Chronic Heart Failure

Last updated 1 Jun 2026 · Cardiology

📋 Key Information Summary

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Heart failure with reduced ejection fraction (HFrEF) is defined as LVEF ≤ 40 % and is also termed systolic heart failure; it is characterised by impaired ventricular contraction and is the most evidence-rich phenotype for disease-modifying pharmacotherapy.
Heart failure with preserved ejection fraction (HFpEF) (LVEF ≥ 50 %), historically called diastolic heart failure, results from impaired ventricular relaxation and increased stiffness; treatment focuses on managing congestion, comorbidities, and SGLT2 inhibitors (empagliflozin, dapagliflozin).
HFmrEF (LVEF 41–49 %) represents a mid-range group; current Australian guidelines recommend ACEi/ARB, beta-blocker, and SGLT2 inhibitor therapy.
NYHA functional classification (Class I–IV) guides prognosis, drug titration, and referral pathways and should be documented at every review.
Ischaemic heart disease remains the leading cause of heart failure in Australia; hypertension, atrial fibrillation, valvular disease, and cardiomyopathy are other major aetiologies.
B-type natriuretic peptide (BNP ≥ 100 pg/mL) or NT-proBNP ≥ 300 pg/mL is the recommended first-line investigation; echocardiography is mandatory to confirm diagnosis, classify phenotype, and identify underlying structural causes.
First-line HFrEF drug therapy consists of an ACE inhibitor (or ARB), a beta-blocker (carvedilol, bisoprolol, or metoprolol succinate), a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and an SGLT2 inhibitor — collectively the "four pillars".
Ace inhibitor dose should be titrated to the maximum tolerated evidence-based dose; blood pressure, renal function, and potassium must be checked 1–2 weeks after initiation or dose change.
Beta-blockers must be initiated at low dose in stable, euvolaemic patients and up-titrated slowly — they are contraindicated in acute decompensation.
Loop diuretics (furosemide, bumetanide) provide symptomatic relief of congestion but do not improve survival; dose is adjusted to maintain euvolaemia.
Spironolactone / eplerenone reduces mortality in NYHA II–IV HFrEF; monitor potassium closely (risk of hyperkalaemia especially if eGFR < 30 mL/min/1.73 m²).
Consider sacubitril–valsartan (Entresto®) as a replacement for ACEi in patients who remain symptomatic (NYHA II–III) on optimised ACEi therapy; a 36-hour washout is required when switching from an ACEi.
Aboriginal and Torres Strait Islander Australians experience heart failure at 1.7–2.4 times the rate of non-Indigenous Australians, with younger age of onset, higher mortality, and significant barriers to specialist access in rural and remote areas.
Self-management support including daily weight monitoring, fluid restriction (1.5–2 L/day), sodium restriction (< 2 g/day), and an action plan for weight gain ≥ 2 kg in 48 hours reduces readmissions.

Introduction & Australian Epidemiology

Chronic heart failure (CHF) is a complex clinical syndrome arising from structural or functional cardiac abnormalities that impair ventricular filling or ejection. It is characterised by cardinal symptoms — dyspnoea, fatigue, and fluid retention — and is the final common pathway of many cardiovascular diseases. In Australia, heart failure affects an estimated 480,000–600,000 individuals, with prevalence increasing sharply with age; approximately 1–2 % of the adult population is affected, rising to > 10 % in those aged over 75 years.

Each year in Australia there are approximately 60,000–70,000 hospitalisations where heart failure is the principal diagnosis, making it one of the leading causes of preventable hospital admissions. The Australian Institute of Health and Welfare (AIHW) reports that heart failure contributed to over 12,000 deaths in 2021, and the five-year mortality rate following diagnosis remains approximately 50 %, comparable to many cancers.

The burden of heart failure is not evenly distributed. Aboriginal and Torres Strait Islander Australians experience heart failure at rates 1.7–2.4 times higher than non-Indigenous Australians, with onset at a significantly younger age and substantially higher mortality. Socioeconomic disadvantage, geographic remoteness, and reduced access to guideline-directed medical therapy and specialist cardiology services compound this disparity.

The economic burden is substantial: heart failure costs the Australian health system an estimated .7 billion annually, with hospital admissions accounting for the majority of expenditure. Strategies that improve adherence to guideline-directed medical therapy (GDMT), facilitate early diagnosis, and optimise transitional care from hospital to community have been shown to reduce readmissions and improve quality of life.

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Australian data snapshot: Heart failure is the most common cause of hospital admission in Australians aged over 65 years. Approximately 30 % of patients discharged with heart failure are readmitted within 30 days. Structured post-discharge programmes (e.g., Heart Foundation-supported HARP clinics) can reduce 30-day readmission rates by up to 30 %.

Systolic vs Diastolic Heart Failure

The classification of heart failure by left ventricular ejection fraction (LVEF) is fundamental to guiding therapy. The 2021 European Society of Cardiology (ESC) and 2023 American Heart Association/American College of Cardiology (AHA/ACC) guidelines classify heart failure into three phenotypes based on echocardiographic LVEF:

Feature	HFrEF (Systolic)	HFmrEF (Mid-Range)	HFpEF (Diastolic)
LVEF	≤ 40 %	41–49 %	≥ 50 %
Primary abnormality	Impaired myocardial contraction (reduced systolic function)	Mixed; may transition between HFrEF and HFpEF	Impaired myocardial relaxation and increased ventricular stiffness (diastolic dysfunction)
Typical patient	Male, post-MI, dilated cardiomyopathy	Older, ischaemic aetiology, comorbid AF	Older female, hypertension, obesity, diabetes, atrial fibrillation, renal impairment
Echocardiographic features	Dilated LV, global hypokinesis, raised LVEDP	Intermediate findings	Normal or small LV cavity, LVH, impaired relaxation (E/A ratio < 1), raised E/e′ ratio (> 14), LA enlargement
Proportion of HF cases	~50 %	~10–15 %	~40–50 % (increasing with an ageing population)
Mortality benefit from GDMT	Strong evidence for all four pillars	Emerging evidence; beta-blockers, ACEi/ARB, SGLT2i recommended	SGLT2i (empagliflozin, dapagliflozin) — first class with mortality/morbidity benefit; diuretics for congestion; treat comorbidities

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Key distinction: The terms "systolic" and "diastolic" heart failure are older terminology. Current guidelines prefer "HFrEF" and "HFpEF" as these terms are more precise. Some patients with HFrEF who recover LVEF to ≥ 50 % on treatment are classified as HFrecEF (recovered EF) and should continue GDMT.

Pathophysiology of Systolic Heart Failure (HFrEF)

In HFrEF, the underlying problem is impaired myocardial contractility. This leads to reduced stroke volume and cardiac output, triggering compensatory neurohormonal activation:

Renin–angiotensin–aldosterone system (RAAS) activation — angiotensin II causes vasoconstriction, sodium retention, and myocardial fibrosis; aldosterone promotes fluid retention and potassium loss.
Sympathetic nervous system (SNS) activation — catecholamines increase heart rate and contractility acutely but cause cardiomyocyte apoptosis, arrhythmias, and beta-receptor downregulation chronically.
Natriuretic peptide release — BNP and ANP provide counter-regulatory vasodilation and natriuresis but are overwhelmed by RAAS/SNS dominance.
Ventricular remodelling — progressive LV dilatation, eccentric hypertrophy, and interstitial fibrosis worsen function and increase mortality.

Pathophysiology of Diastolic Heart Failure (HFpEF)

In HFpEF, the myocardium contracts normally but relaxation is impaired and ventricular compliance is reduced. The underlying mechanisms include:

Myocardial stiffness — driven by cardiomyocyte hypertrophy, titin hypophosphorylation, and interstitial collagen deposition.
Systemic microvascular inflammation — endothelial dysfunction reduces nitric oxide availability, impairing cGMP–PKG signalling in cardiomyocytes.
Increased left atrial pressure — during exertion or tachycardia, the stiff ventricle cannot adequately fill at low pressures, causing pulmonary congestion despite a normal ejection fraction.
Comorbidity-driven pathophysiology — obesity, diabetes, hypertension, atrial fibrillation, and chronic kidney disease each contribute to the inflammatory milieu.

NYHA Functional Classification & Causes

NYHA Functional Classification

The New York Heart Association (NYHA) functional classification remains the most widely used system for grading symptom severity in heart failure. It should be assessed and documented at every clinical encounter, as it guides therapy intensity, prognosis, and access to services (e.g., cardiac rehabilitation, advanced therapies, palliative care referral).

Class I

No Limitation

Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations. No symptoms at rest.

Setting: Community — GP management

Class II

Slight Limitation

Comfortable at rest but ordinary activity (e.g., walking 200 m on flat ground, climbing one flight of stairs) causes symptoms.

Setting: GP ± cardiologist; optimise GDMT

Class III

Marked Limitation

Comfortable at rest but less-than-ordinary activity (e.g., dressing, walking 50 m) causes symptoms. No symptoms at rest.

Setting: Cardiologist-led; consider advanced therapies

Class IV

Unable to Carry Out Any Physical Activity

Symptoms at rest; any physical activity increases discomfort. Hospital admission frequently required.

Setting: Tertiary cardiology / advanced HF / palliative care

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ACC/AHA Stages (complementary to NYHA): Stage A = at risk but no structural disease or symptoms; Stage B = structural disease but no symptoms; Stage C = structural disease with current or prior symptoms; Stage D = refractory HF requiring advanced interventions (transplant, MCS, or palliative care). These stages are irreversible and progressive.

Causes and Aetiologies of Heart Failure

Identifying the underlying aetiology is essential, as many causes are reversible or amenable to specific treatment. In Australia, the most common aetiologies include:

Category	Causes	Specific Considerations
Ischaemic	Coronary artery disease, prior MI, ischaemic cardiomyopathy	Leading cause in Australia (~60–70 % of HFrEF); assess viability for revascularisation
Valvular	Aortic stenosis, mitral regurgitation, rheumatic heart disease	Rheumatic heart disease disproportionately affects Aboriginal and Torres Strait Islander Australians
Hypertensive	Chronic hypertension leading to LVH and diastolic dysfunction	Most common contributor to HFpEF; aggressive BP control is essential
Cardiomyopathy	Dilated (idiopathic), peripartum, alcohol-related, tachycardia-mediated, infiltrative (amyloid, sarcoid), hypertrophic (HCM)	Consider genetic referral for familial DCM; cardiac amyloidosis (ATTR) is increasingly recognised
Arrhythmic	Persistent atrial fibrillation, chronic tachycardia	Rate control or rhythm control may improve LVEF
Drug/toxin	Anthracyclines, trastuzumab, alcohol, methamphetamine, cocaine	Methamphetamine-related cardiomyopathy is an increasing concern in Australia
Other	Thyroid disease, iron overload (haemochromatosis), peripartum cardiomyopathy, myocarditis (viral, immune), congenital heart disease	Iron overload: check ferritin and transferrin saturation; treat with venesection or chelation

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Reversible causes — always consider: Tachycardia-mediated cardiomyopathy, thyroid dysfunction (hypo- or hyperthyroidism), high-output states (anaemia, AV fistula, Paget's disease), alcohol-related cardiomyopathy, peripartum cardiomyopathy, and takotsubo (stress) cardiomyopathy. Addressing the underlying cause can lead to significant or complete recovery of LVEF.

Investigation of Heart Failure

Investigation of suspected heart failure follows a structured approach: (1) confirm the diagnosis, (2) determine the phenotype (HFrEF, HFmrEF, HFpEF), (3) identify the underlying aetiology, and (4) assess severity and comorbidities.

Essential First-Line Investigations

Essential BNP or NT-proBNP BNP ≥ 100 pg/mL or NT-proBNP ≥ 300 pg/mL supports diagnosis. Used to rule out HF (high negative predictive value). Also useful for monitoring treatment response. Available through all Australian pathology providers; MBS item 66559 (BNP).

Essential Transthoracic Echocardiography (TTE) Mandatory to confirm diagnosis, assess LVEF, wall motion, valvular function, diastolic parameters (E/A ratio, E/e′, LA volume index), and estimate pulmonary artery systolic pressure. Should be performed within 2 weeks of suspected HF or urgently if haemodynamically unstable. MBS item 55118.

Essential ECG (12-lead) A completely normal ECG has a high negative predictive value for HFrEF (sensitivity > 95 %). Look for: atrial fibrillation, LVH, Q waves (prior MI), LBBB (consider CRT), conduction abnormalities, and arrhythmias.

Essential Full Blood Examination (FBE) Assess for anaemia (a common HF comorbidity that worsens symptoms and prognosis), and exclude haematological causes.

Essential Urea, Electrolytes & Creatinine (UEC) Baseline renal function (eGFR) and potassium — essential before starting ACEi, ARB, MRA, or SGLT2i. Monitor at 1–2 weeks after initiation and dose changes.

Essential Thyroid Function Tests (TFTs) Both hypothyroidism and hyperthyroidism can cause or exacerbate heart failure. MBS item 66716.

Essential Liver Function Tests (LFTs) Hepatic congestion (raised ALT, ALP, bilirubin) is common in right heart failure; also baseline before drug therapy.

Essential Fasting Lipids, Glucose, HbA1c Cardiovascular risk assessment; diabetes is a major comorbidity and risk factor for HFpEF.

Available Iron Studies (Ferritin, Transferrin Saturation) Iron deficiency (ferritin < 100 µg/L, or ferritin 100–299 µg/L with transferrin saturation < 20 %) is present in up to 50 % of HF patients and independently worsens outcomes. IV iron (ferric carboxymaltose, Ferinject®) improves symptoms and exercise capacity.

Available Chest X-ray May show cardiomegaly, pulmonary congestion, pleural effusions, and upper lobe venous diversion. Normal CXR does not exclude HF.

Second-Line & Specialist Investigations

Referral Cardiac MRI (CMR) Gold standard for LVEF and volumes; superior for tissue characterisation (myocarditis, sarcoidosis, amyloidosis, iron overload, fibrosis). MBS item 63400. Indicated when echocardiography is inconclusive or specific aetiology suspected.

Referral Coronary Angiography / CT Coronary Angiogram (CTCA) Consider in HFrEF of uncertain aetiology, especially if ischaemic aetiology suspected and revascularisation may be indicated. CTCA (MBS item 57360) for low–intermediate risk patients.

Specialist Endomyocardial Biopsy Reserved for specific indications: suspected giant-cell myocarditis, cardiac allograft rejection, or infiltrative cardiomyopathy not diagnosed by non-invasive means.

Specialist Cardiac PET / Technetium-99m PYP Scan For diagnosis of ATTR cardiac amyloidosis; increasingly available at major Australian centres. Genetic testing for TTR mutations should accompany positive scans.

Specialist Cardiopulmonary Exercise Testing (CPET) Peak VO₂ assessment for prognosis and transplant/MCS eligibility. Available at major transplant centres.

Referral Right Heart Catheterisation Invasive haemodynamic assessment; indicated for advanced HF evaluation, pulmonary hypertension assessment, and pre-transplant workup.

Available Holter Monitoring (24–72 hour) Assess for non-sustained ventricular tachycardia, atrial fibrillation burden, and bradycardia that may contribute to HF or influence device therapy decisions.

Available Genetic Testing Consider in dilated cardiomyopathy (especially if family history of sudden cardiac death or DCM), hypertrophic cardiomyopathy, and suspected hereditary transthyretin amyloidosis. Available through clinical genetics services in most Australian states.

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Diagnostic algorithm summary: If BNP/NT-proBNP is elevated and ECG is abnormal → proceed to echocardiography urgently. If BNP is normal (< 100 pg/mL BNP or < 300 pg/mL NT-proBNP) with a normal ECG, heart failure is very unlikely, and alternative causes of symptoms should be sought (COPD, deconditioning, obesity, pulmonary embolism).

Drug Therapy — Guideline-Directed Medical Therapy (GDMT)

Modern HFrEF management is built on four evidence-based pharmacological "pillars", each with independent mortality and/or morbidity benefit. These should be initiated as early as possible after diagnosis and up-titrated to maximum tolerated evidence-based doses. HFmrEF and HFpEF management has a growing evidence base, particularly with SGLT2 inhibitors.

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The Four Pillars of HFrEF Therapy (2023 AHA/ACC / 2021 ESC): (1) ACEi / ARB / ARNI, (2) Evidence-based beta-blocker, (3) Mineralocorticoid receptor antagonist (MRA), (4) SGLT2 inhibitor. All four should be initiated and up-titrated unless contraindicated. Do not sequence them sequentially over months — contemporary practice favours early initiation of all four classes, then titration in parallel.

Pillar 1: RAAS Inhibition — ACE Inhibitors, ARBs, and ARNI

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Enalapril

Renitec® · Generic · ACE Inhibitor

Adult dose Start 2.5 mg PO BD, titrate to 10–20 mg BD (target evidence-based dose: 10 mg BD)

Paediatric dose 0.1 mg/kg/day PO, titrate to max 0.5 mg/kg/day (specialist supervision)

Route Oral

Renal adjustment eGFR 30–60: start 2.5 mg daily; eGFR < 30: use with caution, monitor closely. Contraindicated if bilateral renal artery stenosis.

Hepatic adjustment No specific adjustment; use with caution in severe hepatic impairment

Key monitoring BP, UEC (K⁺, Cr) at baseline, 1–2 weeks, and after each dose change; dry cough occurs in ~10–15 % (switch to ARB)

PBS status ✔ PBS General Benefit

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Ramipril

Tritace® · Generic · ACE Inhibitor

Adult dose Start 1.25–2.5 mg PO daily, titrate to 10 mg daily (target evidence-based dose: 10 mg daily)

Paediatric dose Not routinely used in paediatric HF

Route Oral

Renal adjustment eGFR 30–60: start 1.25 mg daily; eGFR < 30: start 1.25 mg daily with close monitoring

PBS status ✔ PBS General Benefit

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Perindopril

Coversyl® · Generic · ACE Inhibitor

Adult dose Start 2 mg PO daily, titrate to 4–8 mg daily (target evidence-based dose: 4 mg daily)

Route Oral

Renal adjustment eGFR 30–60: start 2 mg daily; eGFR < 30: start 2 mg alternate days, titrate with caution

PBS status ✔ PBS General Benefit

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Candesartan

Atacand® · Generic · Angiotensin II Receptor Blocker (ARB)

Adult dose Start 4 mg PO daily, titrate to 32 mg daily (target evidence-based dose: 32 mg daily)

Paediatric dose 0.2 mg/kg/day PO, max 0.4 mg/kg/day (specialist supervision)

Route Oral

Renal adjustment eGFR < 30: use with caution; monitor K⁺ and Cr closely

Indication Alternative to ACEi if intolerant (e.g., cough). Do NOT combine with ACEi.

PBS status ✔ PBS General Benefit

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Sacubitril–Valsartan

Entresto® · Angiotensin Receptor–Neprilysin Inhibitor (ARNI)

Adult dose Start 24/26 mg PO BD (if prior ACEi/ARB at low dose) or 49/51 mg BD; titrate to 97/103 mg BD (target dose)

Key warning MUST allow 36-hour washout when switching from ACEi to reduce angioedema risk. Not required when switching from ARB.

Renal adjustment eGFR 30–60: start 24/26 mg BD; eGFR < 30: limited data, use with caution

Indication HFrEF NYHA II–III who remain symptomatic on ACEi/ARB, or as first-line replacement for ACEi/ARB per 2021 ESC guidelines

PBS status 🔶 PBS Authority Required (Restricted Benefit) — HFrEF with LVEF ≤ 35 % and NYHA II–IV despite optimal ACEi/ARB for ≥ 4 weeks

Pillar 2: Evidence-Based Beta-Blockers

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Critical prescribing principle: Only three beta-blockers have mortality evidence in HFrEF: carvedilol, bisoprolol, and metoprolol succinate (controlled-release). Other beta-blockers (e.g., atenolol, metoprolol tartrate, nebivolol) are NOT substitutes for HFrEF mortality benefit. Always use the specific evidence-based agent. Initiate only when the patient is euvolaemic and not in acute decompensation.

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Carvedilol

Dilatrend® · Generic · Non-selective β + α₁ blocker

Adult dose Start 3.125 mg PO BD, titrate every 2 weeks to 25 mg BD (or 50 mg BD if > 85 kg). Target evidence-based dose: 25 mg BD.

Paediatric dose 0.05 mg/kg/dose PO BD, titrate to max 0.4 mg/kg/dose BD (specialist supervision)

Route Oral

Renal adjustment No specific adjustment required

Hepatic adjustment Contraindicated in severe hepatic impairment

Key monitoring Heart rate (target ≥ 50 bpm resting), BP; warn patients about initial worsening of fatigue/dyspnoea

PBS status ✔ PBS General Benefit

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Bisoprolol

Cardicor® · Generic · Selective β₁ blocker

Adult dose Start 1.25 mg PO daily, titrate every 2 weeks to 10 mg daily. Target evidence-based dose: 10 mg daily.

Route Oral

Renal adjustment eGFR < 20: max dose 10 mg daily with caution

PBS status ✔ PBS General Benefit

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Metoprolol Succinate (Controlled-Release)

Betaloc CR® / Lopresor CR® · Selective β₁ blocker

Adult dose Start 23.75 mg PO daily (¼ of 95 mg tablet), titrate every 2 weeks to 190 mg daily. Target evidence-based dose: 190 mg daily (or 200 mg daily using tartrate equivalent if CR unavailable).

Route Oral (controlled-release formulation only — tartrate salt is NOT interchangeable)

Key warning Metoprolol tartrate (short-acting) does NOT have mortality evidence in HFrEF and should not be substituted for succinate CR.

PBS status ✔ PBS General Benefit

Pillar 3: Mineralocorticoid Receptor Antagonists (MRAs)

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Spironolactone

Aldactone® · Generic · MRA (non-selective)

Adult dose Start 12.5–25 mg PO daily, titrate to 25–50 mg daily. Target evidence-based dose: 25–50 mg daily.

Route Oral

Renal adjustment eGFR < 30: use with extreme caution (significant hyperkalaemia risk); some guidelines recommend avoidance if eGFR < 20. Do NOT combine with eplerenone or another MRA.

Key monitoring K⁺ and creatinine at baseline, 1 week, 4 weeks, then 3-monthly. Risk of hyperkalaemia increases with concomitant ACEi/ARB, CKD, diabetes, elderly, and high dietary K⁺ intake.

Side effects Gynaecomastia and breast tenderness occur in ~10 % of males (dose-related; switch to eplerenone if intolerable)

PBS status ✔ PBS General Benefit

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Eplerenone

Inspra® · Selective MRA

Adult dose Start 25 mg PO daily, titrate to 50 mg daily. Target: 50 mg daily.

Indication Alternative to spironolactone when gynaecomastia is problematic; less anti-androgenic side effects

Renal adjustment eGFR 30–60: start 25 mg alternate days, titrate to 25 mg daily; eGFR < 30: contraindicated

PBS status ✔ PBS General Benefit

Pillar 4: SGLT2 Inhibitors

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Paradigm shift: SGLT2 inhibitors are now recommended for ALL heart failure phenotypes — HFrEF, HFmrEF, and HFpEF — based on DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved, and DELIVER trials. They reduce the composite of cardiovascular death or HF hospitalisation regardless of diabetes status.

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Dapagliflozin

Forxiga® · SGLT2 Inhibitor

Adult dose 10 mg PO once daily (fixed dose, no titration)

Indication HFrEF, HFmrEF, HFpEF (LVEF > 40 %) — regardless of diabetes status

Renal adjustment Can initiate if eGFR ≥ 20 mL/min/1.73 m² (HF indication); glucose-lowering efficacy reduced at lower eGFRs

Key monitoring eGFR (initial "dip" of 3–5 mL/min expected and transient), volume status, symptoms of genital mycotic infection, DKA risk in T1DM (avoid in T1DM)

PBS status 🔶 PBS Authority Required — for heart failure (with or without T2DM)

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Empagliflozin

Jardiance® · SGLT2 Inhibitor

Adult dose 10 mg PO once daily (fixed dose, no titration)

Indication HFrEF, HFmrEF, HFpEF — regardless of diabetes status

Renal adjustment Can initiate if eGFR ≥ 20 mL/min/1.73 m²

PBS status 🔶 PBS Authority Required — for heart failure (with or without T2DM)

Diuretics — Symptomatic Congestion Management

Loop diuretics are the mainstay of decongestion therapy and are essential for symptom relief but have not been shown to reduce mortality. The goal is to maintain euvolaemia at the lowest effective dose. Thiazide diuretics may be added for diuretic resistance.

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Furosemide

Lasix® · Generic · Loop Diuretic

Adult dose Mild congestion: 20–40 mg PO daily. Moderate–severe: 40–80 mg PO daily–BD. Acute decompensation: 40–80 mg IV bolus or infusion. Titrate to maintain euvolaemia (target weight loss 0.5–1 kg/day until dry weight achieved).

Paediatric dose 0.5–2 mg/kg/dose PO/IV BD–TDS (specialist supervision)

Route Oral, IV (bolus or continuous infusion in hospital)

Renal adjustment Higher doses needed in CKD (bioavailability reduced); IV preferred if eGFR < 30 or gut oedema impairs absorption

Key monitoring Daily weights, fluid balance, UEC (K⁺, Na⁺, Mg²⁺, Cr) weekly during titration; watch for hyponatraemia, hypokalaemia, hypomagnesaemia, gout, ototoxicity (high-dose IV)

PBS status ✔ PBS General Benefit

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Bumetanide

Burinex® · Loop Diuretic

Adult dose 0.5–1 mg PO daily–BD; equivalent to ~40 mg furosemide. Useful in patients with variable oral absorption or requiring lower-volume tablets.

Route Oral, IV

PBS status ✔ PBS General Benefit

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Metolazone

Zaroxolyn® · Thiazide-like Diuretic

Adult dose 2.5–5 mg PO daily (used as adjunct for diuretic resistance — "sequential nephron blockade"). Give 30 min before loop diuretic for maximal effect.

Indication Diuretic resistance: inadequate response to high-dose loop diuretic alone

Key warning Potent diuresis — risk of severe dehydration, hyponatraemia, hypokalaemia. Usually administered in hospital or under close monitoring.

PBS status 🔶 PBS Authority Required

Additional Therapies

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Hydralazine + Isosorbide Dinitrate

BiDil® (combination) · Vasodilator combination

Adult dose Hydralazine 37.5 mg / ISDN 20 mg PO TDS (titrate to max hydralazine 75 mg / ISDN 40 mg TDS)

Indication HFrEF patients who cannot tolerate ACEi/ARB (e.g., renal impairment, hyperkalaemia) or as add-on therapy in self-identified African American patients (A-HeFT trial). Consider in Australian practice when ACEi/ARB/ARNI all contraindicated.

PBS status ❌ Not PBS-listed as combination — individual agents available

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Digoxin

Lanoxin® · Generic · Cardiac Glycoside

Adult dose 62.5–125 µg PO daily (aim for serum level 0.5–0.9 ng/mL for HF benefit; lower levels than for AF rate control)

Indication Add-on therapy for persistent symptoms despite optimal GDMT; reduces HF hospitalisation (DIG trial). Also useful for concomitant AF rate control.

Renal adjustment eGFR 10–50: 62.5 µg daily; eGFR < 10: 62.5 µg every 2 days. Monitor levels closely.

Key monitoring Serum digoxin level (6 h post-dose), K⁺ (hypokalaemia increases toxicity risk), renal function

PBS status ✔ PBS General Benefit

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Ivabradine

Corlanor® · Selective If Channel Inhibitor

Adult dose Start 5 mg PO BD, titrate to 7.5 mg BD if resting HR ≥ 70 bpm despite maximally tolerated beta-blocker

Indication HFrEF with LVEF ≤ 35 %, sinus rhythm, resting HR ≥ 70 bpm despite maximally tolerated beta-blocker dose (SHIFT trial)

Contraindication Atrial fibrillation (ineffective); severe hepatic impairment; BP < 90/50 mmHg

PBS status 🔶 PBS Authority Required

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Vericiguat

Verquvo® · Soluble Guanylate Cyclase (sGC) Stimulator

Adult dose Start 2.5 mg PO daily, titrate to 5 mg daily then 10 mg daily (every 2 weeks) if tolerated

Indication HFrEF following recent hospitalisation or IV diuretic use, with LVEF < 45 % despite optimised GDMT (VICTORIA trial). Reduces composite of CV death or HF hospitalisation.

Key monitoring Hypotension; BP ≥ 100 mmHg required for initiation. Teratogenic — contraindicated in pregnancy.

PBS status ❌ Not PBS-listed

Device Therapy (Brief Overview)

Device therapy is an important adjunct to pharmacotherapy in selected patients:

Implantable Cardioverter-Defibrillator (ICD): Indicated for primary prevention in HFrEF with LVEF ≤ 35 % after ≥ 3 months of optimised GDMT, NYHA II–III, and life expectancy > 1 year. Requires LBBB with QRS ≥ 150 ms for CRT-D benefit.
Cardiac Resynchronisation Therapy (CRT): Indicated for HFrEF with LVEF ≤ 35 %, LBBB with QRS ≥ 150 ms (Class I), QRS 130–149 ms (Class IIa), NYHA II–IV despite optimised GDMT, and sinus rhythm. CRT-P or CRT-D.
Referral to advanced HF service: Consider for refractory NYHA III–IV despite maximised GDMT and devices, for assessment of heart transplantation, left ventricular assist device (LVAD), or palliative care planning.

Special Populations

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Pregnancy

ACEi / ARB / ARNI Contraindicated in all trimesters — teratogenic (renal agenesis, oligohydramnios, skull defects). Discontinue immediately and switch to methyldopa, hydralazine, or labetalol for BP control.

Spironolactone Avoid — anti-androgenic effects (feminisation of male fetus). Eplerenone: limited data, generally avoided.

SGLT2 inhibitors Contraindicated — avoid in pregnancy and breastfeeding.

Beta-blockers Labetalol is the preferred beta-blocker in pregnancy. Metoprolol is acceptable. Bisoprolol and carvedilol have less safety data in pregnancy.

Diuretics Furosemide may be used cautiously if needed for congestion; risk of reduced placental perfusion.

Peripartum cardiomyopathy HF diagnosed in the last month of pregnancy or within 5 months postpartum. Bromocriptine (2.5 mg PO BD for 2 weeks, then 2.5 mg daily for 6 weeks) may be considered — emerging evidence supports its use for LVEF recovery.

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Paediatrics

Aetiology Congenital heart disease, dilated cardiomyopathy (often idiopathic or viral myocarditis), and neuromuscular disease are leading causes. Presentation may include failure to thrive, feeding difficulty, tachypnoea, and hepatomegaly.

ACEi Enalapril 0.1 mg/kg/day PO BD, titrate to 0.5 mg/kg/day. Captopril is commonly used in neonates (0.1–0.3 mg/kg/dose TDS).

Beta-blockers Carvedilol 0.05 mg/kg/dose BD, titrate to 0.4 mg/kg/dose BD. Limited paediatric RCT evidence; extrapolated from adult trials.

Diuretics Furosemide 0.5–2 mg/kg/dose PO/IV BD–TDS. Spironolactone 0.5–1 mg/kg/day PO BD. Monitor electrolytes closely.

SGLT2i Not approved for paediatric heart failure. Use is off-label and restricted to specialist settings.

Specialist care All paediatric heart failure should be managed by or in consultation with a paediatric cardiologist. Consider transfer to a tertiary centre with paediatric cardiac services.

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Elderly (≥ 75 years)

Drug titration Start at the lowest recommended doses and titrate slowly. Elderly patients are more susceptible to hypotension, renal impairment, hyperkalaemia, and bradycardia from GDMT.

Diuretics Higher risk of dehydration, electrolyte imbalance, falls, and acute kidney injury. Review regularly and use the lowest effective dose.

Polypharmacy Review all medications for interactions and deprescribe where appropriate. Anticholinergic medications should be minimised. NSAIDs should be avoided (worsen fluid retention and renal function).

Goals of care Discuss advance care planning, resuscitation status, and realistic treatment goals. Consider frailty assessment and multidisciplinary input (GP, cardiologist, pharmacist, palliative care).

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Renal Impairment

ACEi / ARB / ARNI Start at lower doses. Accept a rise in creatinine of up to 30 % from baseline after initiation — this is expected and reflects reduced glomerular hyperfiltration. Discontinue if Cr rises > 30 % or K⁺ > 6.0 mmol/L.

MRA Spironolactone/eplerenone: use with extreme caution if eGFR < 30. Monitor K⁺ at 1 week, 2 weeks, and monthly thereafter. Avoid if K⁺ > 5.0 mmol/L at baseline.

SGLT2i Can be initiated for HF indication if eGFR ≥ 20 mL/min/1.73 m². Beneficial for slowing CKD progression independently of glucose-lowering effect.

Diuretics Higher doses of loop diuretics needed (oral bioavailability reduced; IV may be required). Consider bumetanide (more reliable oral absorption).

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Hepatic Impairment

Carvedilol Contraindicated in severe hepatic impairment (hepatic metabolism). Use bisoprolol or metoprolol with caution as alternatives.

Spironolactone Can be beneficial in congestive hepatopathy (reduces ascites); monitor for hyperkalaemia. Eplerenone also requires caution.

Monitoring Coagulation studies and albumin in severe liver disease. Drug doses may need adjustment based on hepatic synthetic function.

🛡️

Immunocompromised

Considerations Chemotherapy-induced cardiomyopathy (anthracyclines, trastuzumab) — refer for cardio-oncology assessment. Immunosuppression-related HF (e.g., transplant rejection) requires specialist management. Corticosteroids and calcineurin inhibitors may contribute to hypertension and volume overload.

Infection risk Diuretic-induced hyponatraemia may mimic or mask SIADH from infections. SGLT2i increase genital mycotic infection risk (higher in immunocompromised). Ensure vaccinations (influenza, pneumococcal, COVID-19) are up to date.

Aboriginal and Torres Strait Islander Health Considerations

Heart failure burden among Aboriginal and Torres Strait Islander Australians is disproportionately high, with onset at a younger age, more advanced disease at presentation, and substantially higher mortality compared with non-Indigenous Australians. Culturally safe, community-centred approaches are essential to improving outcomes.

Epidemiology

Aboriginal and Torres Strait Islander Australians experience heart failure at 1.7–2.4 times the rate of non-Indigenous Australians. Hospitalisation rates are 2.3 times higher, and median age of first HF presentation is 10–15 years younger. Rheumatic heart disease (RHD) remains a significant contributor to valvular heart failure, particularly in remote Northern Territory and Central Australian communities. The AIHW reports that cardiovascular disease accounts for approximately 20 % of the health gap between Indigenous and non-Indigenous Australians.

Remote & rural access

Specialist cardiology services (echocardiography, cardiologist review, cardiac rehabilitation) are limited or absent in many remote communities. Patients may need to travel hundreds of kilometres for echocardiography or specialist review. Telehealth cardiology consultations (MBS item 99) and point-of-care echocardiography through visiting specialist services (e.g., RHDAustralia, Northern Territory Cardiac Outreach Service) help bridge this gap. Air medical retrieval for acute decompensation adds delay and complexity.

Rheumatic heart disease (RHD)

RHD is almost exclusively seen in Aboriginal and Torres Strait Islander Australians and is the leading cause of acquired valvular heart disease in young Indigenous Australians. Secondary prophylaxis with benzathine penicillin G (21–28 day IM injections) is essential but adherence is challenging. RHD-related HF requires early surgical assessment; timely access to cardiothoracic surgery remains a major barrier in remote settings.

Comorbidities

High rates of type 2 diabetes (3–4 times higher than non-Indigenous), chronic kidney disease, rheumatic heart disease, and ischaemic heart disease contribute to earlier and more severe HF. Social determinants — housing overcrowding, food insecurity, limited access to fresh food, and transport barriers — complicate self-management strategies (fluid restriction, low-sodium diet, daily weights).

Medication access

PBS co-payment exemptions apply to Aboriginal and Torres Strait Islander patients through the Closing the Gap PBS Co-payment Program, significantly reducing out-of-pocket medication costs. Remote Area Aboriginal Health Workers and pharmacists play a crucial role in medication adherence support, blister-pack coordination, and timely supply. Long-acting injectable formulations and multi-dose aids may improve adherence in communities with limited pharmacy access.

Cultural safety

Care should be delivered in partnership with Aboriginal Community Controlled Health Organisations (ACCHOs). Use of plain language, health literacy-appropriate education materials, and culturally appropriate self-management resources (e.g., Heart Foundation's Indigenous resources, Menzies School of Health Research tools) is essential. Family-centred care models that involve extended family and community Elders in decision-making improve engagement. Acknowledge and accommodate Sorry Business, cultural obligations, and avoidance relationships in scheduling and care planning.

Cardiac rehabilitation

Aboriginal and Torres Strait Islander Australians are significantly under-referred to cardiac rehabilitation. Culturally adapted programmes (e.g., "Heart Health" programmes run through ACCHOs) improve uptake and completion. Telehealth and community-based exercise programmes led by Aboriginal health workers are effective alternatives in remote settings. Australian Government MBS items for chronic disease management plans (721, 723) can support structured follow-up.

📚 References

1. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. doi:10.1093/eurheartj/ehab368
2. 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. doi:10.1161/CIR.0000000000001063
3. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Heart Failure 2018. Med J Aust. 2018;209(7):319–327. doi:10.5694/mja18.00647
4. Australian Institute of Health and Welfare. Heart, stroke and vascular disease — Australian facts. AIHW, Canberra; 2023. Available at: https://www.aihw.gov.au
5. McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019;381(21):1995–2008. doi:10.1056/NEJMoa1911303
6. Packer M, Anker SD, Butler J, et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. N Engl J Med. 2020;383(15):1413–1424. doi:10.1056/NEJMoa2022190
7. Anker SD, Butler J, Filippatos G, et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. N Engl J Med. 2021;385(16):1451–1461. doi:10.1056/NEJMoa2107038
8. McMurray JJV, DeMets DL, Inzucchi SE, et al. A trial to evaluate the effect of the sodium-glucose co-transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA-HF). Eur J Heart Fail. 2019;21(5):665–675. doi:10.1002/ejhf.1432
9. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709–717. doi:10.1056/NEJM199909023411001
10. Australian Institute of Health and Welfare. Cardiovascular disease in Aboriginal and Torres Strait Islander people. AIHW, Canberra; 2023. Available at: https://www.aihw.gov.au
11. National Heart Foundation of Australia. Aboriginal and Torres Strait Islander heart health. Heart Foundation; 2023. Available at: https://www.heartfoundation.org.au
12. Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016;2:15084. doi:10.1038/nrdp.2015.84
13. Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370(15):1383–1392. doi:10.1056/NEJMoa1313731
14. Armstrong PW, Pieske B, Anstrom KJ, et al. Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2020;382(20):1883–1893. doi:10.1056/NEJMoa1915928
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. J Am Coll Cardiol. 2017;70(6):776–803. doi:10.1016/j.jacc.2017.04.025

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).