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Cardiology — Updates Since 2020

Guideline & practice changes since 2020

Heart failure

  • HFpEF is no longer a condition without disease-modifying treatment. SGLT2 inhibitors are first-line regardless of ejection fraction (EMPEROR-Preserved, DELIVER — empagliflozin PBS-listed for LVEF >40% since 1 November 2023, dapagliflozin for HFpEF since 1 March 2024); finerenone is an emerging second pillar after FINEARTS-HF showed a ~16% reduction in cardiovascular death and worsening heart failure events at LVEF ≥40%, including in patients already on an SGLT2 inhibitor; GLP-1 receptor agonists (semaglutide, tirzepatide) are recommended for the obesity phenotype. See HFpEF.
  • HFrEF is four pillars started together, not a stepwise ladder. Current Australian GP-level guidance is to start two drugs, add the other two, then titrate — ARNI preferred over an ACE inhibitor first-line rather than reserved for treatment failure, and an SGLT2 inhibitor for everyone regardless of diabetes. Benefit appears within 30 days. See HFrEF.
  • Eplerenone is no longer PBS-restricted to post-MI patients. From 1 April 2026 the criteria broadened to chronic heart failure (NYHA II–IV, LVEF ≤40%) without requiring a prior MI or inpatient initiation — it can now be started in general practice.
  • Australia has no current national heart failure guideline. The NHFA/CSANZ guideline dates from 2018 and is widely considered outdated. The most current guidance aligned to Australian practice is the 2025 iCARDIO Alliance guideline — co-authored by Australian cardiologists, published in the CSANZ journal, using the Australian LVEF <50% classification rather than the European one. An NHFA/CSANZ update was reported to be in development during 2025.
  • The Australian LVEF cut-off is <50%, not <40%. Trials, PBS criteria and device thresholds mostly use ≤40%, and Australia doesn’t recognise a separate “mildly reduced”/HFmrEF category for LVEF 41–49%. See the HFrEF page’s section on what to do in that band.
  • Smaller HFrEF additions: IV iron now recommended not just for symptoms but to reduce hospitalisation and cardiovascular death, with iron deficiency definable as transferrin saturation <20%; vericiguat after a recent worsening episode; potassium binders to keep patients on pillar therapy rather than sacrificing an MRA.

Other findings

  • Superficial vein thrombosis is now risk-stratified on ultrasound (AJGP, Oct 2026). Thrombus length and distance from the saphenofemoral/saphenopopliteal junction decide treatment: NSAIDs only if <5 cm and >3 cm away; prophylactic-dose anticoagulation for 45 days if ≥5 cm or 3–5 cm away; therapeutic anticoagulation for 3 months if ≤3 cm, recurrent, or with cancer or thrombophilia. D-dimer has no role. See Superficial Thrombophlebitis.
  • Valvular heart disease: new Aortic Stenosis page — severity grading, TAVI-vs-SAVR decision-making.
  • Pacemakers/ICDs: most modern devices are now MRI-conditional (reversing the old blanket MRI contraindication), and remote monitoring is now standard. See Cardiac Implantable Electronic Devices.
  • Kawasaki disease is the leading cause of acquired childhood heart disease in developed countries; rheumatic heart disease remains a serious health equity issue in Australia. Rheumatic fever secondary prophylaxis (2020 RHDAustralia guideline): 5 years post-episode (no cardiac involvement) or 10 years (with cardiac involvement), or until age 21 — whichever is longer (shorter than the old blanket 10-year-minimum rule). See Infective & Inflammatory Heart Disease.
  • RACGP Red Book hypertension guidance is due a full replacement in Q3 2026 — the 2016 guideline will be superseded by a new Heart Foundation/Stroke Foundation/ Hypertension Australia “modular” guideline. See Hypertension.
  • Draft 2027 national hypertension guideline (pending review, 28 Sep 2026). The consultation draft is now out, and its proposed changes are on the Hypertension page in “Update Pending Review” boxes alongside the current guidance: screen every newly diagnosed adult for primary aldosteronism, start drugs at 140/90 or above even at low cardiovascular risk (130/80 at high risk), start with a dual single-pill combination rather than monotherapy, and aim for below 130/80. Not yet standard of care. See Hypertension.
  • 2023 Australian CVD risk guideline replaced the old NVDPA absolute-risk framework (low <5%, intermediate 5–<10%, high ≥10%, diabetes now a calculator input rather than automatic high-risk). See Cardiovascular Risk Assessment.
  • 2025 NHFA/CSANZ ACS guideline tightened the secondary-prevention LDL-C target to <1.4 mmol/L with ≥50% reduction from baseline. See Acute Coronary Syndromes, Hypercholesterolaemia, Lipid Lowering Therapy, Familial Hypercholesterolaemia.
  • 2023 ESC cardiomyopathy guideline formalised HCM sudden-death risk stratification (HCM Risk-SCORE) and added mavacamten to the LVOTO drug ladder, plus a full non-invasive cardiac amyloidosis diagnostic pathway. See Cardiomyopathies.
  • 2023 Duke-ISCVID criteria added cardiac CT and PET/CT as accepted imaging modalities for infective endocarditis diagnosis. See Infective & Inflammatory Heart Disease.
  • Andexanet alfa’s Australian registration has lapsed — relevant to anticoagulant-related bleeding in AF/VTE patients (see haematology).
  • Subclinical (device-detected) AF is now managed cautiously, not anticoagulated routinely. The 2024 ESC AF guideline’s AF-CARE framework (Comorbidity/risk-factor management, Avoid stroke, Rhythm/rate control, Evaluation/reassessment) reflects two large trials, NOAH-AFNET 6 and ARTESiA, which found only a small anticoagulation benefit against an increased bleeding risk for atrial high-rate episodes picked up incidentally on a pacemaker/ICD/loop recorder. See Atrial Fibrillation.
  • Primary aldosteronism screening shouldn’t rely on hypokalaemia alone. A 2022 prospective Melbourne general-practice study found primary aldosteronism in 14% of newly diagnosed, treatment-naive hypertensive patients, with hypokalaemia present in only 30% of cases. A December 2025 Australian Prescriber editorial by three guideline-committee members also previews the still-unreleased national hypertension guideline’s likely direction: lower treatment targets, dual-combination-pill first-line therapy for most patients above 140/90mmHg, and greater emphasis on out-of-clinic (ABPM/HBPM) measurement — not yet the standard of care while the 2016 guideline remains in force. See Hypertension.
  • Varicose veins now has a broadened, sourced page — CEAP classification (C0–C6), compression-therapy ABPI safety thresholds, and injection sclerotherapy technique. See Varicose Veins.
  • SVT & WPW now has dedicated evidence (previously had none): the drug-avoidance rule broadens from “avoid digoxin” to avoid all AV-nodal blocking drugs (digoxin, verapamil, diltiazem, beta-blockers, adenosine) whenever AF/flutter is possible in a WPW patient, and the 2015 ACC/AHA/HRS guideline recommends catheter ablation as first-line therapy for any symptomatic patient. See SVT & WPW.

New pages added

  • ECG Interpretation (2026-09-01) — a systematic reading order (rate, rhythm, axis, intervals, waveform morphology), the patterns that need same-day cardiology input or ED referral (STEMI criteria, high-grade heart block, hyperkalaemia changes, markedly prolonged QT), and technical pitfalls like lead misplacement.

  • VTE Treatment & Anticoagulation Management (2026-08-31) — the long-term half of anticoagulation, which the site had nowhere: agent choice and the exceptions to DOAC-first, duration and low-intensity extended dosing (apixaban 2.5 mg BD, rivaroxaban 10 mg daily), why aspirin is not a substitute, CrCl-not-eGFR monitoring, periprocedural interruption without bridging, reversal, when to restart after a major bleed, and what counts as genuine anticoagulant failure.

  • Pulmonary Embolism (2026-08-31) — the lung half of VTE, which previously had no page of its own: simplified Wells and PERC, where D-dimer helps and where it doesn’t, CTPA vs V/Q, what to give before transfer, apixaban and rivaroxaban dosing, the 3–6 month rule and when to continue indefinitely, why thrombophilia testing is usually not indicated at presentation, and CTEPH follow-up.

  • Aortic Stenosis — severity grading (4 echocardiographic categories), surveillance intervals, TAVI vs SAVR decision-making, and perioperative risk for non-cardiac surgery.

  • Cardiac Implantable Electronic Devices — pacemaker/ICD/CRT/ILR indications, MRI conditionality, remote monitoring, leadless devices, and practical driving/magnet/end-of-life points.

  • SVT & WPW — vagal manoeuvres, adenosine, and ablation referral criteria for PSVT and Wolff-Parkinson-White syndrome.

  • Superficial Thrombophlebitis and Varicose Veins.

  • Kawasaki disease and rheumatic fever sections added within Infective & Inflammatory Heart Disease.