Phenotype shapes treatment and funding. All three ejection-fraction groups now benefit from an SGLT2 inhibitor, but ARNI/MRA evidence is strongest in HFrEF. Self-monitoring and sick-day rules are what keep patients out of hospital.
HFrEF vs HFmrEF vs HFpEF
- HFrEF (EF≤40%): the four pillars all apply with strong trial evidence — the most extensively studied phenotype.
- HFmrEF (EF41–49%): SGLT2 inhibitors strongly supported; ARNI, MRA and beta-blocker are reasonable but with less robust evidence than HFrEF; finerenone is emerging (TGA-approved, not yet PBS-funded for HF — see CV-02A).
- HFpEF (EF≥50%): an SGLT2 inhibitor is now PBS-funded and a cornerstone of treatment; finerenone is emerging with the same funding caveat; GLP-1 receptor agonists (e.g. semaglutide) are increasingly used where obesity coexists, per STEP-HFpEF/SUMMIT evidence; diuretics treat congestion.
NYHA class & biomarkers. NYHA I: no symptoms with ordinary activity. NYHA II: mild symptoms with ordinary activity; comfortable at rest. NYHA III: marked limitation — symptoms with less-than-ordinary activity. NYHA IV: symptoms at rest, or with any activity. NT-proBNP <125pg/mL or BNP <35pg/mL (non-acute outpatient setting) makes HF unlikely; higher levels warrant echocardiography.
Sick day rules
- Daily weight, same scale and time of day — a gain of 2kg or more over 2–3 days needs prompt medical contact.
- Watch for worsening breathlessness, orthopnoea, or increasing ankle/leg swelling.
- If dehydrated (vomiting, diarrhoea, fever, reduced intake): temporarily hold the ACEi/ARB/ARNI, MRA and SGLT2 inhibitor, but continue the beta-blocker unless bradycardic or hypotensive.
- Resume held medicines once well, and seek medical advice if unsure when to restart.
Referral & practical care
- New diagnosis of HFrEF — for confirmation and GDMT initiation/optimisation.
- NYHA III–IV symptoms despite optimised four-pillar therapy.
- EF≤35% on maximised GDMT for more than 3 months — consider ICD/CRT.
- Suspected advanced HF or recurrent decompensation admissions — consider transplant/mechanical support referral.
- Between visits: annual influenza/pneumococcal vaccination, HF nurse or cardiac rehabilitation referral where available, and coordinate care under a chronic disease management plan (confirm item numbers at mbsonline.gov.au).
Safety
- A weight gain of 2kg or more over 2–3 days needs same-day medical contact, not the next routine review.
- Continue the beta-blocker during intercurrent illness unless the patient is bradycardic or hypotensive — stopping it abruptly can precipitate decompensation.
- Don't ignore a new murmur, resting tachycardia or hypotension in a known HF patient — reassess promptly.
Red flags / refer
- New diagnosis of HFrEF → cardiology referral for confirmation and GDMT initiation.
- NYHA III–IV despite optimised therapy, or EF≤35% on maximised GDMT for >3 months → consider device therapy (ICD/CRT).
- Suspected advanced HF or recurrent decompensation admissions → transplant/mechanical support referral.
CV-02B 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-02A Heart Failure — Diagnosis & the Four Pillars.
