Optimising heart failure care for Aboriginal and Torres Strait Islander people with reduced ejection fraction
This resource is designed to support GPs and other clinicians working in Aboriginal Community Controlled Health Organisations (ACCHOs) to deliver holistic, person-centred care that strengthens heart health, promotes wellbeing, and empower individuals and families to get the most from the medicines for HFrEF.
Heart failure (HF) is a complex chronic condition that affects how the heart works, often leading to symptoms like breathlessness or tiredness. Wwith the right care, support, and lifestyle changes, people can live well and enjoy a good quality of life after a diagnosis of heart failure.
Over 60,000 Australians are diagnosed with heart failure every year.(2)
Aboriginal and Torres Strait Islander people are 2.8 times more likely to be hospitalised for heart failure.(8)
The average survival rate following a heart failure diagnosis is around five years.(5)
For Aboriginal and Torres Strait Islander peoples, there are higher rates of health conditions such as high blood pressure, heart and kidney disease, diabetes, and rheumatic heart disease—many of which can begin earlier in life.4 While these conditions can increase the risk of heart failure, they also present powerful opportunities for early intervention, culturally safe care, and community-led health solutions.
By focusing holistically on quality of life and culturally appropriate care, we can help people live stronger and longer.
Key messages
- Check for the common signs and symptoms of heart failure to identify undiagnosed heart failure in the community.
- A transthoracic echocardiogram is recommended for all clients with suspected or newly diagnosed heart failure to support diagnosis and classify heart failure.
- Optimising medication management with the four pillars of heart failure treatment can significantly improve client outcomes for those diagnosed with heart failure with reduced ejection fraction (HFrEF).
- A holistic approach to heart failure management, including cardiac rehabilitation, is recommended for all clients regardless of ejection fraction. This supports overall health by addressing comorbidities and promoting lifestyle changes. Care should be culturally responsive and tailored to the needs of Aboriginal and Torres Strait Islander peoples.
Aboriginal and Torres Strait Islander people may be living with undiagnosed heart failure.5
Check for the common signs and symptoms of heart failure
The signs and symptoms of heart failure can be non-specific and therefore overlooked. During Health Assessments, clients should be asked if they are experiencing any of the symptoms listed below.
If they answer yes, then check for these common signs of heart failure.6
Symptoms
- shortness of breath (especially during physical activity)
- difficulty breathing when lying down
- waking up at night feeling short of breath
- feeling very tired
Signs
- swollen neck veins
- swelling in the abdomen when pressing on the liver
- an extra heart sound
- heartbeat felt in a different place on the chest
When clinical signs and symptoms are suggestive of heart failure, further tests and investigations are required6 for diagnosis. A transthoracic echocardiogramis recommended as one of the essential initial investigations6. This non-invasive test provides critical insights into cardiac structure and function, including left ventricular ejection fraction (LVEF) and valvular performance. It is not only a diagnostic tool but also guides evidence-based management that can improve quality of life as well as survival.6
Enhance access to echocardiograms
Accessing echocardiogram services can be particularly challenging in regional and remote communities. To improve availability and reduce barriers, consider the following strategies:
Explore mobile services
Identify whether mobile enchocardiogram services operate in your area and coordinate their visits to meet local demand.
Leverage support programs
Utilise initiatives such as the Integrated Team Care (ITC) Program to assist with the costs and logistics of accessing echocardiograms, making them more affordable and accessible for clients.
ITC ProgramEngage bulk-billing cardiologists
Connect with local cardiologists who offer bulk billing to help reduce financial barriers for patients.
Collaborate with Indigenous Health Workers
Work alongside Aboriginal and Torres Strait Islander Health Workers, Health Practitioners and Liaison Officers to support culturally safe care, improve communication, and build trust with clients.
Cardiac rehabilitation
A holistic approach to managing heart failure addresses all aspects of a client’s health, including the management of comorbidities such as diabetes, renal disease and chronic obstructive pulmonary disease (COPD), support for smoking cessation, optimisation of diet and physical activity, and attention to social and emotional wellbeing (SEWB).
Cardiac rehabilitation programs offer comprehensive support for people living with health failure including supervised exercise and physical activity, nutrition and fluid management, psychosocial and SEWB support and education on self-management and symptom monitoring.
To be effective and inclusive, cardiac rehabilitation programs should be culturally responsive and tailored to meet the specific needs of Aboriginal and Torres Strait Islander peoples.
Enhance access to cardiac rehabilitation
Access to cardiac rehabilitation is often limited in remote and regional areas. To improve availability and continuity of care, consider the following strategies:
Foster local partnerships
Collaborate with local cardiac rehabilitation providers to co-design culturally safe and supportive programs in partnership with your ACCHO.
Embed referrals in care plans
Ensure referrals to cardiac rehabilitation are a routine part of chronic disease management and discharge planning.
Demystify the process
Organise visits to cardiac rehab providers for clients and staff to build familiarity and reduce anxiety about participation.
Engage community leaders
Involve Elders and community leaders in promoting cardiac rehabilitation and encouraging participation.
Utilise Community Engagement Officers
These team members can play a key role in coordinating care, supporting follow-up, and bridging communication between clients and services.
Multidisciplinary and holistic care
Promote a team-based model of care that clearly defines the roles of all health professionals involved in cardiac rehabilitation and chronic disease management. This may include:
- General Practitioners (GPs)
- Chronic Disease Nurses
- Aboriginal and Torres Strait Islander Health Workers and Health Practitioners
- Pharmacists
- Dietitians
- Exercise Physiologists
- SEWB teams (including psychologists, counsellors, and social workers)
Encouraging collaboration across disciplines ensures clients receive comprehensive, person-centred care that supports both physical and emotional wellbeing. This can be supported through MBS items such as case conferencing or team care arrangements once a GPMP has been completed.
Flexible models for remote communities
To overcome geographical barriers, explore alternative delivery models, such as:
- Home-based cardiac rehabilitation supported by telehealth.
- Mobile health platforms offering remote monitoring and virtual coaching.
- Community-based exercise and education programs delivered by local health workers.
In some remote communities, cardiac rehab is delivered through a hybrid model where clients receive initial assessments via telehealth with a metropolitan cardiac team, followed by ongoing support from local health workers and visiting allied health professionals.
Use LVEF results to guide evidence-based management for HFrEF
Accurate assessment of LVEF helps differentiate between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF), each of which requires a distinct therapeutic approach.6
Those with a LVEF of 40% or less are classified as having HFrEF.3 Studies, in some populations, have shown that treatment with the four pillars of HFrEF management could add up to 8 additional years free from cardiovascular death or HF hospital admission and up to 6 additional years of survival7
It is important to record the heart failure classification and echocardiogram results, including LVEF, in clinical information systems (CIS) to identify clients for four pillars management and and monitor the efficacy of comprehensive client care.
The four pillars of HFrEF management
The four pillars of HFrEF management include the following classes of medicines.
- Renin-angiotensin system (RAS) inhibitors: includes angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor/ neprilysin inhibitor (ARNI) – sacubitril with valsartan, and angiotensin II receptor blockers ().
- Heart failure specific beta-blockers: includes bisoprolol, carvedilol and controlled-release metoprolol and nebivolol.
- Mineralocorticoid receptor antagonists (MRAs): includes spironolactone and eplerenone.
- Sodium-glucose co-transporter 2 (SGLT2) inhibitors: includes dapagliflozin and empagliflozin.
Each class of medication independently reduces hospitalisations, prolongs survival, and improves symptoms and quality of life.6 When the four pillars are initiated together early in diagnosis and titrated to maximal tolerated dose, they combine to greatly improve client outcomes compared to conventional therapy.7
The combination increases both the number of years clients live and the number of years they live without dying from heart-related issues or needing to be hospitalised.7
Optimising medicine management of HFrEF
- Start all four classes of medicines at time of diagnosis or within 2–4 weeks improves client outcomes.8
- Evidence shows that achieving target doses (maximally tolerated doses) of these medications within three months can significantly increase life expectancy and reduce hospitalisations.7,9
- Regularly monitor client’s signs and symptoms of heart failure, functional status, fluid status, kidney function, blood pressure, heart rate, and electrolyte concentrations.3
GPs play a pivotal role in heart failure management by initiating and titrating guideline-directed medical therapy while simultaneously referring clients to cardiology services.
This coordinated approach minimises delays in care, optimises treatment outcomes, and enhances quality of life for clients from the outset.
Overcoming challenges for HFrEF management
Some clients may not be on all four pillars due to various reasons, including recent or previous acute kidney injury (AKI) or concerns about renal function.
- Ensure that clients who have had medications stopped (e.g., due to AKI) are re-evaluated and restarted on appropriate medications when safe.
- Optimise the management of the client’s co-morbidities, as evidence suggests comorbidities can reduce the chance of reaching target doses of all four drug classes and impose additional stress on the heart10.
- Support clients to overcome potential barriers to medication adherence. Build rapport with the client, discuss potential reasons for non-adherence and develop an individualised plan.
- Consider a Home Medicines Review (HMR) or other medicine review for specialist medicines advice when clients have multiple co-morbidities (See Hidden Risks for more information)
Refer to the following resources for detailed guides on how to safely implement and up-titrate the four pillars in primary care.
GP specific resources
– including therapeutic brief, case scenario and patient audit tool.
Medicines Advice Initiative AustraliaLeverage support programs
- Medicines management
ITC ProgramClients can access a Living Well with Heart Failure booklet from the Heart Foundation website here.
Cardiac rehab completes the heart failure care framework—it’s the fifth pillar that drives recovery
This holistic, person-centred approach—grounded in evidence-based interventions and strengthened by meaningful community engagement—drives better health outcomes, enhances quality of life, and supports longer, more fulfilling lives for clients.
Continuous Quality Improvement (CQI) activity
Optimising medicine management in HFrEF
Other resources
Contact
For any inquiries or further information about the Medicines and Pharmacy team at: medicines@naccho.org.au.
