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Congestive heart failure

This fact sheet is to help MBF members and their families be better prepared for the healthcare experience after a diagnosis of congestive heart failure.

Not all of the information here will be applicable to everyone, so it is important to discuss your individual circumstances with your doctor and perhaps with other healthcare professionals in the team caring for you. Please, never hesitate to ask 'why' or to have something explained to you until you understand it. If, after you have been given an answer, you still feel as though there are unanswered questions, ask again or ask someone else. You can help the healthcare team to help you if you feel free to communicate your needs to them. Further research and reading (see 'Learn more about congestive heart failure and its treatment') will also help you make more informed decisions about your treatment.

What is Congestive Heart Failure? 

Congestive heart failure, or heart failure, is a condition that arises when the heart is damaged and can no longer efficiently pump enough blood to other organs of the body.

This can be caused by:

  • damage to the heart muscle itself due to restricted blood supply to the heart muscle (medically known as coronary artery or ischaemic heart disease),
  • high blood pressure,
  • heart valve disease,
  • disease of the heart muscle itself (medically known as cardiomyopathy) that can be the result of a wide range of other conditions,
  • heart defects that one can have at birth,
  • infections of the heart, and
  • other types of heart disease.

It commonly occurs as a result of damage to the heart muscle by coronary heart disease that may have been associated with previous heart attacks.

With congestive heart failure, a "failing" heart keeps working but not as efficiently as it should. Therefore, blood flow out of the heart slows and blood that should be returning to the heart begins to back up in the veins. The body responds to this by allowing fluid to make its way out of the arteries and veins and it causes fluid to collect in the tissues of the body. This results in swelling (medically known as oedema). Most often this swelling occurs in the legs and ankles, or in the lungs. It can however happen in other parts of the body, too. When this fluid collects in the lungs it can interfere with breathing, causing shortness of breath, especially when a person is lying down.

Around 300,000 Australians are living with congestive heart failure, with about 30,000 new cases diagnosed each year.

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Your treatment options 

Treatment for congestive heart failure will most likely include a combination of medication, lifestyle changes and, in some cases, surgery. Both the heart failure and the cause of the heart failure should be treated if possible. The exact treatment will depend on several factors, including the cause of the congestive heart failure and your general health.

Several different types to medications may be prescribed to address different aspects of the problem. For example, there are medications to:

  • help open the blood vessels to deliver more blood, nutrients and oxygen to the heart (medically known as ACE inhibitors). This class of drugs also help not to retain fluid;
  • help the body eliminate excess fluid (medically known as diuretics) and there is growing evidence that "potassium sparing diuretics" in particular are far more effective in managing the condition;
  • lower blood pressure such as the drugs known as "beta blockers"; and
  • help the heart beat properly.

Always share a list of the drugs you are currently taking with your health care provider, including your chemist, when discussing your medication options. Write a complete list of all the current drugs you are taking, including the name of the drug and the dosage (typically stated in mg). Remember to include those drugs prescribed by other doctors and drugs and supplements you buy over-the-counter without a doctor's prescription, even if you take them occasionally.

It is extremely important to continue taking medications as prescribed by your health care providers even if you are feeling well. It is also very important to be well-informed about the medications you have been prescribed, including interactions with other medications you may be taking and with alcohol.

Lifestyle changes are likely to be recommended in every case. Healthy lifestyle habits are important to improve your overall health status and to improve your heart's ability to pump and receive blood. Lifestyle changes may include:

  • losing excess weight,
  • regular gentle to moderate exercise,
  • diet for specific causes of heart disease
  • stopping smoking,
  • reducing salt intake,
  • reducing alcohol intake, and
  • resting appropriately to avoid excess tiredness.

Surgery may also be recommended in certain cases, specifically to:

  • replace or repair heart valves;
  • install a special kind of pacemaker to help the heart to beat properly;
  • install an 'implantable defibrillator', a device that will continually monitor and, if necessary, shock the heart to correct a very abnormal heart beat; or
  • very rarely, replace your heart with a donor heart - a heart transplant (an option usually used only in extreme cases and for certain people).

One of the keys to maintaining your health is remaining watchful for these early signs of problems with your heart failure and then talking to your doctor about what you should be doing to get back to normal, such as taking additional or different medication.

It is strongly recommended that you should be routinely monitoring and paying close attention to:

  • changes in your weight (increases in weight over a short period often represent the first sign of fluid build-up);
  • changes in any foot or ankle swelling due to the fluid build-up;
  • any increased difficulty in breathing, especially when you lie down or try to get to sleep;
  • any cough that gets worse at night when you lie down; and
  • signs of worsening of any underlying condition that may be causing or contributing to the heart failure.

It is generally agreed that lifestyle changes, particularly around diet, exercise, controlling fluid intake and establishing habits for monitoring the warning signs, offer the best chance of optimal long-term management, keeping out of hospital and maximising your quality of life, especially for those whose heart failure is moderate or severe. Medication and surgery may be necessary, but without improving lifestyle habits (such as good eating habits and stop smoking), they are less likely to be as effective over time.

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What is a prosthesis? Is this relevant to you? 

Your specialist may recommend surgery that includes inserting a stent, a pacemaker or implantable defibrillator (see 'Your treatment options'). Each of these is known as a prothesis. A prosthesis is a device that is surgically implanted during a stay in hospital.

This is important not only from a health cover perspective but because a prosthesis may wear out over time. If this situation is severe, it must be replaced by another prosthesis. Several factors will influence whether you could need a replacement in the future:

  • the quality of the prosthesis you receive;
  • your current health status and lifestyle behaviours;
  • personal factors such as obesity and your age; and
  • complications of surgery such as infection.

Read 'Questions to ask your doctors' to prepare for discussions with your specialist so that you feel you have made an informed decision regarding your prosthesis.

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Questions to ask your doctors  

Generally, a GP will initially refer you to a specialist cardiologist for evaluation and to oversee your care. Your GP may then also be closely involved with your ongoing treatment. If you need surgery, a specialist cardiac surgeon will usually perform the procedure. Usually, your GP will suggest one or more specialists and give you a referral.

To your GP/Referring Doctor:

  • Can you explain to me, in simple terms, the cause of my heart failure?
  • Have you got some information for me as to what lifestyle changes I need to make, such as diet, exercise and watching my fluid intake?
  • In the past I used to watch my weight but it could go up a few kilos or down a few over time. I understand that I have to watch my weight much more closely now, maybe even daily. Can you please explain why? Why are changes in weight over short periods more important now?
  • If I am having a diuretic to help get rid of fluid, is it one that keeps the potassium in? (Potassium is a salt in the blood and cells which helps keep fluid inside the cells.)
  • Are you going to put me on an "ACE" (angiotensin converting enzyme) inhibitor?
  • What are the possible complications and/or side effects of my treatment, especially my medication? How can I reduce the risks?
  • What specialist do you recommend? These questions may or may not pertain to you.
  • Why do you recommend this particular specialist?
  • Do you know if they charge a gap that Medicare or my health fund won't cover? Even so, choose your doctor first on their experience and expertise.

To the Specialist:

  • Can you explain to me the cause of my heart failure?
  • Will you please explain, in simple terms, the treatment you are recommending?
  • Why do you think this is the best treatment option for me? What are the other options?
  • What are the likely outcomes of my treatment?
    • What are the chances that the outcomes will be good with this treatment or with the alternative options?
    • What are the possible complications and/or side effects of my treatment, especially my medication? How can I reduce the risks?
  • What sort of monitoring or follow-up treatment do you expect me to need?
  • Have you got some information for me as to what lifestyle changes I need to make, such as diet, exercise and watching my fluid intake?
  • In the past I used to watch my weight but it could go up a few kilos or down a few over time. I understand that I have to watch my weight much more closely now, maybe even daily. Can you explain that to me? Why are changes in weight over short periods more important now?
  • If I am having a diuretic to help get rid of fluid, is it one that keeps the potassium in? (Potassium is a salt in the blood and cells which helps keep fluid inside the cells.)
  • Are you going to put me on an "ACE" (angiotensin converting enzyme) inhibitor?
  • What are the possible complications and/or side effects of my treatment, especially my medication? How can I reduce the risks?

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If your doctor recommends surgery (also see 'What MBF pays toward treatment'):

  • Can you explain the type of procedure I am likely to need? How many of these have you performed? How many do you do each year?
  • Why do you think this is the best treatment option for me? What other options are there?
  • How long do you expect me to be in hospital?
  • Do I require a prosthesis of any kind? If yes,
    • Is the prosthesis you intent to use considered a 'no-gap' prosthesis? A small number of the prosthesis implants can have an associated out-of-pocket charge, but these are almost always limited to those where a similar no gap item is available.
    • If my prosthesis requires a gap, what is the 'gap' and is there a comparable prosthesis that is no-gap? If not, can you explain why?
  • What are the possible complications and/or side effects associated with my surgery?
  • What can I do, prior to hospital, to reduce my risk for complications?
  • Discuss healthy weight, appropriate exercise, how to quit smoking and/or your current medications with your doctor. If you are diabetic, well-managed diabetes prior to your surgery will also help your recovery.
  • Should I stop taking any of my medications prior to going to hospital? If so, how long before?
  • What is my expected recovery time?
  • What sort of monitoring or follow-up treatment do you expect me to need?
  • What restrictions will I have regarding my everyday activities when I go home (such as exercise and other activities, driving or lifting heavy objects)? If so, how long am I likely to need assistance?
  • Do you charge a gap that Medicare or my health fund won't cover? Even so, always choose your doctor/s first based on their experience and expertise.
  • Does the anaesthetist or any other doctor who may assist with the procedure charge a gap? If so, how much should I expect that to be?

What MBF pays toward treatment 

Understanding how the healthcare system works can be confusing. This brief summary outlines what you can expect in terms of your health cover, hospital and medical costs. Always check with MBF before you go to hospital.

Your hospital costs  

MBF Advantage Hospital, MBF Premium Hospital and MBF Standard Hospital cover will help pay for surgery and/or implantation of a prosthesis associated with congestive heart failure provided that:

  • you have the procedure while you have been formally admitted in a hospital;
  • it is a treatment for which Medicare pays a benefit;
  • it is not an Excluded Service on your level of cover; and
  • you've met all the standard conditions of your membership (like serving the relevant waiting periods).

Selected MBF Hospital cover will pay for the following treatments and services so long as you are formally admitted to the hospital and the above conditions are met:

  • shared accommodation (or private room if available);
  • surgery- related expenses including operating theatre and intensive care if needed;
  • certain therapies such as cardiac rehabilitation, physiotherapy and occupational therapy when provided by the hospital and associated with your hospital treatment;
  • certain drugs supplied as part of your inpatient hospital treatment; and
  • the full cost of a government-approved surgically-implanted prosthesis selected from the 'no gap' list developed by the Department of Health and Ageing. Visit here for more about prostheses and your health cover.

Please note that cardiac procedures, including those associated with congestive heart failure, are Excluded services under MBF Budget Hospital cover. This means no benefit will be paid by MBF under this level of cover for hospital and doctors' charges associated with that admission.

Remember, if you are not in an MBF Network Hospital and/or public hospital, you may incur substantial out-of-pocket expenses for your hospital charges.

Please note that the surgeon's and other doctors' charges will be part of your medical costs. In addition, Medicare pays a Medicare benefit toward out-patient cardiac rehabilitation.

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Your prosthesis costs  

Pacemakers, defibrillators, stents and heart valve replacements are known as prostheses. Should your specialist or surgeon feel one is necessary, you should have one or more prostheses available to you at no gap. The cost of a no-gap prosthesis will be fully covered by your MBF hospital cover so long as you hold an appropriate level of cover and standard conditions are met. These conditions include waiting periods, any known Excess or Co-payment and any applicable Exclusions on your level of cover.

In a small number of cases, there may be other more expensive prosthesis that your surgeon or doctor may recommend that could attract a gap. Where your surgeon recommends a prosthesis that attracts a gap and you agree to that prosthesis, you will have to pay a gap amount. Ask your surgeon to explain why he or she is recommending this particular prosthesis over one without a gap.

If applicable, when and where to pay your prosthesis gap

When you are admitted to hospital for surgery, the surgeon should have made the hospital aware that a gap-prosthesis will be used for your procedure. The hospital will often ask you to the pay the prosthesis gap payment when you are admitted to hospital.

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Your medical (doctors') costs  

If you will be going to hospital and/or having surgery, ask your specialist or surgeon to explain the costs of your admission and/or surgery, including any prosthesis gap amount, their own fees, any fees that other doctors involved in the surgery might charge and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as informed financial consent. Obtaining this information is extremely important before any planned hospital admission.

Remember, there may be more than one doctor involved in the procedure. These may include the cardiac surgeon, an anaesthetist and an assistant surgeon. You may not meet them all in person.

Each doctor will charge for his or her services. See Going to hospital and Gap and informed financial consent for a guide to these costs.

Key things for you to know about medical costs and your health cover are:

  • MBF will pay benefits toward your doctors' charges for the service you receive:
    • when formally admitted as an in-patient in hospital or day surgery, and
    • when the service relates to treatment included under your level of cover, and
    • when you are entitled to a Medicare benefit for the treatment.
  • The Medicare Benefits Schedule Fee ('MBS') is the amount determined by the Commonwealth Government for the purpose of paying Medicare Benefits. For eligible in-patient services, Medicare pays for 75% of the MBS; MBF pays the remaining 25%.
  • Many doctors charge above the MBS, creating a 'gap'- an amount the patient has to pay.
  • MBF does not pay any amount charged by your doctor above the MBS unless there is an agreement in place between your doctor and MBF. This agreement is known as the MBF Medical Gap Cover Scheme.
  • MBF has created the MBF Medical Gap Cover Scheme to help reduce gaps paid by members. Doctors who participate in this scheme have agreed to accept the MBF benefit as full payment for your treatment. If a doctor has agreed to treat you under the MBF Medical Gap Cover Scheme there will be no 'gap' to pay for that doctor's charge.
  • It may be that not all doctors involved in your hospital treatment are 'no gap' doctors. So you may have to pay a gap for some doctors' services, but not others.

Remember, doctors are independent of MBF and can decide whether or not to treat you under the MBF Medical Gap Cover Scheme.

Click here for a list of 'no gap' doctors or call MBF.

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Other costs relating to your treatment and recovery  

Depending on your level of MBF extras cover, MBF can also help with the cost of:

  • dietetics provided by a Registered Dietitian to help establish good eating habits;
  • complementary therapies such as therapeutic massage;
  • pharmacy including most prescribed non-PBS listed medications, and
  • gym membership fees and other activities such as yoga through MBF Living Well Programs cover (restrictions apply).

MBF extras benefits are only payable for services provided in Australia by an MBF Recognised Provider. MBF Recognised Providers are health service providers that meet MBF guidelines. Call 131 137 to confirm whether or not your provider is a MBF Recognised Provider.

You can enjoy higher benefits on all preventive and general dental services and selected physiotherapy, optical, pharmacy and gym membership services (restrictions on claiming apply) by using the growing MBF MemberCare network of service providers. With our MBF MemberCare network of providers, you are guaranteed of receiving at least 70%-90% of the charge back on selected services depending on your level of cover, up to the annual limit of your cover. Find an MBF MemberCare service provider.

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Join the MBF Congestive Heart Failure Management Program  

The MBF Congestive Heart Failure Management Program helps you manage your life following a heart failure episode. Based on current research about heart failure, it offers practical advice and information to help you look after your health and make the most of life - while still managing your heart condition.

This program is available on selected levels of MBF hospital cover.

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Learn more about congestive heart failure and its treatment  

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More about going to hospital, MBF Network hospitals, no-gap doctors, and MBF MemberCare providers  

As well as calling MBF, you can find plenty of useful information about your health cover and what to expect when you go to hospital right here on this website.

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Last updated: 05-06-07

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