Heart Failure — Diagnosis & the Four Pillars

Start all four GDMT pillars together, not sequentially

Field: CardiovascularCode: CV-02AUpdated: June 2026Reference: iCARDIO Alliance 2025 / NHFA-CSANZ 2018

All four pillars of GDMT should be started together, not sequentially, and up-titrated rapidly. Suspect HF from breathlessness, fatigue or fluid overload; confirm with NT-proBNP/BNP and echocardiography; classify by ejection fraction to guide therapy.

The four pillars of GDMT

Start together — not sequentially — and up-titrate rapidly, per the iCARDIO Alliance 2025 guidelines.

ARNI/ACEi/ARB: an ARNI (sacubitril/valsartan) is preferred where accessible; an ACE inhibitor or ARB if an ARNI isn't suitable.

Beta-blocker: bisoprolol, carvedilol, metoprolol XR or nebivolol — start low and up-titrate as tolerated.

MRA: spironolactone or eplerenone — monitor potassium and renal function after starting and with dose changes.

SGLT2 inhibitor: dapagliflozin or empagliflozin — PBS-listed across all EF ranges, including HFpEF.

Finerenone: TGA yes, PBS not yet. TGA-approved for HFmrEF/HFpEF (LVEF≥40%) based on FINEARTS-HF, but as at mid-2026 finerenone is PBS-listed only for chronic kidney disease in type 2 diabetes — not yet for heart failure. Confirm current PBS status at pbs.gov.au before assuming subsidised access; spironolactone remains the PBS-funded MRA option for HFpEF in the meantime.

Recognising & confirming HF

Breathlessness, fatigue, reduced exercise tolerance, or fluid overload (peripheral oedema, raised JVP, weight gain) — ask about orthopnoea and paroxysmal nocturnal dyspnoea.
Risk factors: ischaemic heart disease, hypertension, diabetes, valvular disease, atrial fibrillation, or prior cardiotoxic chemotherapy.
NT-proBNP <125pg/mL or BNP <35pg/mL in the non-acute outpatient setting makes HF unlikely; higher levels warrant echocardiography. NT-proBNP is now MBS-rebatable for non-hospital HF exclusion — confirm at mbsonline.gov.au.
Echocardiography confirms the diagnosis and measures ejection fraction (EF) to classify: HFrEF (EF≤40%), HFmrEF (EF41–49%), HFpEF (EF≥50%).
Baseline work-up: FBC and iron studies, renal function and electrolytes, LFTs, TSH, glucose/HbA1c, lipids, and ECG.

Foundation therapy

Loop diuretics relieve congestion and are titrated to euvolaemia — they treat symptoms but aren't one of the four pillars themselves.
IV iron is now more strongly recommended if iron-deficient (ferritin<100 microg/L or transferrin saturation<20%), even without anaemia.
Lifestyle: individualised fluid intake (typically 1.5–2L/day) and reduced salt, influenza/pneumococcal vaccination, and exercise as tolerated.

Safety

Don't start an MRA if potassium >5.0 mmol/L or eGFR<30 without specialist input; recheck U&E 1–2 weeks after starting or up-titrating.
An ARNI needs a 36-hour washout from an ACE inhibitor before starting, to reduce angioedema risk.
SGLT2 inhibitors can cause euglycaemic ketoacidosis — counsel on sick-day pausing and on ketone-related symptoms.

Red flags / refer

New diagnosis of HFrEF → cardiology referral for confirmation and GDMT initiation/optimisation.
NYHA III–IV despite optimised four-pillar therapy → consider device therapy (ICD/CRT) or advanced HF referral.
Diagnostic uncertainty, or HFmrEF with atypical features → echocardiography review and cardiology opinion.

CV-02A v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: iCARDIO Alliance Global HF Guidelines 2025 (CSANZ-affiliated); NHFA/CSANZ 2018. Companion sheet: CV-02B Heart Failure — Practical Care & Monitoring.