Heart failure: the four-pillar approach and what SGLT2 inhibitors changed

What heart failure actually is

Heart failure is a clinical syndrome — not a single disease — in which the heart cannot pump or fill efficiently enough to meet the body’s circulatory needs at normal filling pressures. The result is the classic triad of breathlessness, fatigue, and fluid retention (swollen ankles, raised neck veins, weight gain, congestion in the lungs). The cause varies — prior heart attacks, long-standing high blood pressure, valvular disease, cardiomyopathies, chemotherapy effects, alcohol, and others — but the downstream pathway converges.

The single most important test is an echocardiogram, because the ejection fraction (the percentage of blood the left ventricle pumps out with each beat) divides heart failure into clinically distinct groups with different evidence bases. Per the 2018 NHFA/CSANZ guideline, these are: HFrEF (reduced ejection fraction, ≤40%), HFmrEF (mildly reduced, 41–49%), HFpEF (preserved, ≥50%), and HFimpEF (improved — was ≤40%, now >40% on treatment; treatment is continued because withdrawal causes relapse in around 40% within six months per the TRED-HF trial). Symptoms are graded by the New York Heart Association (NYHA) class: I (no limitation), II (limited by ordinary activity), III (limited by less-than-ordinary activity), IV (symptoms at rest).

Around 480,000 Australians live with heart failure, with ~50,000 new diagnoses each year. Five-year mortality across all severities is approximately 50% — worse than most cancers — and 1-year readmission after a hospital stay sits above 50%. Modern therapy has shifted these numbers, but heart failure remains a serious diagnosis warranting active treatment.

A. Core clinical — the AU primary-care framework

Red flags — escalate immediately

Per eTG and the NHFA/CSANZ 2018 guideline:

• Acute decompensated heart failure — severe breathlessness at rest, pink frothy sputum, inability to lie flat, cold clammy peripheries, low oxygen saturation, or low blood pressure — calls 000 / urgent emergency department transfer.
• Cardiogenic shock — systolic blood pressure under 90 with confusion, oliguria, or cold extremities — emergency department, often intensive care.
• New chest pain suggestive of acute coronary syndrome — heart attack can precipitate new heart failure.
• Syncope — collapse, especially during exertion, raises concern for arrhythmia or severe outflow obstruction.
• Suspected cardiac amyloid — bilateral carpal tunnel surgery, autonomic features, low-flow low-gradient aortic stenosis, very thickened ventricles on echo — needs specialist workup including a Tc-99m PYP scan.

History and examination

A structured history covers symptom pattern, aetiology screen, and modifiable contributors. Symptoms include exertional breathlessness, orthopnoea (breathlessness lying flat), paroxysmal nocturnal dyspnoea (PND — waking gasping after a few hours), fatigue, ankle and abdominal swelling, weight gain, and reduced exercise tolerance — graded by NYHA class. Aetiology screen covers prior heart attack, hypertension, valvular disease, family history of cardiomyopathy, peripartum events, alcohol intake, recreational drug use (cocaine, amphetamines), chemotherapy exposure (anthracyclines, trastuzumab, immune checkpoint inhibitors), radiation, thyroid disease, sleep apnoea, and atrial fibrillation. Drug history is critical — non-steroidal anti-inflammatories, glitazones, certain calcium channel blockers (verapamil and diltiazem in HFrEF), and TNF-alpha inhibitors can all worsen heart failure (AMH).

Examination assesses fluid status (JVP, basal crepitations on auscultation of the chest, peripheral oedema, ascites, hepatomegaly), cardiac findings (displaced apex beat, third heart sound in HFrEF, fourth heart sound in HFpEF, murmurs of mitral regurgitation or aortic stenosis), and clues to specific cardiomyopathies (macroglossia and carpal tunnel signs for amyloid, scleroderma features).

First-line investigations

Per the NHFA/CSANZ 2018 guideline and eTG:

• NT-proBNP or BNP — natriuretic peptides released by stretched cardiac chambers. They have high negative predictive value: a non-acute NT-proBNP under 125 pg/mL or BNP under 35 pg/mL makes heart failure very unlikely. The Medicare item 66830 makes NT-proBNP rebatable in general practice under specific criteria for diagnosing chronic heart failure. Beware false elevations in atrial fibrillation, chronic kidney disease, and older age, and false lows in obesity.
• 12-lead ECG — looks for prior infarction (Q waves), left bundle branch block, atrial fibrillation, and left ventricular hypertrophy.
• Chest X-ray — cardiomegaly, pulmonary venous congestion, interstitial oedema, pleural effusions.
• Transthoracic echocardiogram — the diagnostic anchor. Specialist-performed in Australia; the GP refers. Gives ejection fraction, wall thickness, valve function, atrial size, diastolic function, and right ventricular function.
• Blood tests — full blood count, urea/electrolytes/creatinine, liver function tests, TSH, HbA1c, lipid profile, iron studies including ferritin and transferrin saturation (iron deficiency is common and treatable), troponin if acute presentation, and urinalysis.

The general practice diagnostic pathway in Australia is therefore: clinical suspicion → ECG + NT-proBNP + chest X-ray + bloods → echocardiogram referral → cardiology if anything atypical or if HFrEF is confirmed for shared care.

B. Four-pillar HFrEF therapy — evidence and PBS access

The 2022 MJA consensus statement on pharmacological management recommends starting all four pillars together as soon as clinically feasible — at low doses, titrated up every 2–4 weeks toward target or maximum tolerated within 4–6 weeks. This is a shift from the older sequential approach. The STRONG-HF trial showed that rapid up-titration with close safety monitoring reduces death and readmission.

Pillar 1 — ARNI or ACE inhibitor / ARB

Sacubitril/valsartan (Entresto) is the preferred renin–angiotensin agent based on PARADIGM-HF (NEJM 2014), which showed a 20% mortality reduction versus enalapril. Typical dosing is 49/51 mg twice daily titrated to 97/103 mg twice daily. A 36-hour washout from any prior ACE inhibitor is required to avoid angioedema. If sacubitril/valsartan is not tolerated or accessible, alternatives are an ACE inhibitor (perindopril 4–8 mg, ramipril 2.5–10 mg) or an ARB (candesartan 4–32 mg).

PBS subsidy is via Authority Required (Streamlined) on the PBS for symptomatic chronic HFrEF, NYHA II–IV, LVEF ≤40%, on stable guideline-directed medical therapy and switching from ACE inhibitor or ARB.

Pillar 2 — beta-blocker

Only outcome-trial-proven agents are used in heart failure: bisoprolol (CIBIS-II, 1.25 mg titrated to 10 mg), carvedilol (COPERNICUS, 3.125 mg twice daily titrated to 25 mg twice daily), metoprolol succinate (controlled release) (MERIT-HF, 12.5 mg titrated to 200 mg), and nebivolol. These are all PBS general schedule. Atenolol and other beta-blockers are not used because the outcome data does not transfer.

Pillar 3 — mineralocorticoid receptor antagonist (MRA)

Spironolactone 12.5 mg titrated to 50 mg (RALES) or eplerenone 25 mg titrated to 50 mg (EMPHASIS-HF). Both work by blocking aldosterone. Potassium and kidney function are checked at 1–2 weeks and avoided if potassium is above 5.0 mmol/L or eGFR is below 30. Spironolactone is PBS general schedule; eplerenone has Authority requirements for post-MI left ventricular dysfunction or chronic HFrEF NYHA II.

Pillar 4 — SGLT2 inhibitor

This is the newest pillar and the one that changed practice across the ejection-fraction spectrum. Dapagliflozin 10 mg daily (DAPA-HF, NEJM 2019) and empagliflozin 10 mg daily (EMPEROR-Reduced, NEJM 2020) both reduce cardiovascular death and heart failure hospitalisation, with or without diabetes. They are a single fixed dose — no titration. Avoid if eGFR is below 20. Common side effects include genital fungal infections (usually treatable), mild volume contraction, and a rare risk of diabetic ketoacidosis in those with diabetes.

PBS access pathway in Australia:

• Dapagliflozin (Forxiga) — Authority Required (Streamlined) on PBS for chronic heart failure with LVEF ≤40% (HFrEF), with a separate listing for LVEF >40% since 1 March 2024.
• Empagliflozin (Jardiance) — Authority Required (Streamlined) for HFrEF and from 1 November 2023 expanded to LVEF >40% per RACGP newsGP coverage.

Adjuncts after the four pillars are optimised

For ongoing symptoms or recent worsening on optimal therapy, additional options exist on PBS Authority Required: ivabradine for those in sinus rhythm with heart rate ≥77 on maximum tolerated beta-blocker (SHIFT), vericiguat for recent worsening HFrEF (VICTORIA), digoxin for symptomatic relief and hospitalisation reduction (DIG), and intravenous ferric carboxymaltose for those with iron deficiency on iron studies (FAIR-HF, AFFIRM-AHF). Device therapies — implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) — are considered for those with persisting low ejection fraction and broad QRS on ECG, decided by a cardiologist.

C. HFpEF — what we know, what we don’t

HFpEF (LVEF ≥50%) is a heterogeneous group — many people have hypertension, atrial fibrillation, obstructive sleep apnoea, obesity, kidney disease, and the typical age over 70. For decades there was no disease-modifying drug. That changed with the SGLT2 inhibitor trials.

EMPEROR-Preserved (NEJM 2021) showed empagliflozin reduced the combined outcome of cardiovascular death or heart failure hospitalisation in HFpEF, mainly driven by fewer hospitalisations. DELIVER (NEJM 2022) confirmed the finding with dapagliflozin and extended it across HFmrEF and HFimpEF. Both are now on PBS for the LVEF >40% indication in Australia as outlined above.

The remainder of HFpEF management is comorbidity-anchored and symptom-driven:

• Loop diuretic (usually furosemide 20–40 mg orally, titrated to dry weight) for congestion.
• Tight blood pressure control below 130/80 — see the Heart Foundation guidelines.
• Atrial fibrillation — rate or rhythm control plus anticoagulation per CHA₂DS₂-VA risk score.
• Obstructive sleep apnoea — diagnose and treat where present.
• Weight loss — approximately 10% if obesity is present; the STEP-HFpEF trial (NEJM 2023) showed semaglutide improved symptoms and exercise capacity in HFpEF with obesity.
• Spironolactone — secondary analyses (TOPCAT Americas substudy) suggest modest event reduction in HFpEF; can be considered if potassium permits.

If the echo shows very thickened ventricles, low-flow low-gradient aortic stenosis, or there is a history of bilateral carpal tunnel surgery, cardiac amyloidosis must be excluded — a specialist workup including a Tc-99m PYP scan, and tafamidis if transthyretin amyloid is confirmed (PBS Authority Required).

D. Australian operations

MBS items relevant to heart failure management

For consultations, MBS items 3, 23, 36, and 44 cover general practice attendances of different lengths. An ECG in general practice attracts MBS item 11707. NT-proBNP testing for diagnosing chronic heart failure is MBS item 66830, with specific clinical criteria. The echocardiogram itself is performed and billed by specialists (MBS 55126 baseline, 55130 follow-up).

The chronic disease management framework was reformed on 1 July 2025: the old item numbers 721, 723, and 732 have been replaced by the General Practitioner Chronic Condition Management Plan (GPCCMP), items 965 and 967, with telehealth equivalents 92029, 92030, 92060, and 92061, per the CDM reform fact sheet. Heart failure qualifies. A GPCCMP supports referrals to allied health — most commonly exercise physiology and dietetics — and structures the team-based plan.

A Mental Health Treatment Plan (items 2715/2717) is worth considering early: depression affects around 30% of people with heart failure and worsens self-care and outcomes.

PBS authority pathways at a glance

All four-pillar agents are PBS-subsidised in Australia. Sacubitril/valsartan, dapagliflozin, empagliflozin, ivabradine, vericiguat, eplerenone, ferric carboxymaltose, and tafamidis are Authority Required (Streamlined) with specific clinical criteria. ACE inhibitors, ARBs, heart-failure beta-blockers, spironolactone, loop diuretics, and digoxin sit on the general schedule.

Cardiac rehabilitation and the heart failure helpline

Cardiac rehabilitation is the single highest-yield non-pharmacological intervention — the Cochrane review of heart failure disease management programs (2017) showed reduced all-cause mortality and readmission. State-funded outpatient cardiac rehabilitation programs are available across Australia; ask your GP for the local referral pathway. The Heart Foundation Helpline (13 11 12) connects you to a qualified health professional for free advice on heart conditions and Australian self-management resources including My Heart, My Life.

Driving and heart failure

Per Austroads — Assessing Fitness to Drive: NYHA III–IV symptoms or syncope are generally unfit for a commercial licence. Private driving is usually permitted unless an implantable defibrillator has fired or specific shock criteria are met, in which case a temporary suspension applies. Your GP and cardiologist will discuss this with you.

Vaccinations

Annual influenza, pneumococcal, COVID-19 boosters, and RSV vaccination per the Australian Immunisation Handbook are recommended for everyone with heart failure — respiratory infections are a common precipitant of decompensation.

E. Special populations

Aboriginal and Torres Strait Islander Australians. AIHW data show heart failure occurs at roughly three times the incidence in ATSI Australians and at significantly younger ages — often in the 30s and 50s — reflecting a major equity gap in cardiovascular care. The MBS-rebatable ATSI Health Assessment (item 715) is one tool for earlier detection. Culturally safe care, attention to social determinants, and active screening of family members are part of best practice.

Older adults and frailty. The four-pillar approach still benefits older adults, but deprescribing for frailty matters — polypharmacy, low blood pressure, falls, and cognitive impairment can outweigh medication benefit at the very end of life. Conversations about goals of care and advance care planning are integral, not optional, and Australian evidence shows that introducing palliative input alongside active treatment improves outcomes (SADHART-HF).

Pregnancy. Peripartum cardiomyopathy — heart failure developing late in pregnancy or in the first 5 months after delivery — needs urgent obstetric and cardiology input. Most renin–angiotensin drugs (ACE inhibitors, ARBs, ARNI) and SGLT2 inhibitors are contraindicated in pregnancy. Refer to a high-risk obstetric service.

Chronic kidney disease overlap. Many people with heart failure also have CKD. Renin–angiotensin agents, MRAs, and SGLT2 inhibitors all need attention to eGFR and potassium — but most are continued in CKD because they protect both heart and kidney. Direct oral anticoagulants (DOACs) and SGLT2 inhibitors both have dose adjustments by eGFR — your GP and cardiologist will check kidney function regularly.

When to escalate / cardiology referral

Refer to cardiology — usually rapid-access — when:

• Urgent / emergency department — acute pulmonary oedema, cardiogenic shock, suspected acute coronary syndrome, severe symptomatic low blood pressure, syncope.
• Same-week cardiology — newly diagnosed heart failure, NYHA III–IV symptoms, deterioration despite optimal therapy, suspected secondary cause (amyloid, sarcoid, peripartum cardiomyopathy, valvular cause).
• Routine cardiology — stable HFrEF for ICD or CRT device assessment, transplant assessment in advanced disease, palliative care input alongside active treatment for end-stage disease.

What to send with the referral: most recent echocardiogram, ECG, NT-proBNP and other bloods, current medications and doses, weight trend, NYHA class, list of any NSAIDs or over-the-counter medications, vaccination status, and any advance care plan already in place.

What this article is and is not

This is general health information drawn from current Australian primary-tier sources — the 2018 NHFA/CSANZ heart failure guideline, the 2022 MJA consensus statement on pharmacological management, Therapeutic Guidelines (eTG), the Australian Medicines Handbook, NPS MedicineWise, the Heart Foundation, and key Australian and international trials. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatment, including medication choices and dose titration, are made with your own general practitioner and treating cardiologist.

For Australian consumer-friendly sources: HealthDirect — Heart failure, Heart Foundation — Living with heart failure, Better Health Channel — Heart failure, and the Heart Foundation Helpline on 13 11 12.

For acute mental-health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

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Sources cited

1. NHFA/CSANZ — Guidelines for the Prevention, Detection and Management of Heart Failure in Australia 2018
2. Atherton JJ et al. — Consensus statement on pharmacological prevention and management of heart failure (MJA 2022)
3. Consensus statement on optimisation of patient care after hospitalisation for acute heart failure (Heart Lung Circ 2025)
4. RACGP newsGP — second SGLT2 inhibitor approved for heart failure
5. Therapeutic Guidelines (eTG) — Heart failure
6. Australian Medicines Handbook
7. NPS MedicineWise — empagliflozin for HFrEF
8. PSA — Four pillars of HFrEF Quick Reference Guide 2025
9. Heart Foundation — Heart failure clinical guidelines hub
10. AIHW — Heart failure facts
11. PBS
12. MBS Online
13. MBS — CDM reform fact sheet (1 July 2025)
14. Austroads — Assessing Fitness to Drive
15. Australian Immunisation Handbook
16. PARADIGM-HF (NEJM 2014)
17. CIBIS-II (Lancet 1999)
18. MERIT-HF (Lancet 1999)
19. COPERNICUS (NEJM 2001)
20. RALES (NEJM 1999)
21. EMPHASIS-HF (NEJM 2011)
22. DAPA-HF (NEJM 2019)
23. EMPEROR-Reduced (NEJM 2020)
24. EMPEROR-Preserved (NEJM 2021)
25. DELIVER (NEJM 2022)
26. STRONG-HF (Lancet 2022)
27. SHIFT (Lancet 2010)
28. VICTORIA (NEJM 2020)
29. DIG (NEJM 1997)
30. FAIR-HF (NEJM 2009)
31. AFFIRM-AHF (Lancet 2020)
32. TRED-HF (Lancet 2019)
33. STEP-HFpEF (NEJM 2023)
34. TOPCAT Americas substudy (Circulation 2015)
35. SODIUM-HF (Lancet 2022)
36. SADHART-HF (Eur J Heart Fail 2009)
37. Cochrane — Heart failure disease management 2017
38. HealthDirect — Heart failure
39. Heart Foundation — Living with heart failure
40. Better Health Channel — Heart failure
41. Heart Foundation — My Heart, My Life
42. Lifeline
43. Beyond Blue
44. TGA