Heart Failure Clinical Practice Guidelines (2018)

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Reviewed and summarized by Medscape editors

September 14, 2018

The clinical practice guidelines for heart failure diagnosis and treatment were released on August 2, 2018, by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.[1]

Diagnosis

A 12-lead electrocardiogram (ECG) is recommended in patients with suspected or new diagnosis of heart failure to assess cardiac rhythm, QRS duration, and underlying conditions such as myocardial ischemia or LV hypertrophy.

A chest radiograph is recommended in patients with suspected or new diagnosis of heart failure to help identify pulmonary congestion and alternative cardiac or noncardiac causes of symptoms.

Transthoracic echocardiography should be considered in patients with heart failure with reduced ejection fraction (HFrEF) 3 to 6 months after the start of optimal medical therapy or if there has been a change in clinical status, to assess appropriateness of other treatments such as device therapy (eg, implantable cardioverter defibrillator [ICD] or cardiac resynchronization therapy [CRT]).

Invasive coronary angiography should be considered in patients with heart failure associated with refractory angina, resuscitated cardiac arrest, sustained ventricular arrhythmias, or evidence of ischemic heart disease to determine the need for coronary revascularization.

Monitoring of peripheral arterial oxygen saturation is recommended in patients with acute heart failure.

Nonsurgical Therapy

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended in patients with type 2 diabetes mellitus associated with cardiovascular disease and insufficient glycemic control despite metformin.

Oxygen therapy is recommended in patients with acute heart failure associated with oxygen saturation levels below 94%.

Noninvasive ventilation should be considered in patients with acute heart failure associated with pulmonary congestion who remain hypoxemic and tachypneic despite oxygen therapy.

Intravenous loop diuretics are recommended in patients with acute heart failure associated with congestion.

Intravenous vasodilators may be considered in patients with acute heart failure if the systolic blood pressure is more than 90 mm Hg.

Intravenous inotropic therapy may be considered in patients with acute heart failure associated with symptoms or signs of peripheral hypoperfusion (usually accompanied by a systolic BP <90 mm Hg) and congestion refractory to other treatment.

An ACE inhibitor is recommended in patients with HFrEF associated with moderate or severe reduction in LVEF (LVEF ≤40%) unless contraindicated or not tolerated.

A beta blocker is recommended in patients with HFrEF associated with moderate or severe reduction in LVEF (LVEF ≤40%) unless contraindicated or not tolerated.

An angiotensin receptor neprilysin inhibitor (ARNI) is recommended as a replacement for an ACE inhibitor (with at least a 36-hour washout window) or an ARB in patients with HFrEF associated with an LVEF ≤40% despite receiving maximally tolerated or target doses of an ACE inhibitor (or ARB) and a beta blocker (unless contraindicated), with or without an MRA.

Cardiac resynchronization therapy (CRT) is recommended in patients with HFrEF associated with sinus rhythm, an LVEF ≤35%, and a QRS duration of 150 ms or more despite optimal medical therapy.

CRT is contraindicated in patients with QRS duration less than 130 ms.

Pharmacologic therapy aiming for a resting ventricular rate of 60 to 100 bpm should be considered in patients with heart failure associated with AF and a rapid ventricular response.

Erythropoietin should not be used routinely for the treatment of anemia in patients with heart failure, because of an increased risk of thromboembolic adverse events.

Surgical Management

Coronary artery bypass graft (CABG) surgery should be considered in patients with HFrEF associated with ischemic heart disease and an LVEF ≤35% if they have surgically correctable coronary artery disease.

Mitral valve (MV) repair or replacement at the time of elective CABG should be considered in patients with moderate to severe mitral regurgitation in association with heart failure and ischemic heart disease.

Surgical aortic valve replacement (SAVR) is recommended in patients with severe aortic stenosis or severe aortic regurgitation and heart failure in the absence of major comorbidities or frailty.

Transcatheter aortic valve implantation (TAVI) should be considered in patients with severe aortic stenosis and heart failure at intermediate to high operative mortality risk, or considered inoperable for SAVR, who are deemed suitable for TAVI following assessment by a heart team.

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