Chronic heart failure: four-pillar GDMT approach in Australian general practice

Chronic heart failure (CHF) is a clinical syndrome in which the heart cannot pump or fill adequately to meet the body’s needs — producing the classic triad of dyspnoea, fatigue, and fluid retention. Around 480,000 Australians live with heart failure, with approximately 50,000 new diagnoses each year. The five-year mortality is roughly 50%, which is worse than many common cancers, yet modern guideline-directed medical therapy (GDMT) — particularly the four-pillar drug approach — has substantially shifted outcomes over the last decade.

Heart failure is phenotyped by the left ventricular ejection fraction (LVEF) on echocardiogram. The NHFA/CSANZ 2018 guidelines classify three main phenotypes: HFrEF (reduced, LVEF ≤40%), HFmrEF (mildly reduced, 41–49%), and HFpEF (preserved, ≥50%). A fourth category — HFimpEF — describes patients whose LVEF recovered above 40% on therapy; they should continue GDMT indefinitely.

Aboriginal and Torres Strait Islander Australians develop heart failure at younger ages — often in their 30s and 40s — and at approximately three times the incidence of non-Indigenous Australians, according to AIHW data. This makes early identification and aggressive management of cardiovascular risk factors a particular priority in this population.

A. Core clinical — the AU general-practice framework

How to approach the diagnosis

The Heart Foundation’s clinical guidelines hub recommends BNP or NT-proBNP as the first-line investigation for suspected new heart failure in general practice. The thresholds for non-acute presentations: BNP below 35 pg/mL or NT-proBNP below 125 pg/mL has high negative predictive value — making heart failure unlikely. Above these thresholds, referral for echocardiogram is warranted to confirm the diagnosis and identify the phenotype. Note that obesity lowers BNP falsely; chronic kidney disease, atrial fibrillation, and older age raise it. BNP/NT-proBNP is rebatable under MBS item 66830 in general practice under specific clinical criteria for diagnosing chronic heart failure.

Symptoms and history to take

The core symptoms are exertional dyspnoea, orthopnoea (needing to raise the head of the bed), paroxysmal nocturnal dyspnoea, fatigue, leg or ankle swelling, and reduced exercise tolerance. Functional assessment using the New York Heart Association (NYHA) classification — I (asymptomatic), II (limited on ordinary activity), III (limited on less than ordinary activity), IV (symptoms at rest) — guides management intensity.

History elements to cover: prior myocardial infarction or coronary artery disease; hypertension; valvular disease; atrial fibrillation; family history of cardiomyopathy; peripartum (timing relative to delivery); alcohol use (a direct cardiotoxin and reversible cause); chemotherapy (anthracyclines, trastuzumab, immune checkpoint inhibitors); comorbidities including type 2 diabetes, chronic kidney disease, COPD, anaemia, and depression.

Drug review must include: NSAIDs (worsen heart failure and renal function — a common and avoidable precipitant), glitazones (TZDs), verapamil and diltiazem (negative inotropes in HFrEF), tricyclics, methadone (QT prolongation).

Watch for amyloid red flags: bilateral carpal tunnel surgery history, autonomic features (postural hypotension, diarrhoea, erectile dysfunction), and thickened ventricles on echo in an older man with HFpEF — these warrant Tc-99m PYP scan.

Examination

Measure blood pressure, heart rate and rhythm, and weight at every visit to compare against the known dry weight. On auscultation, S3 gallop suggests HFrEF; S4 suggests HFpEF. Assess JVP elevation with hepatojugular reflux, displaced apex beat, basal lung crepitations, hepatomegaly in right heart failure, sacral and peripheral oedema.

First-line investigations

Per the eTG cardiovascular module and NHFA/CSANZ guidelines:

• BNP / NT-proBNP — item 66830
• 12-lead ECG — item 11707; Q waves, left bundle branch block, AF, left ventricular hypertrophy
• Chest X-ray — cardiomegaly, pulmonary venous congestion, interstitial oedema, pleural effusions
• Bloods — FBC, UEC [item 66500], LFTs [item 66512], TSH [item 66716], HbA1c [item 66551], lipids, iron studies including ferritin [item 66599] and transferrin saturation [item 66596], troponin [item 66514], urinalysis
• Echocardiogram — specialist-referred; baseline [item 55126], follow-up [item 55130]; GPs cannot bill echo independently

B. Evidence appraisal — the four pillars of HFrEF

The 2022 MJA consensus statement by Atherton et al. — building on the NHFA/CSANZ 2018 guidelines — now recommends starting all four pillar medicines simultaneously as soon as clinically feasible, rather than sequentially as was previous practice. The rationale: the STRONG-HF Lancet 2022 trial showed intensive early up-titration reduces the combined endpoint of death or hospitalisation by approximately 34% at 180 days compared with usual-care sequential introduction.

Pillar	Agent (starting → target dose)	Key outcome trial
1. ARNI or ACEi / ARB	Sacubitril/valsartan 49/51 mg BD → 97/103 mg BD; or perindopril 4→8 mg, ramipril 2.5→10 mg, candesartan 4→32 mg	PARADIGM-HF NEJM 2014 — sacubitril/valsartan 20% mortality reduction vs enalapril
2. Beta-blocker	Bisoprolol 1.25→10 mg; carvedilol 3.125→25 mg BD; metoprolol succinate 12.5→200 mg; nebivolol 1.25→10 mg	CIBIS-II, MERIT-HF, COPERNICUS — use outcome-trial-proven agents only
3. Mineralocorticoid receptor antagonist	Spironolactone 12.5→50 mg; eplerenone 25→50 mg	RALES, EMPHASIS-HF — avoid if K+ over 5.0 or eGFR under 30
4. SGLT2 inhibitor	Dapagliflozin 10 mg or empagliflozin 10 mg daily (single fixed dose)	DAPA-HF NEJM 2019; EMPEROR-Reduced — avoid if eGFR under 20

Switching from ACE inhibitor to sacubitril/valsartan requires a 36-hour washout to prevent angioedema — this is a critical safety step. Allow an acceptable eGFR decline of up to 30% provided it stabilises within two weeks of starting the renin-angiotensin agent, or within four to twelve weeks for the SGLT2 inhibitor. Potassium may rise transiently; recheck UEC at one to two weeks, and a potassium below 5.5 is acceptable during titration.

Loop diuretic for congestion: furosemide 20–40 mg orally daily, titrated to euvolaemia and dry weight. The TRANSFORM-HF JAMA 2023 trial found torasemide and furosemide equivalent for mortality; torasemide’s superior bioavailability may help in patients with gut oedema reducing oral absorption.

SGLT2 inhibitors in HFpEF — the 2021–24 paradigm shift

For HFpEF (LVEF ≥50%), the landscape changed fundamentally with the EMPEROR-Preserved NEJM 2021 and DELIVER NEJM 2022 trials, both demonstrating that SGLT2 inhibitors reduce heart failure hospitalisation across the ejection fraction spectrum, independent of glucose levels or diabetes status. In Australia:

• Dapagliflozin (Forxiga) — PBS-listed for HFpEF and HFmrEF (LVEF >40%) from 1 March 2024
• Empagliflozin (Jardiance) — PBS-listed for LVEF >40% from 1 November 2023

Additional management targets for HFpEF: loop diuretic for congestion; blood pressure below 130/80; AF rate/rhythm control plus anticoagulation per CHA₂DS₂-VA; weight loss of approximately 10% in obesity (semaglutide improved symptoms and exercise capacity in the STEP-HFpEF NEJM 2023 trial).

C. Self-management and cardiac rehabilitation

Self-management is central to preventing hospital readmissions — approximately 25% of patients are readmitted within 30 days, a figure that Cochrane disease management evidence (2017) shows can be significantly reduced through structured nurse-led programmes and cardiac rehabilitation.

Daily weight monitoring is the most powerful early-warning tool available outside the clinic. Patients weigh themselves at the same time each morning — after toileting, before eating, in similar clothing. A gain of 2 kg or more over three days is the standard action threshold. Acting on this promptly — adjusting diuretic dose or contacting the GP — prevents the escalating oedema that otherwise leads to emergency admission.

Sodium restriction — below 2 g per day (one teaspoon of salt) is conventional guidance. However, the SODIUM-HF Lancet 2022 trial found neutral outcomes, suggesting extreme restriction below 1.5 g/day is unnecessary and may worsen neurohormonal activation. Moderate restriction and avoiding highly processed, canned, and takeaway foods is a practical approach.

Exercise and cardiac rehabilitation — all stable heart failure patients should be referred to cardiac rehabilitation. The Cochrane systematic review (2017) confirms multidisciplinary disease management programmes reduce all-cause mortality and hospitalisations. Exercise physiologist referral is available under GPCCMP allied health items.

Vaccinations — annual influenza, pneumococcal, COVID-19 boosters, and RSV per the Australian Immunisation Handbook. Heart failure is a recognised indication for enhanced vaccination priority.

Avoid NSAIDs absolutely — including over-the-counter ibuprofen and naproxen. They worsen fluid retention, blunt the diuretic response, and can precipitate acute decompensation rapidly.

D. Australian operations

MBS access points for GPs:

• BNP/NT-proBNP: item 66830 — rebatable in general practice for diagnosing chronic HF
• ECG: item 11707
• GPCCMP preparation 965 and review 967 — from 1 July 2025, these replace the former GPMP/TCA items 721/723/732; heart failure almost universally qualifies
• ATSI Health Assessment: item 715
• Mental Health Care Plan: items 2715/2717 — depression is present in approximately 30% of people with heart failure

PBS Authority items (all Authority Required, Streamlined):

• Sacubitril/valsartan (Entresto) — symptomatic HFrEF NYHA II–IV, LVEF ≤40%, stable on GDMT, switching from ACEi/ARB
• Dapagliflozin (Forxiga) — separate Authority Required listings for HFrEF (LVEF ≤40%) and HFpEF/HFmrEF (LVEF >40%)
• Empagliflozin (Jardiance) — HFrEF and HFmrEF/HFpEF (LVEF >40%) from November 2023
• Eplerenone — Authority Required for post-MI LV dysfunction (LVEF ≤40%) or HFrEF NYHA II
• Ivabradine — sinus rhythm, HR ≥77 bpm on maximum tolerated beta-blocker, LVEF ≤35%, NYHA II–IV
• Ferric carboxymaltose (Ferinject) — iron deficiency in HFrEF; AFFIRM-AHF Lancet 2020

General schedule: ACEi, ARB, beta-blockers (carvedilol, bisoprolol, metoprolol succinate), loop diuretics, spironolactone, digoxin, hydralazine.

Driving: Per Austroads Assessing Fitness to Drive, NYHA III–IV symptoms or syncope generally restricts commercial driving. An ICD shock triggers a private driving suspension; document this clearly. Advance care planning is appropriate to offer early given the prognosis — a concurrent palliative care approach alongside active GDMT aligns with evidence.

E. Special populations

ATSI Australians — heart failure incidence is approximately three times higher, at younger ages. The ATSI Health Assessment item 715 creates a structured opportunity to identify early disease and risk factors. Wraparound care through Aboriginal Community Controlled Health Organisations improves engagement and outcomes. Cardiovascular risk factor management — particularly rheumatic heart disease, hypertension, and diabetes — is a major lever.

Cardiac amyloid (ATTR-CM) — transthyretin amyloid cardiomyopathy is an underdiagnosed cause of HFpEF, particularly in older men and in people of West African ancestry. The diagnostic clue is HFpEF resistant to usual treatment with red flags: bilateral carpal tunnel surgery history, low-flow low-gradient aortic stenosis, autonomic dysfunction, and thickened ventricles on echo. Tc-99m PYP scan provides non-invasive diagnosis; tafamidis (Vyndaqel) is PBS-listed under Authority for ATTR-CM with NYHA I–II.

HFimpEF — when LVEF recovers above 40% with GDMT, do not stop medications. The TRED-HF Lancet 2019 trial showed 40% of patients relapse within six months of therapy withdrawal. Continue all four pillars indefinitely.

Depression and anxiety — present in roughly 30% of people with heart failure, independently worsening functional status, medication adherence, and readmission rates. Screen actively with PHQ-9. Better Access psychology via Mental Health Care Plan items is rebatable.

Elderly and frail patients — polypharmacy review is particularly important. Deprescribing medications that worsen heart failure (NSAIDs, verapamil, diltiazem, glitazones) takes priority. Simplified regimens and blister packs support adherence. The Home Medicines Review (HMR) through item 900 provides pharmacist domiciliary review.

When to escalate

Refer urgently to the emergency department for:

• Acute pulmonary oedema — severe dyspnoea, hypoxia, diaphoresis, inability to lie flat; call 000
• Cardiogenic shock — systolic BP below 90 with cool peripheries and end-organ hypoperfusion
• New HFrEF with ischaemia — suspected acute MI precipitating heart failure; urgent cardiologist and revascularisation pathway
• Refractory hyperkalaemia (K+ over 5.5 not correcting) or acute kidney injury on GDMT
• Severe acute decompensation not responding to increased oral diuresis within 24 hours

Refer same-week to cardiology for:

• Newly diagnosed heart failure requiring specialist echocardiogram, phenotyping, and GDMT initiation plan
• NYHA III–IV or deterioration despite apparently optimised GDMT
• Suspected reversible aetiology — tachy-cardiomyopathy (rate-control AF), severe aortic stenosis or mitral regurgitation, peripartum, alcohol-related, infiltrative disease
• ICD or CRT consideration — LVEF ≤35% on ≥3 months of optimal GDMT, NYHA II–IV, LBBB with QRS ≥130 ms for CRT
• Cardiac amyloid red flags — for Tc-99m PYP scan

What to send: echocardiogram report, ECG, BNP/NT-proBNP, recent bloods (UEC, iron studies), full medication list with doses, weight chart, NYHA classification, vaccination status, advance care plan if any.

What this article is and is not

This is general health information drawn from current Australian guidelines — the NHFA/CSANZ 2018 heart failure guidelines, the 2022 MJA pharmacological consensus, eTG cardiovascular, AMH, and NPS MedicineWise. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific medicines, doses, and investigations are made by your own GP and specialist with full knowledge of your clinical situation.

MBS and PBS items should be verified against current MBS Online and PBS schedules before billing or prescribing — listings update quarterly.

For Australian consumer resources: Heart Foundation — Living with heart failure, HealthDirect — Heart failure, Better Health Channel, AIHW heart failure data.

For acute cardiac emergency — call 000.

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Sources cited

1. NHFA/CSANZ — Heart Failure Guidelines 2018
2. Atherton JJ et al — MJA consensus 2022
3. Heart Foundation — HF clinical guidelines hub
4. eTG — Cardiovascular: Heart failure
5. AMH
6. NPS MedicineWise — empagliflozin for HF
7. PBS
8. AIHW — Heart failure
9. PARADIGM-HF (NEJM 2014)
10. DAPA-HF (NEJM 2019)
11. DELIVER (NEJM 2022)
12. EMPEROR-Preserved (NEJM 2021)
13. STRONG-HF (Lancet 2022)
14. SODIUM-HF (Lancet 2022)
15. STEP-HFpEF (NEJM 2023)
16. TRED-HF (Lancet 2019)
17. TRANSFORM-HF (JAMA 2023)
18. AFFIRM-AHF (Lancet 2020)
19. Cochrane — HF disease management 2017
20. HealthDirect — Heart failure
21. Better Health Channel — Heart failure
22. Austroads — Assessing Fitness to Drive