Chronic heart failure

Chronic heart failure is a complex condition with exacerbating features caused by structural or functional abnormalities of the heart. It is a severe, disabling condition with multiple comorbidities which negatively impact on quality of life.

The aims of this initiative are to:

  • reduce unwarranted clinical variation
  • support patients to self-manage their condition by tailoring education and resources to meet their needs
  • facilitate optimal care across the continuum and between settings, particularly after discharge and at the end of life.

The incidence of chronic heart failure increases with age, and it is a common comorbidity with conditions such as atrial fibrillation, diabetes and renal disease. Prevalence remains high and it is one of the leading causes of admission and readmission to hospital in NSW.

Evidence-based management involves the multidisciplinary coordination of care across acute and primary care providers to support self-management and reduce unwarranted clinical variation.

Best practice principles include:

  • adherence with optimal pharmacotherapy
  • non-pharmacological interventions
  • community heart failure management programs
  • implantation of devices
  • surgical procedures
  • supportive end of life care.


Snapshot of chronic heart failure in NSW

In 2016-17...
69 hospitals
admitted more than
50 patients each year

Model of care

3Ci model of care 2023

Organisational model of care to improve outcomes and reduce unnecessary hospitalisations for people with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in NSW.

View model of care


Guidelines for the prevention, detection and management of chronic heart failure in Australia 2018

Clinical guidelines for the management of heart failure, produced by the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand.

View guidelines

NSW clinical service framework for chronic heart failure 2016

Best practice guidance across nine key standards, providing a benchmark for optimal care delivery.

View framework

For clinicians and services

What to improve

Read about the four clinical priority areas of care for chronic heart failure:

  1. diagnostics
  2. exacerbation management
  3. optimising health through ongoing care
  4. last year of life

How to improve

Explore options for different organisational models to tailor clinical services for your local requirements:

  • heart failure nurse-coordinated care model
  • nurse-led models including clinics and home visits
  • virtual health model

Additional resources

Contact the Cardiac Network

Email the team at or visit the ACI Cardiac Network.

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