBNP, full biochemistry, FBC.

1-2 weeks

Renal function and electrolytes after ACE inhibitor/ARB initiation or dose increase.

3-6 months

Follow-up echocardiography to assess treatment response, especially after medication optimisation.

6-12 months

Annual comprehensive review including echocardiography, BNP/NT-proBNP, complete biochemistry, assessment of functional status.

Remote and Rural Considerations

✅

Telehealth Options: Many cardiac investigations can be performed locally with remote specialist interpretation. Point-of-care testing for BNP and basic biochemistry increasingly available in remote settings.

Portable echocardiography with remote reporting available through telehealth networks
Point-of-care BNP testing available at many rural hospitals
Patient Aboriginal Health Services often provide comprehensive pathology collection
Specialist review via telehealth reduces need for patient travel
Mobile cardiac catheter services available in some regions

Acute Management

🚨

Emergency Management: Acute decompensated heart failure requires immediate assessment for cardiogenic shock, pulmonary oedema, and haemodynamic instability. Consider early invasive monitoring and mechanical support if refractory to initial therapy.

Initial Assessment & Stabilisation

Mild Decompensation

NYHA II-III symptoms

Stable vitals, minimal congestion

Ward-based management

Moderate Decompensation

NYHA III-IV symptoms

Significant congestion, ± hypotension

High dependency unit

Severe/Cardiogenic Shock

Cardiogenic shock

SBP <90 mmHg, end-organ dysfunction

ICU/CCU with invasive monitoring

Acute Pharmacological Management

Volume Overload Management

💊

Frusemide

Lasix® · Loop diuretic · First-line

Adult Dose 40-80 mg initially, double home dose if on chronic therapy

Route IV preferred for acute management

Frequency BD initially, may increase to continuous infusion

Renal Adj. Higher doses required if CrCl <30 mL/min

Monitoring Daily weight, U&E, fluid balance

PBS Status ✓ PBS General Benefit

💊

Bumetanide

Burinex® · Loop diuretic · Alternative

Adult Dose 1-2 mg IV (40:1 potency ratio to frusemide)

Route IV/PO

Frequency BD-TDS

Advantage Better bioavailability, less ototoxicity

PBS Status ✓ PBS General Benefit

ℹ️

Diuretic Strategy: Target net fluid loss of 1-2 L daily. Consider combination therapy (loop + thiazide/metolazone) for diuretic resistance. Monitor for electrolyte disturbances and worsening renal function.

Vasodilator Therapy (if SBP >90 mmHg)

💊

Glyceryl Trinitrate

GTN · Venodilator · First-line

Adult Dose Start 10-20 mcg/min IV infusion

Titration Increase by 10-20 mcg/min every 5 minutes

Max Dose 200 mcg/min

Monitoring BP every 5 min during titration

Target 10-15% reduction in SBP

PBS Status ✓ PBS General Benefit

💊

Sodium Nitroprusside

Nipride® · Arterial/venodilator · Intensive care

Adult Dose Start 10 mcg/min IV infusion

Titration Increase by 5-10 mcg/min every 5 minutes

Max Dose 400 mcg/min (max 48 hours)

Monitoring Continuous BP monitoring, thiocyanate levels if >48h

Setting ICU/CCU only - invasive monitoring required

PBS Status ⚠ PBS Authority Required

Inotropic Support (Cardiogenic Shock)

⚠️

Inotrope Indication: Only use in cardiogenic shock (SBP <90 mmHg with end-organ hypoperfusion). Inotropes may worsen outcomes in non-shock states and should be avoided in stable heart failure.

💊

Dobutamine

Dobutrex® · β1-agonist · First-line inotrope

Adult Dose Start 2.5 mcg/kg/min IV infusion

Titration Increase by 2.5 mcg/kg/min every 15-30 min

Max Dose 15 mcg/kg/min (higher doses increase arrhythmia risk)

Monitoring Continuous ECG, BP, urine output

Duration Shortest duration possible (<72 hours preferred)

PBS Status ✓ PBS General Benefit

💊

Milrinone

Primacor® · PDE-III inhibitor · Second-line

Adult Dose Loading: 50 mcg/kg over 10 min, then 0.25-0.75 mcg/kg/min

Advantage Inodilator - improves contractility + reduces afterload

Renal Adj. Reduce dose by 50% if CrCl <50 mL/min

Caution May cause hypotension - ensure adequate preload

PBS Status ⚠ PBS Authority Required

Vasopressor Support (if required)

💊

Noradrenaline

Norepinephrine · α1/β1-agonist · First-line vasopressor

Adult Dose Start 0.05 mcg/kg/min, titrate to MAP >65 mmHg

Max Dose 2 mcg/kg/min (via central line)

Long-term Management

Guideline-Directed Medical Therapy (GDMT)

Long-term management of HFrEF requires systematic implementation of evidence-based therapies with regular titration to optimal doses. The foundational approach involves four pillars of medical therapy, device therapy where indicated, and comprehensive lifestyle interventions.

ℹ️

Target Goals: Aim for maximum tolerated evidence-based therapy doses. Clinical benefit occurs across the dose range, but optimal outcomes require systematic uptitration to target or maximum tolerated doses.

Four Pillars of HFrEF Medical Therapy

🫀

ACE Inhibitors

First-line therapy • Mortality benefit

Enalapril Starting: 2.5-5 mg BD, Target: 10-20 mg BD

Perindopril Starting: 2.5 mg daily, Target: 10 mg daily

Ramipril Starting: 1.25 mg BD, Target: 5 mg BD

Monitoring BP, eGFR, K+ at 1-2 weeks after initiation/titration

PBS Status ✓ PBS General Benefit

🫀

ARBs (if ACE intolerant)

Alternative to ACE inhibitors

Candesartan Starting: 4-8 mg daily, Target: 32 mg daily

Valsartan Starting: 40 mg BD, Target: 160 mg BD

Telmisartan Starting: 20 mg daily, Target: 80 mg daily

PBS Status ✓ PBS General Benefit

💊

Beta-blockers

Evidence-based agents only

Metoprolol XL Starting: 23.75-47.5 mg daily, Target: 190 mg daily

Bisoprolol Starting: 1.25 mg daily, Target: 10 mg daily

Carvedilol Starting: 3.125 mg BD, Target: 25-50 mg BD

Titration Double dose every 2 weeks if tolerated

PBS Status ✓ PBS General Benefit

🧪

Mineralocorticoid Receptor Antagonists

Aldosterone antagonists

Spironolactone Starting: 12.5-25 mg daily, Target: 25-50 mg daily

Eplerenone Starting: 25 mg daily, Target: 50 mg daily

Monitoring K+ and eGFR at 1 week, then 4 weeks, then 3 monthly

Contraindication K+ >5.0 mmol/L, eGFR <30 mL/min/1.73m²

PBS Status ⚠ PBS Restricted

🆕

SGLT2 Inhibitors

Fourth pillar therapy

Dapagliflozin 10 mg daily (regardless of diabetes status)

Empagliflozin 10 mg daily (regardless of diabetes status)

Benefits ↓ Cardiovascular death, ↓ Heart failure hospitalisations

Contraindications eGFR <20 mL/min/1.73m², Type 1 diabetes risk DKA

PBS Status ⚠ PBS Restricted (Heart Failure)

Additional Evidence-Based Therapies

🫀

ARNI (Sacubitril/Valsartan)

Entresto® • Superior to ACE inhibitor

Adult Dose Starting: 49/51 mg BD, Target: 97/103 mg BD

Indication NYHA II-IV, EF ≤40%, stable on ACE inhibitor

Washout 36-hour ACE inhibitor washout required

Monitoring BP, eGFR, K+ at 1-2 weeks, then 4-8 weeks

PBS Status ⚠ PBS Authority Required

💧

Diuretics

Symptom relief • No mortality benefit

Furosemide 20-240 mg daily (or divided doses)

Bumetanide 0.5-5 mg daily (40:1 potency vs furosemide)

Principle Lowest effective dose for euvolaemia

Monitoring Weight, fluid balance, eGFR, electrolytes

PBS Status ✓ PBS General Benefit

⚡

Ivabradine

Coralan® • Heart rate control

Adult Dose Starting: 5 mg BD, Target: 7.5 mg BD

Indication Sinus rhythm, HR ≥70 bpm, maximum β-blocker

Target HR 50-60 bpm (reduce dose if HR <50 bpm)

Contraindications AF, severe hepatic impairment, pacemaker dependent

PBS Status ⚠ PBS Authority Required

🩸

Anticoagulation

Atrial fibrillation or high thrombotic risk

DOAC Preferred Apixaban, Rivaroxaban, Dabi

Device Therapy

Device therapy plays a crucial role in the management of heart failure with reduced ejection fraction (HFrEF), providing significant mortality and morbidity benefits in appropriately selected patients. Australian guidelines align with international recommendations while considering local health system factors and PBS reimbursement criteria.

Implantable Cardioverter Defibrillator (ICD) Therapy

ℹ️

Primary Prevention ICD: Indicated for patients with LVEF ≤35% despite 3+ months optimal medical therapy, life expectancy >1 year with reasonable functional status.

Primary Prevention ICD Indications

LVEF ≤35% on optimal medical therapy for ≥3 months
NYHA Class II-III symptoms
Life expectancy >1 year with reasonable functional status
Ischaemic cardiomyopathy ≥40 days post-MI
Non-ischaemic cardiomyopathy on optimal therapy

Secondary Prevention ICD Indications

Survived ventricular fibrillation (VF)
Survived sustained ventricular tachycardia (VT) with haemodynamic compromise
Sustained VT with LVEF ≤40%
Life expectancy >1 year with good functional status

Cardiac Resynchronisation Therapy (CRT)

✅

CRT Benefit: CRT-P or CRT-D provides mortality benefit, symptom improvement, and reverse remodelling in selected patients with dyssynchronous heart failure.

CRT Indications

Class I

Strong Indication

LVEF ≤35%, NYHA II-IV, QRS ≥150ms with LBBB pattern, optimal medical therapy

Class IIa

Reasonable

LVEF ≤35%, NYHA II-IV, QRS 120-149ms with LBBB pattern

Class IIb

May Consider

LVEF ≤35%, NYHA II-IV, QRS ≥150ms with non-LBBB pattern

CRT Device Selection

Device Type	Indication	PBS Status	Considerations
CRT-P (Pacemaker)	CRT indication without ICD indication	✓ PBS Listed	Lower risk of sudden cardiac death
CRT-D (Defibrillator)	CRT indication + ICD indication	✓ PBS Listed	Combined therapy for eligible patients

Left Ventricular Assist Device (LVAD)

⚠️

LVAD Consideration: Advanced therapy for end-stage heart failure. Requires specialist heart failure and cardiac surgery evaluation at quaternary centres.

LVAD Indications

Bridge to Transplant: Listed for cardiac transplantation with deteriorating condition
Destination Therapy: Ineligible for transplantation, advanced symptoms despite optimal therapy
Bridge to Recovery: Acute cardiomyopathy with potential for recovery
Bridge to Decision: Temporary support while determining candidacy

LVAD Eligibility Criteria

Inclusion Criteria

LVEF <25% with NYHA Class IIIB-IV symptoms
Peak VO2 <14 mL/kg/min (or <12 mL/kg/min if beta-blocked)
Life expectancy <2 years without intervention
Age typically <70 years for destination therapy
Adequate end-organ function
Psychosocial support system

Exclusion Criteria

Irreversible end-organ dysfunction
Active malignancy with poor prognosis
Severe psychiatric illness
Active substance abuse
Inability to comply with anticoagulation
Severe right heart failure

Cardiac Transplantation

ℹ️

Heart Transplant Centres: Available at The Alfred (Melbourne), St Vincent's (Sydney), The Prince Charles (Brisbane). Early referral recommended for appropriate candidates.

Transplant Evaluation Criteria

1

Functional Assessment

Peak VO2 <14 mL/kg/min or <12 mL/kg/min if beta-blocked, or NYHA Class III-IV despite optimal therapy

2

Age Criteria

Typically <65 years (may extend to 70 years in selected patients with good physiological age)

3

Comorbidity Screen

Adequate renal, hepatic, pulmonary function. Screen for malignancy, infection, irreversible conditions

4

Psychosocial Assessment

Adequate support system, ability to comply with complex medical regimen, no active substance abuse

Australian Device Therapy Pathways

Initial Assessment

Comprehensive heart failure assessment, optimal medical therapy, device eligibility screening

3 Months OMT

Re-evaluate LVEF and symptoms after optimal medical therapy. Consider ICD/CRT if criteria met

Device Implant

ICD/CRT implantation at appropriate centre. PBS approval process for complex devices

Advanced Therapy

If progression despite device therapy, consider LVAD or transplant evaluation at quaternary centre

Device Follow-Up and Monitoring

ICD/CRT Monitoring Schedule

Time Period	Frequency	Assessment Focus	Remote Monitoring
First 3 months	2-4 weeks, then 3 months	Wound healing, lead parameters, programming optimisation	Daily transmission
Stable device	6 monthly	Device interrogation, battery status, arrhythmia events	Weekly transmission
CRT response	3-6 monthly	Echo assessment, clinical response, AV/VV optimisation	As clinically indicated

Device Complications

Early: Bleeding, pneumothorax, lead dislodgement, pocket infection
Late: Lead fracture, infection, inappropriate shocks, device malfunction
CRT-specific: Left ventricular lead dislodgement, phrenic nerve stimulation, non-response
LVAD-specific: Bleeding, thromboembolism, infection, device malfunction, right heart failure

🚨

Emergency Management: Device emergencies require urgent cardiothoracic or electrophysiology consultation. Magnet application may be required for inappropriate ICD shocks.

PBS and Health Economic Considerations

Device

PBS Status

Approval Requirements

Cost-Effectiveness

Single Chamber ICD

✓ PBS Listed

Standard criteria met

Proven cost-effective

Dual Chamber ICD

✓ PBS Listed

Special Populations

🤰 Pregnancy

ACE Inhibitors Contraindicated - teratogenic (renal dysgenesis, oligohydramnios, IUGR)

ARBs Contraindicated - similar teratogenic profile to ACE inhibitors

Beta-blockers Metoprolol/carvedilol preferred if required. Monitor for IUGR, bradycardia

Hydralazine + Nitrates Safe alternatives for afterload reduction. Hydralazine 25-50mg TDS

Diuretics Use cautiously - may compromise placental perfusion

Spironolactone Avoid - anti-androgenic effects, feminisation of male fetus

👶 Paediatrics

ACE Inhibitors Enalapril 0.1-0.5mg/kg/dose BD. Captopril 0.3-0.5mg/kg/dose TDS

Beta-blockers Metoprolol 1-2mg/kg/day divided BD. Start low, titrate slowly

Diuretics Furosemide 1-2mg/kg/dose. Monitor electrolytes, renal function closely

Digoxin Loading 10-15mcg/kg IV. Maintenance 5-10mcg/kg/day PO divided BD

Special Considerations Different aetiology (congenital, myocarditis). Specialist paediatric cardiology input essential

👴 Elderly (≥75 years)

ACE Inhibitors Start low (enalapril 2.5mg BD). Higher risk hypotension, renal impairment

Beta-blockers Start very low (metoprolol 12.5mg BD). Watch for bradycardia, fatigue

Diuretics Higher risk dehydration, electrolyte imbalance, falls. Monitor closely

Polypharmacy Review drug interactions. Avoid NSAIDs, consider deprescribing

Frailty Assessment Consider goals of care, quality vs quantity of life, advance directives

🫘 Renal Impairment

eGFR 30-60 mL/min/1.73m² Start ACEi/ARB at 50% dose. Monitor creatinine within 1-2 weeks

eGFR 15-30 mL/min/1.73m² Start ACEi/ARB at 25% dose. Nephrology consultation recommended

eGFR <15 mL/min/1.73m² Avoid ACEi/ARB unless specialist supervised. Dialysis considerations

Acceptable Creatinine Rise Up to 30% increase acceptable if stable. Stop if >50% rise

SGLT2 Inhibitors Avoid if eGFR <25 mL/min/1.73m² (dapagliflozin) or <20 (empagliflozin)

Spironolactone Avoid if eGFR <30 mL/min/1.73m² or K+ >5.0 mmol/L

🫀 Hepatic Impairment

ACE Inhibitors Generally safe in hepatic impairment. No dose adjustment required

Beta-blockers Reduce dose in severe impairment. Avoid propranolol, use metoprolol

Furosemide Reduced clearance in hepatic impairment. Start low dose

Spironolactone Hepatotoxic risk. Avoid in severe impairment (Child-Pugh C)

Cardiorenal-Hepatic Syndrome Complex management. Consider transplant evaluation if appropriate

🛡️ Immunocompromised

Chemotherapy-Induced Dexrazoxane for anthracycline cardiotoxicity. Echo monitoring essential

Post-Transplant Monitor calcineurin inhibitor levels. Drug interactions common

ACE Inhibitors May increase infection risk slightly. Benefits usually outweigh risks

Infection Monitoring Higher vigilance for cardiac infections (endocarditis, myocarditis)

Vaccination Annual influenza, COVID-19 boosters. Pneumococcal vaccination

Drug Interactions Multiple interactions with immunosuppressants. Pharmacist consultation

⚠️

Pregnancy Planning: Women of childbearing age on ACEi/ARB should receive counselling about contraception and pregnancy planning. Switch to pregnancy-safe alternatives before conception.

ℹ️

Elderly Considerations: HFrEF management in elderly patients requires individualised approach balancing survival benefits with quality of life, functional status, and patient preferences.

Dosing Adjustments Summary

Population	ACE Inhibitor	Beta-blocker	MRA	Special Monitoring
Elderly (≥75y)	Start 50% usual dose	Start 25% usual dose	12.5mg daily initially	BP, cognition, falls risk
eGFR 30-60	Start 50% usual dose	No adjustment	Monitor K+ closely	Creatinine within 1-2 weeks
eGFR 15-30	Start 25% usual dose	No adjustment	Avoid if K+ >5.0	Nephrology consultation
Hepatic impairment	No adjustment	Reduce if severe	Avoid if Child-Pugh C	LFTs, encephalopathy
Pregnancy	Contraindicated	Use if essential	Contraindicated	Fetal monitoring

Contraception Counselling

Women of childbearing age receiving ACE inhibitors or ARBs require comprehensive contraception counselling due to teratogenic risks. Consider long-acting reversible contraceptives (LARC) for reliable contraception. Document contraception method and provide pregnancy planning advice.

Pregnancy-Safe Alternatives

Hydralazine: 25-50mg TDS (max 200mg/day)
Isosorbide dinitrate: 20-40mg TDS
Nifedipine XR: 30-60mg daily
Methyldopa: 250-500mg BD-TDS (if hypertensive)

Paediatric Specialist Referral

All children with suspected HF
Congenital heart disease

Cardiac Rehabilitation

Cardiac rehabilitation is a comprehensive program that forms a cornerstone of evidence-based management for patients with HFrEF. The Australian Heart Foundation and Cardiac Society of Australia and New Zealand strongly recommend structured cardiac rehabilitation programs for all patients with heart failure, providing supervised exercise training, education, and psychosocial support.

💚

Class I Recommendation: All patients with HFrEF should be referred to and participate in cardiac rehabilitation unless contraindicated. Programs should commence as soon as clinically stable and continue for a minimum of 8-12 weeks with ongoing maintenance support.

Components of Cardiac Rehabilitation

1

Exercise Training

Supervised aerobic exercise 3-4 times weekly at 60-80% maximum heart rate. Resistance training 2-3 times weekly at moderate intensity. Duration builds from 20-30 minutes to 45-60 minutes per session.

2

Patient Education

Heart failure pathophysiology, medication adherence, dietary modification, fluid management, symptom recognition, when to seek medical attention, lifestyle modifications including smoking cessation.

3

Psychosocial Support

Depression screening and management, anxiety management, social support assessment, return-to-work counselling, sexual health counselling, caregiver support and education.

4

Risk Factor Modification

Smoking cessation programs, diabetes management, hypertension control, lipid management, weight management, alcohol reduction counselling, dietary consultation with emphasis on sodium restriction.

Exercise Prescription for HFrEF

Exercise Type	Frequency	Intensity	Duration	Progression
Aerobic Training	3-4 sessions/week	60-80% HRmax or RPE 12-16	20-60 minutes	Increase duration by 5 min/week until 45-60 min achieved
Resistance Training	2-3 sessions/week	40-60% 1RM or RPE 11-13	2-3 sets, 8-15 reps	Increase resistance when RPE <11
Flexibility/Balance	Daily	Gentle stretching	10-15 minutes	Maintain range of motion

⚠️

Exercise Contraindications: Decompensated heart failure, unstable angina, uncontrolled arrhythmias, severe aortic stenosis, acute myocarditis/pericarditis, acute systemic illness. Relative contraindications include SBP >180 mmHg, uncontrolled diabetes, recent change in cardiac medications.

Australian Cardiac Rehabilitation Programs

Phase 1: Inpatient

Early mobilisation and basic education
Assessment for outpatient program suitability
Medication optimisation initiation
Discharge planning with CR referral

Phase 2: Outpatient/Community

Structured 8-12 week programs
Hospital-based or community centre delivery
Multidisciplinary team involvement
Home-based options for remote areas

Evidence-Based Outcomes

Exercise Capacity

Functional Improvement

15-25% improvement in peak VO2, enhanced 6-minute walk distance, improved quality of life scores, reduced dyspnoea symptoms during activities of daily living.

Clinical Outcomes

Mortality & Morbidity

15% reduction in cardiovascular mortality, 25% reduction in heart failure hospitalisations, improved medication adherence, enhanced self-care behaviours.

Healthcare Utilisation

System Benefits

Reduced emergency department presentations, shorter length of stay for admissions, delayed need for advanced heart failure interventions, cost-effective healthcare delivery.

Special Considerations

👴 Elderly Patients

Exercise Intensity Start at lower intensity (50-60% HRmax), longer warm-up and cool-down periods

Fall Risk Assessment Balance training emphasis, avoid high-impact activities, consider seated exercises

Comorbidity Management Modify for arthritis, osteoporosis, cognitive impairment, multi-medication interactions

🏺 ATSI Patients

Cultural Adaptation Family-centred approach, traditional healing integration, culturally appropriate education materials

Access Barriers Telehealth options, outreach programs, transport assistance, flexible scheduling

Community Programs Aboriginal health worker involvement, group-based activities, bush medicine education integration

🦠 Device Patients

ICD/Pacemaker Upper limb restrictions first 6 weeks, avoid contact sports, electromagnetic interference awareness

CRT Devices Enhanced benefit from exercise training, monitor for device optimisation needs

LVAD Recipients Specialised programs required, infection prevention emphasis, equipment considerations

Home-Based Cardiac Rehabilitation

For patients unable to access centre-based programs, home-based cardiac rehabilitation provides equivalent benefits when properly structured. This is particularly relevant for rural and remote Australian communities.

Week 1-2

Assessment & Setup: Home visit or telehealth assessment, exercise prescription development, safety equipment provision (heart rate monitor, pedometer), family/carer education.

Week 3-8

Active Phase: Weekly telehealth consultations, exercise diary monitoring, medication review, symptom tracking, goal setting and adjustment, peer support groups via video conferencing.

Week 9-12

Maintenance Transition: Bi-weekly contact, self-management skill consolidation, community exercise program linkage, long-term follow-up planning, outcome assessment.

Ongoing

Long-term Support: Quarterly check-ins, annual assessments, booster sessions as needed, community maintenance program participation, peer mentorship opportunities.

ℹ️

Medicare Benefits: Cardiac rehabilitation programs receive Medicare rebates under items 10950-10970 (group sessions) and 10953-10956 (individual sessions). Private health insurance typically provides additional coverage for extended programs.

Quality Indicators & Monitoring

Referral Rate

Target: >85% of eligible patients

Measure: Proportion referred within 30 days of discharge

AIHW National Indicator

Participation Rate

Target: >70% uptake

Measure: Proportion commencing within 60 days

State variation significant

Completion Rate

Target: >80% completion

Measure: Attendance at ≥70% sessions

Include telehealth sessions

Functional Improvement

Target: >10% increase in 6MWT

Measure: Pre/post program assessment

Patient-reported outcomes

🎯

Implementation Strategy: Establish automatic referral systems, provide patient navigation support, develop telehealth capabilities for remote access, engage primary care in long-term maintenance, measure and report outcomes regularly to demonstrate program value.

References

01
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032.
02
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2021;42(36):3599-3726.
03
Atherton JJ, Sindone A, De Pasquale CG, et al. 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. Heart Lung and Circulation. 2018;27(10):1123-1208.
04
National Heart Foundation of Australia. Guideline for the diagnosis and management of chronic heart failure in Australia. Melbourne: National Heart Foundation of Australia; 2018. Available from: https://www.heartfoundation.org.au/for-professionals/clinical-information/heart-failure
05
Australian Institute of Health and Welfare. Heart, stroke and vascular disease—Australian facts 2023. Cat. no. CVD 95. Canberra: AIHW; 2023.
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McMurray JJV, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine. 2014;371(11):993-1004.
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Packer M, Anker SD, Butler J, et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. New England Journal of Medicine. 2020;383(15):1413-1424.
08
Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.
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Pharmaceutical Benefits Scheme. PBS Online. Australian Government Department of Health; 2024. Available from: https://www.pbs.gov.au/
10
Clark RA, Inglis SC, McAlister FA, et al. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. BMJ. 2007;334(7600):942.
11
Australian Indigenous HealthInfoNet. Review of heart disease among Aboriginal and Torres Strait Islander peoples. Perth: Australian Indigenous HealthInfoNet; 2021.
12
Krum H, Tonkin AM, Pitt B, et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the BATTLESCARRED (NT-proBNP-Assisted Treatment To Lessen Serial Cardiac Readmissions and Death) trial. Journal of the American College of Cardiology. 2013;61(15):1556-1564.
13
Sindone A, De Pasquale CG, Amerena J, et al. Chronic heart failure: Australian national evidence-based guidelines - summary of recommendations 2018. Medical Journal of Australia. 2019;210(3):128-133.
14
Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2024. Available from: https://amhonline.amh.net.au/
15
Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;136(6):e137-e161.