Gary Kilov: Please share one or two key points from the updated heart failure guidelines that are important for GPs.
Ralph Audehm: There are a couple of things from the updated guidelines that are really important for GPs. The first is about what to do with patients who have a left ventricular ejection fraction (LVEF) of 40 to 50% – it has caused a lot of consternation within primary care. Previously there was a gap with no formal approach to this group of people.
Going right back to basics, the first thing to remember is that heart failure is a clinical diagnosis. To categorise heart failure and determine the LVEF, an echocardiogram is performed. According to the updated Australian guidelines, the LVEF will be reported as above or below 50%. The guidelines are now clear that this previous grey zone of LVEF of 40 to 50% should be treated as heart failure with reduced ejection fraction (HFrEF).
Gary Kilov: Isn’t this discordant with European guidelines?
Ralph Audehm: Yes, and there has been diagnostic uncertainty in Europe. So in Australia we now have clarity on how to treat people with LVEF of 40 to 50%. We have done away with this diagnostic uncertainty. It is not going to increase the number of people with heart failure, because the diagnosis has already been made. This is about clarifying how to treat them.
Gary Kilov: Why has the 10% been done away with?
Ralph Audehm: First of all, we know that echocardiograms themselves are not accurate and they have a margin of error, believe it or not, of plus or minus 10%. So in fact we were not confident that the mid-range could be effectively identified because of the margin of error. So theoretically, taking the margin of error into account, somebody could be categorised in three different groups.
Advertisement
Another reason we are no longer considering that 10% LVEF group is that there is no phenotypically relevant disease process that separates patients with mid-range LVEF from those with reduced LVEF. Recent studies have found that patients with an LVEF of 40 to 50% behave more like people with reduced LVEF. So we have shifted that whole group now into reduced LVEF where they belong. An LVEF below 50% is abnormal; it makes sense that these patients fit in the HFrEF group.
Gary Kilov: Are there any other highlights that came out of these new guidelines that GPs should be aware of?
Ralph Audehm: The other thing that has been updated in the guidelines is the uptitration schedule for people with heart failure who are euvolaemic. These patients are not fluid overloaded and the guidelines now clearly state that an ACE inhibitor/angiotensin receptor blocker (ARB) and a heart failure-specific beta blocker can be started at the same time.
Another nuance within that treatment algorithm is to titrate the heart failure-specific beta blocker first in preference to the ACE inhibitor/ARB. This is really important because we know that the mortality and functional benefit from these heart failure-specific beta blockers is actually better than the ACE inhibitor/ARB.
So now we want people to be on both medications and then we uptitrate them rather than start with one, titrate to maximum and then start the second. We want to start them both at the same time.
Gary Kilov: How do the guidelines suggest that patients with heart failure and iron deficiency be best managed?
Ralph Audehm: Iron deficiency is another important aspect that is often missed in primary care. Functional iron deficiency within heart failure is defined as ferritin levels below 100 mcg/L. The guidelines recommend an iron infusion in this group and we know that they do better. It is quite specifically an iron infusion, not oral replacement as oral iron makes no difference in patients with heart failure.
Gary Kilov: A major strength of primary care is our relationships with our patients and allied health professionals. We are set up for chronic disease management. Can you talk about the evidence around utilising a team approach?
Ralph Audehm: One of the exciting things about these guidelines is they specifically mention the role that nurses have in uptitrating the heart failure medications to an optimised dose. There is good-quality evidence to suggest that nurses should be involved from the start of management, within two weeks of discharge from a hospital. They should be under the role of either a GP or a cardiologist, and can actually help support the uptitration of medication so patients can reach targets within weeks, rather than months.
And we know that will save lives. We have good evidence of that. So nurses who have a special interest in heart failure and are able to uptitrate medication have got a great role to play in managing this dreadful disease. CT
COMPETING INTERESTS: Associate Professor Audehm has received funds for consultancy, advisory boards and lectures from Novartis, Sanofi, AstraZeneca and Amgen. Associate Professor Kilov has served on advisory boards or provided education for AstraZeneca, iNova, Lily, MSD, Novartis, Novo Nordisk and Sanofi.
Further reading
NHFA CSANZ Heart Failure Guidelines Working Group; Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018; 27: 1123-1208.
