Heart failure — Australian GP reference

A structured reference for managing chronic heart failure in Australian general practice. EF-based classification, foundational quadruple therapy for HFrEF, what's PBS-supported, when to refer. Source: NHFA / CSANZ 2018 guideline with the MJA 2022 consensus update for SGLT2i, ARNI and IV iron.

📋 Sources (verified June 2026):

NHFA / CSANZ Heart Failure Guidelines Working Group. Guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018;27:1123–1208 (open access).
Sindone A, De Pasquale C, Amerena J, et al. Consensus statement on the current pharmacological prevention and management of heart failure. MJA 2022;217(4):212–217 — SGLT2i, ARNI, IV iron evidence post-2018.
Optimising transitional care following a heart failure hospitalisation in Australia. Heart Lung Circ 2024 — foundational quadruple therapy framing.
Landmark trial data: PARADIGM-HF (ARNI), DAPA-HF / EMPEROR-Reduced (SGLT2i in HFrEF), DELIVER / EMPEROR-Preserved (SGLT2i in HFpEF/HFmrEF), AFFIRM-AHF (IV iron), STRONG-HF (rapid up-titration).
Confirm current PBS criteria for ARNI, SGLT2i, ivabradine on pbs.gov.au before prescribing.

Reference for registered medical professionals. Not prescribing advice. Heart failure management requires individualised clinical judgement against the patient's BP, HR, renal function, electrolytes, comorbidities, and current TGA Product Information.

Tier 2 — use clinical judgement. Heart-failure pharmacotherapy involves dose-titration against blood pressure, heart rate, kidney function, potassium, and clinical response. This page is a structured reference, not a prescribing protocol. Always individualise for your patient and the current TGA Product Information. Specialist input recommended where titration, comorbidities or symptom progression suggest. Verified June 2026.

EF-based classification

Enter LVEF to classify and see what foundational therapy applies. NHFA/CSANZ 2018 thresholds; ESC/AHA align.

LVEF (%)

NYHA functional class (optional)

Foundational quadruple therapy (HFrEF, LVEF ≤ 40%)

NHFA/CSANZ 2018 + MJA 2022 consensus. All four pillars are recommended for every HFrEF patient unless specifically contraindicated. Modern practice favours starting all four early at low doses rather than sequentially up-titrating one before adding the next — benefits of ARNI and SGLT2i are seen early and don't require fully optimised background therapy.

1. RAAS inhibitor: ARNI (preferred) or ACEi or ARB

Strong recommendation (Class I) — NHFA/CSANZ 2018; ARNI upgraded over ACEi/ARB in MJA 2022 consensus.

ARNI: sacubitril/valsartan. Replaces ACEi/ARB; switch after 36-hour washout from ACEi (no washout from ARB). Start low and uptitrate; hypotension is the main limiter. ACEi or ARB if ARNI not tolerated or unavailable. Renal monitoring (creatinine, K⁺) before, 1–2 weeks after start, then per response.

2. HF-specific β-blocker

Strong recommendation — only these four agents have HF outcome data.

Bisoprolol, carvedilol, metoprolol succinate (CR/XL), or nebivolol (in elderly per SENIORS trial). Start at very low dose when haemodynamically stable and titrate every 2–4 weeks. Avoid initiation during acute decompensation. Other β-blockers are not equivalent for HFrEF.

3. MRA (mineralocorticoid receptor antagonist)

Strong recommendation if eGFR > 30 mL/min/1.73m² and K⁺ ≤ 5.0 mmol/L.

Spironolactone or eplerenone (eplerenone preferred for gynaecomastia avoidance and post-MI). Check K⁺ and creatinine at baseline, 1 week, 1 month, then every 3–6 months. Hyperkalaemia is the main risk — especially when combined with ACEi/ARB/ARNI.

4. SGLT2 inhibitor

Strong recommendation (MJA 2022 consensus, post-DAPA-HF/EMPEROR-Reduced).

Dapagliflozin 10 mg daily or empagliflozin 10 mg daily — both PBS-listed for HFrEF (with or without T2DM). Don't down-titrate based on eGFR (use to eGFR ~20 in most cases); withhold during acute illness/dehydration. Small initial creatinine bump expected. Diabetic ketoacidosis risk — "sick day" rules apply.

Dose targets (NHFA/CSANZ 2018)

Drug class & agent	Starting dose	Target dose
ARNI — sacubitril/valsartan	49/51 mg BD (or 24/26 mg BD if low BP or prior low-dose ACEi/ARB)	97/103 mg BD
ACEi — perindopril — ramipril — enalapril	2 mg daily 1.25–2.5 mg BD 2.5 mg BD	8–10 mg daily 5 mg BD 10–20 mg BD
ARB — candesartan — valsartan	4 mg daily 40 mg BD	32 mg daily 160 mg BD
β-blocker — bisoprolol — carvedilol — metoprolol succinate — nebivolol	1.25 mg daily 3.125 mg BD 23.75 mg daily 1.25 mg daily	10 mg daily 25 mg BD (50 mg BD if >85 kg) 190 mg daily 10 mg daily
MRA — spironolactone — eplerenone	12.5–25 mg daily 25 mg daily	25–50 mg daily 50 mg daily
SGLT2i — dapagliflozin — empagliflozin	10 mg daily 10 mg daily	10 mg daily (no up-titration) 10 mg daily (no up-titration)

Target doses are those used in landmark trials. Aim for maximum tolerated dose if target not achievable. Confirm current TGA Product Information before prescribing.

Selected additional therapies (HFrEF)

Loop diuretic (furosemide, bumetanide) — symptomatic congestion only; titrate to lowest effective dose. Not disease-modifying.
Ivabradine — consider if symptomatic, sinus rhythm, HR ≥ 70 bpm on maximally tolerated β-blocker, and LVEF ≤ 35%. PBS Authority required.
IV iron (ferric carboxymaltose) — for symptomatic HFrEF with iron deficiency (ferritin < 100 µg/L, or 100–299 µg/L with TSat < 20%), regardless of anaemia. AFFIRM-AHF and FAIR-HF support symptomatic and hospitalisation benefit. See iron infusion monitoring.
Cardiac rehabilitation + multidisciplinary HF clinic referral — Class I recommendation. Reduces readmission and mortality.
Implantable cardioverter-defibrillator (ICD) / cardiac resynchronisation (CRT) — specialist-led decision based on LVEF, QRS duration, NYHA class on optimised therapy.

HFmrEF and HFpEF

HFmrEF (LVEF 41–49%)

Treat as HFrEF — emerging evidence supports the same four pillars, with the strongest evidence for SGLT2i (DELIVER, EMPEROR-Preserved subgroup analyses). MJA 2022 consensus supports extension of HFrEF therapies into HFmrEF.

HFpEF (LVEF ≥ 50%)

SGLT2i is the only class with strong RCT evidence (EMPEROR-Preserved, DELIVER) — Class I recommendation. Treat comorbidities aggressively: hypertension (BP target <130/80), AF rate/rhythm control, obesity (semaglutide STEP-HFpEF data), CAD, OSA. Diuretics for symptomatic congestion. MRA (spironolactone, TOPCAT post-hoc analysis) may be considered in selected patients. ACEi/ARB/ARNI evidence in HFpEF is weaker; not routine.

When to refer

Same-day / urgent referral or ED:

Acute decompensation — worsening dyspnoea/orthopnoea, weight gain > 2 kg in days, signs of pulmonary or peripheral oedema
Suspected new HF without an established diagnosis — needs echo, BNP/NT-proBNP, and likely admission
Symptomatic hypotension, syncope, sustained arrhythmia
Suspected ACS, suspected PE

Outpatient cardiology / HF clinic referral:

Newly diagnosed HFrEF — for foundational therapy initiation, device assessment, aetiology workup
Persistent symptoms (NYHA III–IV) despite optimised foundational therapy
Frequent hospitalisations
LVEF persistently ≤ 35% on optimised therapy — ICD/CRT eligibility
Suspected cardiomyopathy with familial features, recent pregnancy, chemotherapy exposure, sarcoidosis
Considering advanced therapies (LVAD, transplant)

GP follow-up framework

Stable established HF: every 3–6 months. Symptoms, daily weights, BP, HR, fluid status, U&E, eGFR, K⁺.
During up-titration: 1–2 weeks after each dose change. Bloods 1–2 weeks after starting ACEi/ARB/ARNI/MRA/SGLT2i.
Annual: echo if change in clinical status. Lipids, HbA1c, iron studies (ferritin < 100 µg/L or 100–299 with TSat < 20% prompts IV iron consideration).
Vaccinations: annual influenza (Class I); pneumococcal per NIP; COVID per current ATAGI advice; consider RSV in eligible groups. See vaccine eligibility checker.
Lifestyle: fluid plan (typically 1.5–2 L/day; lower if severely congested), sodium < 2–3 g/day, daily weights, alcohol limitation, smoking cessation, weight-bearing cardiac rehab.

MBS billing context

Most HF care fits within standard GP items (23, 36, 44) or longer consultations during titration. Chronic disease management: GPMP (item 965) and TCA (item 967) apply — HF is a qualifying chronic condition. See the CDM changes guide and care plan tips. Cardiac rehabilitation referrals via TCA. Heart Health Check (item 699) is for primary prevention only — not for patients with established HF. See item 699 guide.

For patients: Heart failure explained →
Plain-language companion: what HF means, why all four medications matter, what to watch for at home. Iron infusion monitoring →
For HFrEF + iron deficiency (ferritin < 100 or 100–299 with TSat < 20%). eGFR / CrCl calculator →
For drug-dose adjustment and SGLT2i / MRA eligibility. Atrial fibrillation management →
~50% of HF patients have AF; early rhythm control / ablation reduces mortality in HFrEF (CASTLE-AF). CKD management reference →
Cardio-renal cluster — SGLT2i overlap, MRA hyperkalaemia caution, IV iron criteria. CDM billing — GPMP & TCA →
HF qualifies as a chronic condition for items 965 / 967.