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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018

Authors:

Abstract

Introduction: Heart failure (HF) is a clinical syndrome that is secondary to an abnormality of cardiac structure or function. These clinical practice guidelines focus on the diagnosis and management of HF with recommendations that have been graded on the strength of evidence and the likely absolute benefit versus harm. Additional considerations are presented as practice points. Main recommendations: Blood pressure and lipid lowering decrease the risk of developing HF. Sodium-glucose cotransporter 2 inhibitors decrease the risk of HF hospitalisation in patients with type 2 diabetes and cardiovascular disease. An echocardiogram is recommended if HF is suspected or newly diagnosed. If an echocardiogram cannot be arranged in a timely fashion, measurement of plasma B-type natriuretic peptides improves diagnostic accuracy. Angiotensin-converting enzyme inhibitors, β-blockers and mineralocorticoid receptor antagonists improve outcomes in patients with HF associated with a reduced left ventricular ejection fraction. Additional treatment options in selected patients with persistent HF associated with reduced left ventricular ejection fraction include switching the angiotensin-converting enzyme inhibitor to an angiotensin receptor neprilysin inhibitor; ivabradine; implantable cardioverter defibrillators; cardiac resynchronisation therapy; and atrial fibrillation ablation. Multidisciplinary HF disease management facilitates the implementation of evidence-based HF therapies. Clinicians should also consider models of care that optimise medication titration (eg, nurse-led titration). Changes in management as a result of the guideline: These guidelines have been designed to facilitate the systematic integration of recommendations into HF care. This should include ongoing audit and feedback systems integrated into work practices in order to improve the quality of care and outcomes of patients with HF.
National Heart Foundation of Australia and
Cardiac Society of Australia and New Zealand:
Australian clinical guidelines for the
management of heart failure 2018
John J Atherton
1
, Andrew Sindone
2
, Carmine G De Pasquale
3
, Andrea Driscoll
4,5
, Peter S MacDonald
6
, Ingrid Hopper
7
,
Peter Kistler
8
, Tom G Briffa
9
, James Wong
10
, Walter P Abhayaratna
11
, Liza Thomas
12
, Ralph Audehm
13
, Phillip J Newton
14
,
Joan OLoughlin
15
, Cia Connell
16
, Maree Branagan
16
The National Heart Foundation of Australia and the Cardiac
Society of Australia and New Zealand have developed
new guidelines to assist Australian clinicians in the care of
adult patients with heart failure (HF). The guidelines are based on
current evidence, and replace the 2011 guidelines for the preven-
tion, detection and management of chronic HF in Australia.
1
This executive summary provides important recommendations
together with their strength of evidence and guidance for their
implementation in clinical practice (practice points). The full clin-
ical guidelines are available in Heart, Lung and Circulation at
https://doi.org/10.1016/j.hlc.2018.06.1042.
2
Denition of heart failure
HF is a complex clinical syndrome with typical symptoms and
signs that generally occur on exertion but may also occur at rest
(particularly when recumbent). HF is secondary to an abnormality
of cardiac structure or function that impairs the ability of the heart
to ll with blood at normal pressure or eject blood sufcient to full
the needs of the metabolising organs. Following clinical diagnosis,
HF is generally categorised according to whether it is associated
with a reduced left ventricular ejection fraction (LVEF) below
50% (heart failure with reduced ejection fraction [HFrEF]) or pre-
served LVEF of 50% or more (heart failure with preserved ejection
fraction [HFpEF]) (Box 1).
Method
The National Heart Foundation of Australia, in partnership with
the Cardiac Society of Australia and New Zealand, appointed an
expert writing group. The HF guideline development working
group comprised an executive and four writing groups covering
the topics of diagnosis; pharmacological management; devices and
surgery; and non-pharmacological management. The working
group comprised a broad mix of health professionals, including
cardiologists (including an electrophysiologist), nurses, general
practitioners, a clinical pharmacologist and general physician, an
exercise health and professional epidemiologist, and a consumer
representative.
In addition, a reference group including representatives from
stakeholder groups, potential endorsing organisations and
regional experts provided input into the scope and content of the
guideline.
A draft of the guideline was open for a 21-day period of public
consultation in April 2018 to capture stakeholder views and
facilitate engagement. Appropriate governance processes
were followed to ensure transparency, minimise bias, manage
conict of interest and limit other inuences during guideline
development.
Abstract
Introduction: Heart failure (HF) is a clinical syndrome that is
secondary to an abnormality of cardiac structure or function.
These clinical practice guidelines focus on the diagnosis and
management of HF with recommendations that have been
graded on the strength of evidence and the likely absolute
benet versus harm. Additional considerations are presented as
practice points.
Main recommendations:
Blood pressure and lipid lowering decrease the risk of
developing HF. Sodiumeglucose cotransporter 2 inhibitors
decrease the risk of HF hospitalisation in patients with type 2
diabetes and cardiovascular disease.
An echocardiogram is recommended if HF is suspected or
newly diagnosed.
If an echocardiogram cannot be arranged in a timely fashion,
measurement of plasma B-type natriuretic peptides
improves diagnostic accuracy.
Angiotensin-converting enzyme inhibitors,
b
-blockers and
mineralocorticoid receptor antagonists improve outcomes in
patients with HF associated with a reduced left ventricular
ejection fraction. Additional treatment options in selected
patients with persistent HF associated with reduced left
ventricular ejection fraction include switching the
angiotensin-converting enzyme inhibitor to an angiotensin re-
ceptor neprilysin inhibitor; ivabradine; implantable cardioverter
debrillators; cardiac resynchronisation therapy; and atrial
brillation ablation.
Multidisciplinary HF disease management facilitates the
implementation of evidence-based HF therapies. Clinicians
should also consider models of care that optimise medication
titration (eg, nurse-led titration).
Changes in management as a result of the guideline: These
guidelines have been designed to facilitate the systematic
integration of recommendations into HF care. This should
include ongoing audit and feedback systems integrated into
work practices in order to improve the quality of care and
outcomes of patients with HF.
1
Royal Brisbane and Womens Hospital and University of Queensland, Brisbane, QLD.
2
Concord Repatriation General Hospital, Sydney, NSW.
3
Flinders Medical Centre, Flinders
University, Adelaide, SA.
4
Deakin University, Melbourne, VIC.
5
Austin Health, Melbourne, VIC.
6
St Vincents Hospital, Sydney, NSW.
7
Monash University, Melbourne, VIC.
8
The
Alfred Hospital, Melbourne.
9
University of Western Australia, Perth, WA.
10
Royal Melbourne Hospital, Melbourne, VIC.
11
Canberra Hospital, Canberra, ACT.
12
Westmead Private
Hospital, Sydney, NSW.
13
University of Melbourne, Melbourne, VIC.
14
Western Sydney University, Sydney, NSW.
15
Consumer Representative, Perth, WA.
16
National Heart
Foundation of Australia, Melbourne, VIC. john_atherton@health.qld.gov.au jdoi: 10.5694/mja18.00647 jPublished online 02/08/2018
Guideline summary
MJA 2018
1
Key evidence-based recommendations
Each recommendation is presented with a Grading of Recom-
mendations Assessment, Development and Evaluation (GRADE)
strength of recommendation and quality of evidence.
3
Practice
points are also provided.
Prevention of heart failure
Blood pressure
4
and lipid
5
lowering according to published
guidelines is recommended, to decrease the risk of cardio-
vascular events and the risk of developing HF. GRADE:
Strong; Evidence: High.
Sodiumeglucose cotransporter 2 inhibitors are recommended
in patients with type 2 diabetes mellitus associated with car-
diovascular disease and insufcient glycaemic control despite
metformin, to decrease the risk of cardiovascular events and
decrease the risk of HF hospitalisation.
6
GRADE: Strong;
Evidence: High.
Angiotensin-converting enzyme (ACE) inhibitors are recom-
mended in patients with left ventricular systolic dysfunction,
to decrease the risk of developing HF.
7
GRADE: Strong;
Evidence: High.
Diagnosis of heart failure
Plasma B-type natriuretic peptide (BNP) or N-terminal
proBNP levels are recommended for diagnosis in patients
with suspected HF when the diagnosis is uncertain.
8
GRADE:
Strong; Evidence: High.
A transthoracic echocardiogram is recommended in patients
with suspected HF, to improve diagnostic accuracy, and in
patients with a new diagnosis of HF, to assess cardiac struc-
ture and function (including the measurement of LVEF), assist
in classication and therefore guide management.
9
GRADE:
Strong; Evidence: Low.
<Practice point: The diagnostic work-up of a patient with
suspected HF is summarised in Box 2. The single most
useful investigation is the echocardiogram. However, if the
diagnosis is unclear and an echocardiogram cannot be
arranged in a timely fashion, measurement of either
plasma BNP or N-terminal proBNP has been shown to
improve diagnostic accuracy.
2
<Practice point: Evaluation of coronary arteries should be
guided by the presence or absence of symptoms of coro-
nary artery disease and the pre-test probability of coronary
artery disease.
<Practice point:Box 3 lists red ags where early specialist
referral may be considered.
Management of heart failure
The management of acute HF should be guided by the patients
vital signs, oxygen saturation, and the presence or absence of
congestion and hypoperfusion. Management includes intravenous
diuretics in most patients accompanied by the selected use of
oxygen therapy (if hypoxaemic), positive pressure ventilation,
vasodilators and inotropes.
2
Effective long term management of
HF is key to decreasing hospitalisation and improving survival.
Although a number of evidence-based interventions exist for
HFrEF (Box 4 and Box 5), none have been shown to reduce
mortality in HFpEF.
Pharmacological management of chronic heart failure
An ACE inhibitor is recommended in all patients with HFrEF
associated with an LVEF 40%, unless contraindicated or not
tolerated, to decrease mortality and decrease hospitalisation.
10
GRADE: Strong; Evidence: High.
A
b
-blocker (specically bisoprolol, carvedilol, controlled or
extended release metoprolol or nebivolol) is recommended in
all patients with HFrEF associated with an LVEF 40% unless
contraindicated or not tolerated, and once stabilised with no
or minimal clinical congestion on physical examination, to
decrease mortality and decrease hospitalisation.
11-14
GRADE:
Strong; Evidence: High.
A mineralocorticoid receptor antagonist (MRA) is recom-
mended in all patients with HFrEF associated with an
LVEF 40% unless contraindicated or not tolerated, to
decrease mortality and decrease hospitalisation for HF.
15,16
GRADE: Strong; Evidence: High.
An angiotensin receptor blocker (ARB) is recommended
in patients with HFrEF associated with an LVEF 40% if
an ACE inhibitor is contraindicated or not tolerated,
to decrease the combined endpoint of cardiovascular mor-
tality and HF hospitalisation.
17
GRADE: Strong; Evidence:
Moderate.
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
b
-blocker (unless contraindicated), with or
without an MRA, to decrease mortality and decrease hospi-
talisation.
18
GRADE: Strong; Evidence: High.
Ivabradine should be considered in patients with HFrEF
associated with an LVEF 35% and with a sinus
rate 70 bpm, despite receiving maximally tolerated or target
doses of an ACE inhibitor (or ARB) and a
b
-blocker (unless
1 Heart failure diagnostic criteria
Heart failure with reduced ejection fraction
Symptoms signs of heart failure
and
LVEF < 50%*
Heart failure with preserved ejection fraction
Symptoms signs of heart failure
and
LVEF 50%
and
Objective evidence of:
<relevant structural heart disease (LV hypertrophy, left atrial
enlargement)
and/or
<diastolic dysfunction, with high lling pressure demonstrated
by any of the following:
invasive means (cardiac catheterisation)
echocardiography
biomarker (elevated BNP or NT proBNP)
exercise (invasive or echocardiography)
*If LVEF mildly reduced (LVEF, 41e49%), additional criteria required (eg, signs of
heart failure; diastolic dysfunction with high lling pressure demonstrated by
invasive means or echocardiography or biomarker testing). BNP ¼B-type
natriuretic peptide; LV ¼left ventricular; LVEF ¼left ventricular ejection fraction;
NT ¼N-terminal. u
Guideline summary
MJA 2018
2
contraindicated), with or without an MRA, to decrease the
combined endpoint of cardiovascular mortality and HF hos-
pitalisation.
19
GRADE: Strong; Evidence: High.
A diuretic should be considered in patients with HF and
clinical symptoms, or signs of congestion, to improve
symptoms and manage congestion.
20
GRADE: Strong;
Evidence: Very low.
Unless a reversible cause has been corrected, neurohormonal
antagonists (ACE inhibitors or ARBs or ARNIs,
b
-blockers and
MRAs) should be continued at target doses in patients with
HF associated with a recovered or restored ejection fraction, to
decrease the risk of recurrence.
21
GRADE: Strong; Evidence:
Low.
<Practice point: Aim for the target doses used in the rando-
mised controlled trials (RCTs) that showed the benets of
these drugs. Most of the RCTs were conducted in patients
with HF associated with an LVEF < 35e40%; however,
post hoc analyses of patients with HF associated with a
mild reduction in LVEF (LVEF, 41e49%) enrolled in RCTs
have reported similar benets with
b
-blockers and drugs
that antagonise the renineangiotensinealdosterone sys-
tem.
22-24
<Practice point: Patients with HFpEF are generally
older with multiple comorbidities. The main aims of
treatment are to improve symptoms and quality of life
and decrease hospitalisation. Although the evidence
for neurohormonal antagonists is less robust, these
agents are often used to manage comorbidities. Low dose
spironolactone may be considered to decrease HF
hospitalisation.
25
Non-pharmacological management
Referral to a multidisciplinary HF disease management pro-
gram is recommended in patients with HF associated with
high risk features, to decrease mortality and rehospitalisa-
tion.
26
GRADE: Strong; Evidence: High.
3 When to consider early referral in the community setting
(red ags)
Symptoms
Orthopnoea
Paroxysmal nocturnal dyspnoea
Syncope
Ischaemic chest pain
Signs
Tachycardia (heart rate > 100 bpm)
Bradycardia (heart rate < 40 bpm)
Hypotension (systolic blood pressure < 90 mmHg)
Hypoxaemia
Gallop rhythm
Signicant heart murmur
Investigations
Evidence of ischaemia or infarction on 12-lead electrocardiogram
Pulmonary oedema on chest x-ray
Raised cardiac troponin level
Moderate or severe valvular heart disease on echocardiography
Left ventricular ejection fraction 40%
Ischaemia on stress testing u
2 Diagnostic work-up of a patient with suspected heart failure
ACEI ¼angiotensin-converting enzyme inhibitor; ARB ¼angiotensin receptor blocker; BNP ¼B-type natriuretic peptide; CXR ¼chest x-ray; ECG ¼electrocardiogram;
EUC ¼electrolytes/urea/creatinine; FBC ¼full blood count; HFpEF ¼heart failure with preserved ejection fraction; HFrEF ¼heart failure with reduced ejection fraction;
HTN ¼hypertension; LFTs ¼liver function tests; MRA ¼mineralocorticoid receptor antagonist; NTproBNP ¼N-terminal pro B-type natriuretic peptide. Adapted with permission
from Tomlinson S, Atherton JJ. Heart failure ethe crucial role of the GP. Medicine Today 2018; 19: 19-27. u
Guideline summary
MJA 2018
3
In areas where access to a face-to-face multidisciplinary HF
disease management program after discharge is limited,
patients should be followed up with a multidisciplinary tele-
monitoring or telephone support program.
27
GRADE: Strong;
Evidence: Moderate.
<Practice point: These programs should focus on high risk
patients, especially those recently discharged after hospi-
talisation for HF. Patient and carer education, including
self-management, should commence soon after diagnosis,
be patient-centred appropriate to their level of health lit-
eracy, and be revised continually for life.
Nurse-led medication titration is recommended in patients
diagnosed with HFrEF who have not achieved maximum
tolerated doses of ACE inhibitors, ARBs, ARNIs,
b
-blockers
or MRAs, to decrease hospitalisation.
28
GRADE: Strong; Evi-
dence: High.
Regular performance of up to moderate intensity (ie, breathe
faster but hold conversation) continuous exercise is recom-
mended in patients with stable chronic HF, particularly those
with reduced LVEF, to improve physical functioning and
quality of life and to decrease hospitalisation.
29
GRADE:
Strong; Evidence: High.
4 Evidence summary for management of heart failure with reduced ejection fraction
2
Treatment effect All patients
Selected patients
Strong recommendation Weak recommendation
Decrease morbidity/mortality ACEI (or ARB*)
b
-blocker
MRA
Switch ACEI or ARB to ARNI (LVEF 40%)
Ivabradine (SR 70 bpm, LVEF 35%)
Multidisciplinary HF disease management
Nurse-led medication titration
ICD (IHD, LVEF 35%)
CRT (SR, QRS 130 ms, LVEF 35%)
AF ablation (paroxysmal/persistent AF,
LVEF 35%)
CABG (IHD, LVEF 35%)
VAD (intractable severe HF)
Heart transplantation (intractable severe HF)
ICD (DCM, LVEF 35%)
CRT (AF, QRS 130 ms, LVEF 35%)
Hydralazine þnitrates
N-3 polyunsaturated fatty acids
Improve symptoms Diuretics (congested)
Exercise training (also decreases hospitalisation)
Intravenous iron (iron decient)
Digoxin (refractory symptoms)
ACEI ¼angiotensin-converting enzyme inhibitor; AF ¼atrial brillation; ARB ¼angiotensin receptor blocker; ARNI ¼angiotensin receptor neprilysin inhibitor; CABG ¼coronary
artery bypass graft surgery; CRT ¼cardiac resynchronisation therapy; DCM ¼dilated cardiomyopathy; ICD ¼implantable cardioverter debrillator; IHD ¼ischaemic heart disease;
LVEF ¼left ventricular ejection fraction; MRA ¼mineralocorticoid receptor antagonist; SR ¼sinus rhythm; VAD ¼ventricular assist device. *ARB should only be used if ACEI is
contraindicated or not tolerated. Carvedilol, bisoprolol, metoprolol succinate, nebivolol. u
5 Management of patients with heart failure with reduced ejection fraction (HFrEF)*
ACEI ¼angiotensin-converting enzyme inhibitor; ARB ¼angiotensin receptor blocker; ARNI ¼angiotensin receptor neprilysin inhibitor; CRT ¼cardiac resynchronisation therapy;
ICD ¼implantable cardioverter debrillator; LVEF ¼left ventricular ejection fraction; MRA ¼mineralocorticoid receptor antagonist. * HFrEF refers to patients with symptoms
signs of heart failure associated with and LVEF < 50% (unless otherwise specied). yARB should only be used if ACEI is contraindicated or not tolerated. zCarvedilol, bisoprolol,
metoprolol succinate, nebivolol.
ˇ
Commencing MRA usually avoided if serum K > 5 mmol/L or CrCl < 30 mL/m. BICD and/or CRT. Adapted with permission from Tomlinson S,
Atherton JJ. Heart failure ethe crucial role of the GP. Medicine Today 2018; 19: 19-27. u
Guideline summary
MJA 2018
4
<Practice point: Exercise can be considered as soon as prac-
tical in clinically stable patients. An initial period of su-
pervision may be warranted to verify individual responses
and tolerability.
Devices, surgery and percutaneous procedures
Cardiac resynchronisation therapy (CRT) is recommended in
patients with HFrEF associated with sinus rhythm, an
LVEF 35% and a QRS duration 150 ms despite optimal
medical therapy, to decrease mortality, decrease hospital-
isation for HF, and improve symptoms.
30,31
GRADE: Strong;
Evidence: High.
CRT should be considered in patients with HFrEF associated
with sinus rhythm, an LVEF 35% and a QRS duration of
130e149 ms despite optimal medical therapy, to decrease
mortality, decrease hospitalisation for HF, and improve
symptoms.
30
GRADE: Strong; Evidence: Moderate.
CRT should be considered in patients with HFrEF associated
with an LVEF of 50% accompanied by high grade atrio-
ventricular block requiring pacing, to decrease hospitalisation
for HF.
32
GRADE: Weak; Evidence: Moderate.
CRT is contraindicated in patients with a QRS
duration < 130 ms, because of lack of efcacy and possible
harm.
33
GRADE: Strong Against; Evidence: Moderate.
<Practice point: Resynchronisation of ventricular contraction
is achieved by pacing both the left and the right ventricles
simultaneously. The benet is greater in patients with a
broader QRS duration,
30,31
and in some studies for left
bundle branch block morphology and prolonged PR in-
terval.
31,34
If CRT is performed in patients in atrial bril-
lation (AF), measures are required to ensure at least
92% biventricular capture.
35
An implantable cardioverter debrillator (ICD) should be
considered as a primary prevention indication in patients with
HFrEF associated with ischaemic heart disease and an
LVEF 35%, to decrease mortality.
36,37
GRADE: Strong;
Evidence: Moderate.
An ICD may be considered as a primary prevention indication
in patients with HFrEF associated with dilated cardiomyop-
athy and an LVEF 35%, to decrease mortality.
37-39
GRADE:
Weak; Evidence: Low.
Coronary artery bypass graft surgery should be considered
in patients with HFrEF associated with ischaemic heart
disease and an LVEF 35% if they have surgically correct-
able coronary artery disease, to improve symptoms (eg, re-
lief of angina and HF symptoms) and decrease morbidity
and long term mortality.
40
GRADE: Strong; Evidence:
Moderate.
<Practice point: The benets must be balanced against the
short term morbidity and mortality risk related to coronary
artery bypass graft surgery. Factors unrelated to the
severity of HF including age, frailty and comorbidities
are important contributors to surgical risk.
Surgical aortic valve replacement is recommended in patients
with severe aortic stenosis or severe aortic regurgitation and HF
in the absence of major comorbidities or frailty, to improve
symptoms and decrease mortality.
41
GRADE: Strong; Evidence:
Low.
Transcatheter aortic valve implantation should be consid-
ered in patients with severe aortic stenosis and HF at in-
termediate to high operative mortality risk, or considered
inoperable for surgical aortic valve replacement, and who
are deemed suitable for transcatheter aortic valve implan-
tation following assessment by a heart team, to improve
symptoms and decrease mortality.
42-45
GRADE: Strong;
Evidence: Moderate.
Referral to a specialist centre for consideration of ventricular
assist device implantation should be considered in patients
with intractable, severe HF despite guideline-directed medical
and pacemaker therapy, and who do not suffer from major
comorbidities, to decrease mortality.
46
GRADE: Strong;
Evidence: Moderate.
<Practice point: Timing of implantation of ventricular assist
devices and patient selection are critical to achieving a
successful outcome. Longer term harms including disabling
stroke, bleeding and infection remain major limitations.
Referral for heart transplant assessment should be consid-
ered in patients with HF associated with intractable New
York Heart Association class IIIeIV symptoms who have
exhausted all alternative therapies and who do not have
overt contraindications, to decrease mortality.
47
GRADE:
Strong; Evidence: Low.
Comorbidities in heart failure
Pharmacological therapy aiming for a resting ventricular rate
of 60e100 bpm should be considered in patients with HF
associated with AF and a rapid ventricular response.
48,49
GRADE Strong; Evidence: Low.
<Practice point:
b
-Blockers and/or digoxin are generally
favoured for ventricular rate control. Consider non-
dihydropyridine calcium entry blockers in patients with
HFpEF to control the ventricular rate of AF; however,
these drugs should be avoided in patients with HFrEF.
Catheter ablation for AF (either paroxysmal or persistent)
should be considered in patients with HFrEF associated with
an LVEF 35%, who present with recurrent symptomatic AF,
to decrease mortality and hospitalisation for HF.
49,50
GRADE:
Strong; Evidence: Moderate.
<Practice point: Consider oral amiodarone in patients
with HF associated with AF, to facilitate attainment
and maintenance of sinus rhythm (with or without
electrical cardioversion), improve symptoms, or guide
decisions regarding the need for more invasive ap-
proaches (eg, AF catheter ablation or atrioventricular
node ablation).
Adaptive servoventilation is not recommended in patients
with HFrEF and predominant central sleep apnoea because of
increased all-cause and cardiovascular mortality.
51
GRADE:
Strong Against; Evidence: Moderate.
<Practice point: Although clinicians may consider positive
pressure ventilation to improve quality of life and
decrease sleepiness in patients with predominant
obstructive sleep apnoea, the primary aim in patients
with predominant central sleep apnoea should be to treat
the HF.
Erythropoietin should not be used routinely for the treatment
of anaemia in patients with HF, because of an increased risk of
thromboembolic adverse events.
52
GRADE: Strong Against;
Evidence: Moderate.
In patients with HFrEF associated with persistent symptoms
despite optimised therapy, iron studies should be performed
and, if the patient is iron decient (ie, ferritin < 100 mg/L, or
Guideline summary
MJA 2018
5
ferritin 100e300 mg/L with transferrin saturation < 20%),
intravenous iron should be considered, to improve symptoms
and quality of life.
53
GRADE: Strong; Evidence: Moderate.
<Practice point: If iron deciency is diagnosed, one should
consider investigation for gastrointestinal pathology,
including peptic ulcer and malignancy (especially if also
anaemic). Intravenous ferric carboxymaltose was evalu-
ated in most of the RCTs, usually involving one to two
doses between 500 mg and 1000 mg. Re-check iron studies
after 4 months.
Palliative care in heart failure
Referral to palliative care should be considered in patients
with advanced HF to alleviate end-stage symptoms,
improve quality of life and decrease rehospitalisation.
Involvement of palliative care should be considered early in
the trajectory towards end-stage HF.
54
GRADE: Strong;
Evidence: High.
<Practice point: In patients with an ICD, discussions con-
cerning deactivation should occur between the patient,
family and cardiologist. Patients should be encouraged to
have an advanced care plan, regardless of clinical status
and soon after diagnosis.
Competing interests: A full conict of interest register is available at: https://www.heartfoundation.
org.au/for-professionals/clinical-information/atrial-brillation.
Provenance: Not commissioned; externally peer reviewed. n
ª2018 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
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... Sessions could be provided individually or in a group, either face-toface or via telehealth. Given the extensive evidence for group-based pulmonary and cardiac rehabilitation alone, 8 13 only studies including participants with severe chronic obstructive pulmonary disease (COPD) (predicted forced expiratory volume in one second <50%) 14 or advanced heart failure (class III-IV) 15 were included. If trials included participants with a mix of disease severity, studies were included if >50% participants had severe disease. ...
... The intervention teams also included physical therapists (12 trials), social workers (10 trials), occupational therapists (9 trials), psychologists (9 trials) and dietitians (9 trials) (online supplemental file 2). 15 interventions were delivered face-toface 22 24 27 29-40 with 11 delivered via a combination of face-to-face and telephone contacts. 23 25 26 41-48 One trial also offered the option of videoconference delivery. ...
Article
Importance International guidelines recommend the integration of multidisciplinary rehabilitation into palliative care services but its impact on quality of life across disease types is not well understood. Objective To determine the effect of multidisciplinary palliative rehabilitation on quality of life and healthcare service outcomes for adults with an advanced, life-limiting illness. Data sources Electronic databases CINAHL, EMBASE, MEDLINE and PEDro were searched from the earliest records to February 2024. Study selection Randomised controlled trials examining the effect of multidisciplinary palliative rehabilitation in adults with an advanced, life-limiting illness and reported quality of life were eligible. Data extraction and synthesis Study characteristics, quality of life and health service usage data were extracted, and the methodological quality was assessed using PEDro. Meta-analyses using random effects were completed, and Grades of Recommendation, Assessment, Development and Evaluation criteria were applied. Main outcomes Quality of life and healthcare service outcomes. Results 27 randomised controlled trials (n=3571) were included. Palliative rehabilitation was associated with small improvements in quality of life (standardised mean difference (SMD) 0.40, 95% CI 0.23 to 0.56). These effects were significant across disease types: cancer (SMD 0.22, 95% CI 0.03 to 0.41), heart failure (SMD 0.37, 95% CI 0.61 to 0.05) and non-malignant respiratory diagnoses (SMD 0.77, 95% CI 0.29 to 1.24). Meta-analysis found low-certainty evidence, palliative rehabilitation reduced the length of stay by 1.84 readmission days. Conclusions and relevance Multidisciplinary palliative rehabilitation improves quality of life for adults with an advanced, life-limiting illness and can reduce time spent in hospital without costing more than usual care. Palliative rehabilitation should be incorporated into standard palliative care. PROSPERO registration number CRD42022372951.
... Community-dwelling adults living with HF and their caregivers were invited to participate, through study posters placed in the HF outpatient clinics of participating hospitals. Inclusion criteria were as follows: adults with a primary diagnosis of HF with reduced ejection fraction (HFrEF), as per the National Heart Foundation [2] and European Society of Cardiology guidelines (patients) [3]; the ability to participate in face-to-face focus groups or via videoconference; and the ability to communicate and consent in English. ...
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Having briefly introduced this topic from the perspective of the United Nation Development Programme Goals , this introductory chapter provides a personal to scientific perspective on climate change in the modern era. As such, it will specifically describe how it (climate change) has the potential to adversely influence the heart health of the global population. In making this case, a cruel irony will be highlighted—that is, while most of the world’s poorest people barely contribute(d) to the reasons why climate change occurred, unlike high-polluting countries, they still suffer the same and even worse consequences. Moreover, they have limited resources and capacity to address the difficult challenges arising from climate change. In this context, while clinicians are mostly focussed on the individuals they care for, this chapter further explores why having a “ climatic conscience ” or at least awareness of climatic conditions on health, is the pathway to better health outcomes. Specifically, it provides a rationale why health services and clinicians alike, need to acknowledge and understand the link between external conditions and the physiological status of any individual—thereby thinking beyond the four walls of an environmentally controlled hospital or GP clinic.
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Aims Clinical practice guidelines are commonly written by professional societies in high‐income countries (HIC) with limited anticipation of implementation obstacles in other environments. We used heart failure (HF) guidelines as a paradigm to examine this concern, by conducting a survey to understand clinicians' ability to implement HF guidelines and their perceptions of the current HF guideline applicability in low‐ and middle‐income countries (LMIC). Methods and results An online survey of physicians in the database of the Translational Medicine Academy who treat HF patients was offered by email from 5 October to 27 November 2023, inquiring of participants' demographic information, experience, and views of HF guidelines as related to their practice. Of 2622 participating clinicians, 1592 partially completed, and an additional 1030 fully completed the survey. Participants were from 138 countries; 668 practiced in HIC, and 1954 in LMIC. Those from LMIC regarded HF guidelines to be less applicable in their country than did those from HIC ( p = 0.0002). Of all those responding, 75.3% indicated that it was somewhat or mostly true that the HF guidelines were mostly applicable to HIC. Those from LMIC, but not HIC indicated that the greatest implementation obstacle was that the guidelines were for HIC (51.3% vs. 43.1%; p = 0.0387). A significantly higher proportion of respondents from LMIC indicated that resources for caring for their patients were somewhat or mostly limiting in most cases, than did those in HIC (41.6% vs. 32.5%, p = 0.0068). Conclusion This survey examined the widely‐held thought that HF guidelines are broadly applicable to all regions of the world, concluding that such a perception is incorrect. Clinicians from LMIC view the absence of consideration of local resource limitations as the greatest obstacle for guideline implementation. The results regarding HF guidelines likely also have implications for other guidelines and resultant patient outcomes.
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This study aims to assess the global prevalence of kinesiophobia and the potential influencing factors among patients with heart disease. A comprehensive search was conducted in PubMed, Embase, Web of Science, PsycINFO, and Scopus databases to identify studies reporting on the prevalence of kinesiophobia and its influencing factors in heart disease patients up to January 2024. A random-effects model was employed to aggregate prevalence rates. Heterogeneity sources were investigated through subgroup analysis, while differences in the prevalence of kinesiophobia across regions, types of heart disease, and gender were evaluated. Additionally, a qualitative analysis of the factors influencing kinesiophobia was performed. This research incorporated 15 studies from six countries, with 14 providing data on the prevalence of kinesiophobia and nine exploring its potential influencing factors. The findings indicated that the overall prevalence of kinesiophobia among heart disease patients was 61.0% (95% CI 49.4–72.6%). Subgroup analysis revealed that the prevalence in upper-middle-income countries was 71.8% (95% CI 66.2–77.4%), while it stands at 49.9% (95% CI 30.2–69.5%) in high-income countries. The prevalence rates among patients with coronary artery disease, heart failure, and atrial fibrillation were 63.2% (95% CI 45.2–81.3%), 69.2% (95% CI 57.6–80.8%), and 71.6% (95% CI 67.1–76.1%), respectively. Gender-wise, no significant difference was observed in the prevalence of kinesiophobia between men and women (52.2% vs. 51.8%). A total of 24 potential influencing factors of kinesiophobia were identified, with education level, monthly income, anxiety, and exercise self-efficacy being the most recognized. The prevalence of kinesiophobia in patients with heart disease is notably high and is influenced by a multitude of factors. Early implementation of targeted preventive measures is imperative to mitigate the incidence of kinesiophobia in this population.
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Background Provision of palliative care in chronic heart failure (CHF) can support complex decision‐making, significantly improve quality of life and may lower healthcare costs. Aims To examine whether healthcare costs differed in terminal admissions according to the adoption of a palliative approach. Design Retrospective review of medical records and costing data for all admissions resulting in death from CHF (July 2011 to December 2019), analysed as two groups (2011–2016 and 2016–2019) because of background changes in costings. Setting Admissions with CHF resulting in death in an Australian tertiary referral centre. Results The cohort ( n = 439) were elderly (median age 83.7 years, interquartile range (IQR) = 77.6–88.7 years) and mostly men (54.9%). Half (230, 52.4%) were referred to a specialist palliative care team, whereas over a third (172, 39.2%) received a palliative approach. Receiving a palliative approach was associated with a nonstatistically significant lower admission cost (AU12710vsAU12 710 vs AU15 978; P = 0.19) between 2011 and 2016 ( n = 101, 38.8%) and a significantly lower cost (AU11319vsAU11 319 vs AU15 978; P < 0.01) between 2016 and 2019 ( n = 71, 39.7%). Intensive care admission resulted in the single greatest additional cost at AU14624(IQR=AU14 624 (IQR = AU4130–AU44197)(n=48,20112016).Medianterminaladmissioncostwaslowerforpatientswithcomfortgoalsofcare(P<0.01),withoutlifesustaininginterventions(P<0.01)orwhoreceivedapalliativeapproach(P<0.01).Referraltoinpatientspecialistpalliativecareorreceivingapalliativeapproachresultedincomparableadmissioncostings(AU44 197) ( n = 48, 2011–2016). Median terminal admission cost was lower for patients with comfort goals of care ( P < 0.01), without life‐sustaining interventions ( P < 0.01) or who received a palliative approach ( P < 0.01). Referral to inpatient specialist palliative care or receiving a palliative approach resulted in comparable admission costings (AU11 621 [IQR = AU4705–AU32 457] and AU11466[IQR=AU11 466 [IQR = AU4973–AU$25 614]). Conclusion A palliative approach in terminal CHF admission may improve quality at the end of life and decrease costs associated with care.
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Introduction: Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: • screening, prevention and diagnostic work‐up; • acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; • stroke prevention and optimal use of anticoagulants; and • integrated multidisciplinary care. Changes in management as a result of the guideline: • Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. • The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β‐Blockers or non‐dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. • The sexless CHA2DS2‐VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non‐vitamin K oral anticoagulants are recommended in preference to warfarin. • An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.
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Background: Mortality and morbidity are higher among patients with atrial fibrillation and heart failure than among those with heart failure alone. Catheter ablation for atrial fibrillation has been proposed as a means of improving outcomes among patients with heart failure who are otherwise receiving appropriate treatment. Methods: We randomly assigned patients with symptomatic paroxysmal or persistent atrial fibrillation who did not have a response to antiarrhythmic drugs, had unacceptable side effects, or were unwilling to take these drugs to undergo either catheter ablation (179 patients) or medical therapy (rate or rhythm control) (184 patients) for atrial fibrillation in addition to guidelines-based therapy for heart failure. All the patients had New York Heart Association class II, III, or IV heart failure, a left ventricular ejection fraction of 35% or less, and an implanted defibrillator. The primary end point was a composite of death from any cause or hospitalization for worsening heart failure. Results: After a median follow-up of 37.8 months, the primary composite end point occurred in significantly fewer patients in the ablation group than in the medical-therapy group (51 patients [28.5%] vs. 82 patients [44.6%]; hazard ratio, 0.62; 95% confidence interval [CI], 0.43 to 0.87; P=0.007). Significantly fewer patients in the ablation group died from any cause (24 [13.4%] vs. 46 [25.0%]; hazard ratio, 0.53; 95% CI, 0.32 to 0.86; P=0.01), were hospitalized for worsening heart failure (37 [20.7%] vs. 66 [35.9%]; hazard ratio, 0.56; 95% CI, 0.37 to 0.83; P=0.004), or died from cardiovascular causes (20 [11.2%] vs. 41 [22.3%]; hazard ratio, 0.49; 95% CI, 0.29 to 0.84; P=0.009). Conclusions: Catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure than was medical therapy. (Funded by Biotronik; CASTLE-AF ClinicalTrials.gov number, NCT00643188 .).
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Background: The cardiovascular and long-term noncardiovascular safety and efficacy of SGLT2 (sodium-glucose cotransporter 2) inhibitors have not been well documented. Methods and results: For cardiovascular outcomes, we performed a meta-analysis with trial sequential analysis of randomized controlled trials and adjusted observational studies, each with a minimum of 26 weeks and 2000 patient-years of follow-up. For long-term noncardiovascular safety and efficacy outcome analyses, we included only randomized controlled trials with at least 2 years and 1000 patient-years of follow-up. Five studies with 351 476 patients were included in cardiovascular outcomes analysis. Meta-analyses showed that SGLT2 inhibitors significantly reduced the risks of major adverse cardiac events (hazard ratio [HR]: 0.80; 95% confidence interval [CI], 0.69-0.92; P=0.002), all-cause mortality (HR: 0.67; 95% CI, 0.54-0.84; P<0.001), cardiovascular mortality (HR: 0.77; 95% CI, 0.60-0.98; P=0.03), nonfatal myocardial infarction (HR: 0.86; 95% CI, 0.76-0.98; P=0.02), hospitalization for heart failure (HR: 0.62; 95% CI, 0.55-0.69; P<0.001), and progression of albuminuria (HR: 0.68; 95% CI, 0.58-0.81; P<0.001). No significant difference in nonfatal stroke was found. Analyses limited to randomized controlled trials showed similar findings. Trial sequential analysis provided firm evidence of a 20% reduction in major adverse cardiac events, all-cause mortality, and hospitalization for heart failure with SGLT2 inhibitors, but evidence remains inconclusive for cardiovascular mortality. Nine randomized controlled trials contributed to long-term noncardiovascular and efficacy analyses. SGLT2 inhibitors reduced incidence of hypoglycemia and acute kidney injury but increased the risks of urinary tract and genital infections. Conclusions: SGLT2 inhibitors showed remarkable cardiovascular- and renal-protective effects and good long-term noncardiovascular safety with sustained efficacy.
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Aims: Recent guidelines recommend that patients with heart failure and left ventricular ejection fraction (LVEF) 40-49% should be managed similar to LVEF ≥ 50%. We investigated the effect of beta-blockers according to LVEF in double-blind, randomized, placebo-controlled trials. Methods and results: Individual patient data meta-analysis of 11 trials, stratified by baseline LVEF and heart rhythm (Clinicaltrials.gov: NCT0083244; PROSPERO: CRD42014010012). Primary outcomes were all-cause mortality and cardiovascular death over 1.3 years median follow-up, with an intention-to-treat analysis. For 14 262 patients in sinus rhythm, median LVEF was 27% (interquartile range 21-33%), including 575 patients with LVEF 40-49% and 244 ≥ 50%. Beta-blockers reduced all-cause and cardiovascular mortality compared to placebo in sinus rhythm, an effect that was consistent across LVEF strata, except for those in the small subgroup with LVEF ≥ 50%. For LVEF 40-49%, death occurred in 21/292 [7.2%] randomized to beta-blockers compared to 35/283 [12.4%] with placebo; adjusted hazard ratio (HR) 0.59 [95% confidence interval (CI) 0.34-1.03]. Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97). Over a median of 1.0 years following randomization (n = 4601), LVEF increased with beta-blockers in all groups in sinus rhythm except LVEF ≥50%. For patients in atrial fibrillation at baseline (n = 3050), beta-blockers increased LVEF when < 50% at baseline, but did not improve prognosis. Conclusion: Beta-blockers improve LVEF and prognosis for patients with heart failure in sinus rhythm with a reduced LVEF. The data are most robust for LVEF < 40%, but similar benefit was observed in the subgroup of patients with LVEF 40-49%.
Article
Background In an early analysis of this trial, use of a magnetically levitated centrifugal continuous-flow circulatory pump was found to improve clinical outcomes, as compared with a mechanical-bearing axial continuous-flow pump, at 6 months in patients with advanced heart failure. Methods In a randomized noninferiority and superiority trial, we compared the centrifugal-flow pump with the axial-flow pump in patients with advanced heart failure, irrespective of the intended goal of support (bridge to transplantation or destination therapy). The composite primary end point was survival at 2 years free of disabling stroke (with disabling stroke indicated by a modified Rankin score of >3; scores range from 0 to 6, with higher scores indicating more severe disability) or survival free of reoperation to replace or remove a malfunctioning device. The noninferiority margin for the risk difference (centrifugal-flow pump group minus axial-flow pump group) was −10 percentage points. Results Of 366 patients, 190 were assigned to the centrifugal-flow pump group and 176 to the axial-flow pump group. In the intention-to-treat population, the primary end point occurred in 151 patients (79.5%) in the centrifugal-flow pump group, as compared with 106 (60.2%) in the axial-flow pump group (absolute difference, 19.2 percentage points; 95% lower confidence boundary, 9.8 percentage points [P<0.001 for noninferiority]; hazard ratio, 0.46; 95% confidence interval [CI], 0.31 to 0.69 [P<0.001 for superiority]). Reoperation for pump malfunction was less frequent in the centrifugal-flow pump group than in the axial-flow pump group (3 patients [1.6%] vs. 30 patients [17.0%]; hazard ratio, 0.08; 95% CI, 0.03 to 0.27; P<0.001). The rates of death and disabling stroke were similar in the two groups, but the overall rate of stroke was lower in the centrifugal-flow pump group than in the axial-flow pump group (10.1% vs. 19.2%; hazard ratio, 0.47; 95% CI, 0.27 to 0.84, P=0.02). Conclusions In patients with advanced heart failure, a fully magnetically levitated centrifugal-flow pump was superior to a mechanical-bearing axial-flow pump with regard to survival free of disabling stroke or reoperation to replace or remove a malfunctioning device. (Funded by Abbott; MOMENTUM 3 ClinicalTrials.gov number, NCT02224755.)
Article
Aims: We tested the hypothesis that candesartan improves outcomes in heart failure (HF) with mid-range ejection fraction [HFmrEF; ejection fraction (EF) 40-49%]. Methods and results: In 7598 patients enrolled in the CHARM Programme (HF across the spectrum of EF), we assessed characteristics, outcomes and treatment effect of candesartan according to EF. Patients with HFmrEF (n = 1322, 17%) were similar to those with HF with reduced EF (HFrEF; n = 4323, 57%) with respect to some characteristics, and intermediate between HFrEF and HF with preserved EF (HFpEF; n = 1953, 26%) with respect to others. Over a mean follow-up of 2.9 years, the incidence rates for the primary outcome of cardiovascular death or HF hospitalization were 15.9, 8.5 and 8.9 per 100 patient-years in HFrEF, HFmrEF and HFpEF. In adjusted analyses, the rates of the primary outcome declined with increasing EF up to 50%. For treatment effect, the incidence rates for the primary outcome for candesartan vs. placebo were 14.4 vs. 17.5 per 100 patient-years in HFrEF [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.75-0.91; P < 0.001], 7.4 vs. 9.7 per 100 patient-years in HFmrEF (HR 0.76, 95% CI 0.61-0.96; P = 0.02), and 8.6 vs. 9.1 per 100 patient-years in HFpEF (HR 0.95, 95% CI 0.79-1.14; P = 0.57). For recurrent HF hospitalization, the incidence rate ratios were 0.68 in HFrEF (95% CI 0.58-0.80; P < 0.001), 0.48 in HFmrEF (95% CI 0.33-0.70; P < 0.001), and 0.78 in HFpEF (95% CI 0.59-1.03; P = 0.08). With EF as a continuous spline variable, candesartan significantly reduced the primary outcome until EF well over 50% and recurrent HF hospitalizations until EF well over 60%. Conclusion: Candesartan improved outcomes in HFmrEF to a similar degree as in HFrEF. ClinicalTrials.gov: CHARM Alternative NCT00634400, CHARM Added NCT00634309, CHARM Preserved NCT00634712.
Article
Background: Implantable cardioverter defibrillators (ICDs) improve survival in patients with heart failure due to ischemic cardiomyopathy, but their benefit in non-ischemic cardiomyopathy (NICM) has been recently questioned. We performed a meta-analysis of randomized clinical trials to examine the effect of ICDs on total mortality and arrhythmic death in patients with NICM. We also examined the impact of age and cardiac resynchronization therapy (CRT) on the relative effect of ICD compared to control. Methods and results: We searched the MEDLINE and EMBASE databases for randomized trials evaluating the effect of ICD versus control in patients with NICM. Hazard ratios (HR) with 95% confidence interval (CI) were calculated using a random effects model. Six trials involving 2,967 patients were included (ICD, n = 1,553; control, n = 1,414). Based on the pooled estimate across the 6 studies, the use of ICD was associated with a significant reduction in total mortality (HR = 0.78, 95% CI 0.66-0.92; p = 0.003), as well as arrhythmic death (HR = 0.46, 95% CI 0.29-0.71; p = 0.0005) compared to control. ICD decreased total mortality in younger patients compared to control (HR = 0.63, 95% CI 0.46 to 0.86; p = 0.004), but not in older patients (HR = 0.97, 95% CI 0.56 to 1.68; p = 0.92). In patients with CRT, ICD reduced total mortality compared to control (HR = 0.78, 95% CI 0.65 to 0.95; p = 0.02), but not in patients with CRT (HR = 0.71, 95% CI 0.40 to 1.26). Conclusions: ICDs decrease total mortality and arrhythmic deaths in patients with NICM. The benefit of ICD appears to be dependent on age and concomitant use of CRT. This article is protected by copyright. All rights reserved.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To summarise the current evidence for conventional diuretic therapy in patients with CHF based on data from published randomised controlled trials to determine whether there were any effects on clinical outcomes. The review is being done now because mainly stimulated by the main RALES Study (RALES 1999) which actually investigated the role of aldosterone antagonist (not classically a diuretic) and it raised a question in our mind about the formal evidence for the conventional loop or thiazide diuretics. The implication for clinical practice is that a common, simple treatment is being used without clear evidence of major benefit on important clinical outcomes. We felt it was first important to inform the scientific community of this fact and also to stimulate interest in further clinical trials that may help us to understand both how to use diuretics better and to understand more about their benefits.