What is the initial management of heart failure according to Australian guidelines?

Initial Management of Heart Failure According to Australian Guidelines

The initial management of heart failure in Australia should begin with ACE inhibitors as first-line therapy for all patients with reduced left ventricular ejection fraction (LVEF <40-45%), combined with diuretics if fluid overload is present, followed by beta-blockers once the patient is stabilized. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis:

• Obtain an echocardiogram to assess myocardial structure, function, and measure LVEF to classify heart failure type (HFrEF, HFmrEF, or HFpEF) 2, 1
• If echocardiography cannot be arranged promptly, measure plasma B-type natriuretic peptides (BNP or NT-proBNP) to improve diagnostic accuracy and differentiate cardiac from non-cardiac causes of dyspnea 2, 1

Initial Pharmacological Treatment Algorithm

Step 1: Address Fluid Overload (If Present)

For patients with signs of congestion (peripheral edema, pulmonary rales, elevated jugular venous pressure):

• Start loop diuretics immediately (furosemide 20-40 mg IV for diuretic-naïve patients, or equivalent to oral dose for those already on diuretics) 3, 2
• Loop diuretics provide rapid improvement in dyspnea and exercise tolerance 3
• Monitor closely: symptoms, urine output, renal function, and electrolytes during diuretic therapy 2
• If GFR <30 mL/min, avoid thiazides except when combined synergistically with loop diuretics 3

Step 2: Initiate ACE Inhibitor

All patients with HFrEF (LVEF <40-45%) should receive an ACE inhibitor regardless of symptom severity:

• Start with low dose and uptitrate to target doses proven effective in clinical trials (not based on symptomatic improvement alone) 3, 2

• Initiation protocol 3:

  • Review and potentially reduce diuretics 24 hours before starting
  • Consider evening dosing when supine to minimize hypotension
  • Start low dose, double every 1-2 weeks as tolerated
  • Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months 3, 2

• Key safety considerations 3:

  • Avoid NSAIDs during ACE inhibitor therapy 3, 2
  • Avoid potassium-sparing diuretics during initiation 3
  • Contraindicated in bilateral renal artery stenosis and history of angioedema 3
  • If cough or angioedema develops, switch to angiotensin receptor blocker (ARB) 3

Step 3: Add Beta-Blocker

Once the patient is stabilized on ACE inhibitor and diuretics, add a beta-blocker:

• Beta-blockers reduce mortality and hospitalization in stable HFrEF patients (NYHA class II-IV) 3, 2

• Patient must be relatively stable: no IV inotropes needed, no marked fluid retention 3

• Initiation protocol 3:

  • Start with very low dose
  • Uptitrate slowly, doubling dose every 1-2 weeks if tolerated
  • Target maintenance doses proven effective in large trials
  • Most patients can be managed as outpatients

• Monitoring during titration 3:

  • Watch for worsening heart failure symptoms, fluid retention, hypotension, or bradycardia
  • If symptoms worsen: increase diuretics or ACE inhibitor first, temporarily reduce beta-blocker only if necessary
  • If hypotension: reduce vasodilators first, then beta-blocker dose if needed
  • Always attempt reintroduction/uptitration when patient stabilizes

• Contraindications 3: asthma, severe bronchial disease, symptomatic bradycardia or hypotension

Important note: The CARMEN trial demonstrated that early combination of ACE inhibitor and beta-blocker reverses left ventricular remodeling more effectively than either agent alone, supporting a strategy where beta-blocker initiation should not be delayed 4

Step 4: Consider Mineralocorticoid Receptor Antagonist

For patients with advanced heart failure (NYHA class III-IV) who remain symptomatic despite ACE inhibitor and diuretics:

• Add spironolactone to improve survival and reduce morbidity 3, 2, 1
• Initiation protocol 3:
  • Start with low dose (typically 12.5-25 mg daily)
  • Check serum potassium and creatinine after 5-7 days
  • Recheck every 5-7 days until potassium values are stable
  • Use only if hypokalaemia persists after ACE inhibitor initiation

Advanced Treatment Options

For patients who remain symptomatic despite optimal ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist therapy:

• Consider switching ACE inhibitor to sacubitril/valsartan (angiotensin receptor neprilysin inhibitor) 2, 1
• Consider ivabradine in selected patients 1
• Evaluate for device therapy (implantable cardioverter defibrillator, cardiac resynchronization therapy) in appropriate candidates 3, 1

Non-Pharmacological Management

Patient education is essential 3, 2:

• Explain heart failure pathophysiology and symptom recognition
• Teach daily self-weighing to detect fluid retention early
• Emphasize medication adherence
• Advise smoking cessation

Lifestyle modifications 3, 2:

• Sodium restriction for symptomatic patients to reduce congestion 2
• Regular aerobic exercise in stable patients to improve functional capacity and reduce hospitalization risk 3, 2
• Avoid excessive fluid intake in severe heart failure 3
• Avoid excessive alcohol 3

Multidisciplinary care 3, 1:

• Enroll patients in heart failure disease management programs to reduce hospitalization 3
• Consider nurse-led medication titration models 1

Medications to Avoid

The following medications worsen heart failure outcomes and should be avoided 3, 2:

• NSAIDs and COX-2 inhibitors: increase risk of worsening heart failure and hospitalization 3, 2
• Thiazolidinediones (glitazones): increase heart failure hospitalization risk 3, 2
• Non-dihydropyridine calcium channel blockers: may be harmful in patients with reduced LVEF 2

Special Considerations for Acute Decompensated Heart Failure

If patient presents with acute decompensation 2:

• Continue evidence-based disease-modifying therapies unless haemodynamically unstable or contraindicated 3
• Avoid inotropic agents unless patient is symptomatically hypotensive or hypoperfused due to safety concerns 3
• If cardiogenic shock suspected, immediate ECG and echocardiography required, with rapid transfer to tertiary center 3

Common Pitfalls to Avoid

• Do not delay beta-blocker initiation once patient is stable on ACE inhibitor—early combination therapy is more effective 4
• Do not titrate ACE inhibitors based on symptoms alone—uptitrate to target doses proven in trials 3
• Do not discontinue beta-blockers abruptly if patient develops mild worsening—adjust other medications first and attempt reintroduction 3
• Do not use digoxin as first-line therapy—reserve for patients with atrial fibrillation or those remaining symptomatic despite optimal therapy 3