Heart failure is a chronic, progressive condition in which the heart cannot pump sufficient blood to meet the body's demands. It affects an estimated 1–2% of South African adults and accounts for a substantial proportion of hospital admissions. While it is often associated with other CDL-listed conditions — hypertension, diabetes, and dysrhythmia in particular — heart failure itself is not on the CDL. Its PMB status covers acute hospital admissions but not the full cost of optimised chronic management.
What Is Heart Failure?
Heart failure does not mean the heart has stopped. It means the heart is functioning below the capacity needed to maintain adequate circulation, leading to a build-up of fluid (congestion) in the lungs and body, reduced exercise tolerance, and fatigue.
HFrEF (Heart Failure with Reduced Ejection Fraction): The left ventricle is weak and does not contract effectively. Ejection fraction (EF) < 40%. Most responsive to guideline-directed medical therapy. Causes: ischaemic heart disease (coronary artery disease), cardiomyopathy, long-standing hypertension.
HFpEF (Heart Failure with Preserved Ejection Fraction): The heart contracts normally but is stiff and does not relax or fill properly. EF ≥ 50%. Less responsive to some standard HFrEF therapies. Strongly associated with hypertension, obesity, and diabetes.
NYHA Functional Classification: - Class I: No symptoms at ordinary activity - Class II: Mild symptoms at ordinary activity - Class III: Significant symptoms at less-than-ordinary activity - Class IV: Symptoms at rest; severe limitation
Heart Failure and Comorbid Conditions in SA
Heart failure in South Africa most commonly arises from or is associated with: - Hypertension (CDL): The leading cause of HFpEF and a major contributor to HFrEF in SA - Coronary artery disease (PMB): Myocardial infarction leading to systolic dysfunction - Atrial fibrillation / dysrhythmia (CDL): Both cause and consequence of heart failure - Diabetes (CDL): Major risk factor; SGLT2 inhibitors (prescribed for diabetes) now have strong heart failure benefit - Rheumatic heart disease: Significant in SA, particularly in younger patients from lower-income communities
The multi-CDL picture is important: most heart failure patients have 2–3 CDL-registered conditions. These CDL conditions are separately funded — managing them correctly reduces heart failure progression and reduces total healthcare cost.
Is Heart Failure a PMB Condition?
Heart failure is a PMB condition — hospital admissions for acute decompensated heart failure must be funded. However, the nuance is important:
- Acute decompensated heart failure (hospitalisation): PMB — your scheme must fund the acute hospital admission under the heart failure DTP.
- Chronic heart failure management (outpatient): NOT PMB as a standalone. Cardiologist visits, echocardiography, and outpatient medication come from day-to-day benefits and CDL (for comorbid conditions).
- Heart failure medication for comorbid CDL conditions: If furosemide, ACE inhibitor, or beta-blocker is prescribed for hypertension (CDL), the medication may be CDL-funded. The heart failure diagnosis itself does not give CDL medication access — it must be linked to a CDL-listed condition.
How Does Medical Aid Cover Heart Failure?
| Service | PMB/CDL? | Typical cover | Notes |
|---|---|---|---|
| GP consultation | No | Day-to-day | |
| Cardiologist consultation | No | Day-to-day | Shortfall likely; R2,000–R4,000/visit |
| Echocardiogram (echo) | No | Radiology/cardiology benefit | R3,000–R7,000; critical diagnostic and monitoring tool |
| ECG | No | Day-to-day | Inexpensive |
| BNP/NT-proBNP blood test | No | Pathology benefit | Key diagnostic marker for HF |
| Chest X-ray | No | Radiology benefit | |
| Acute hospital admission (decompensated HF) | Yes — PMB | Hospital benefit | IV diuresis, oxygen, haemodynamic monitoring |
| ICU / HDU (severe HF) | Yes — PMB | Hospital benefit | Inotropic support, ventilation if required |
| Furosemide (diuretic) | CDL if hypertension co-registered | CDL or day-to-day | Very inexpensive generic |
| ACE inhibitor / ARB (enalapril, ramipril, losartan) | CDL if hypertension co-registered | CDL chronic benefit | |
| Beta-blocker (carvedilol, bisoprolol, metoprolol) | CDL if hypertension co-registered | CDL chronic benefit | |
| Aldosterone antagonist (spironolactone, eplerenone) | CDL if hypertension co-registered | CDL | |
| Sacubitril/valsartan (Entresto) | No CDL | Day-to-day — check formulary | R1,500–R2,800/month; newer class; not universally on formulary |
| SGLT2 inhibitor (dapagliflozin/empagliflozin for HF) | CDL if diabetes co-registered | CDL if diabetic | Strong HF mortality benefit even in non-diabetic HF |
| ICD (implantable cardioverter-defibrillator) | PMB (cardiac arrhythmia DTP) | Hospital benefit | For HFrEF with EF <35%; reduces SCD risk |
| CRT (cardiac resynchronisation therapy) | PMB (cardiac DTP) | Hospital benefit | For selected HFrEF patients with conduction delay |
| Heart transplant | PMB | Hospital benefit (specialist centre) | End-stage HF; very limited capacity in SA |
Entresto (Sacubitril/Valsartan) — The Key Coverage Gap
Entresto (sacubitril/valsartan) is the most evidence-backed disease-modifying therapy for HFrEF, demonstrating ~20% reduction in mortality versus enalapril in the landmark PARADIGM-HF trial. South African cardiologists increasingly prescribe it for appropriate HFrEF patients.
The problem: Entresto is not a CDL medicine and is not universally on scheme formularies. At R1,500–R2,800/month, it represents a significant day-to-day cost. Patients who cannot afford it may continue on older (still effective) ACE inhibitor therapy.
What to do: 1. Ask your cardiologist whether Entresto is indicated for your HF profile. 2. Call your scheme: "Is sacubitril/valsartan (Entresto) on my formulary, and is it funded under my chronic medication benefit?" 3. If not on formulary, your cardiologist can submit a clinical motivation for a non-formulary medicine approval.
Day-to-Day Costs: What to Budget For
| Scenario | Estimated annual cost |
|---|---|
| Stable HF, well-controlled comorbidities on CDL, cardiologist 2×/year | R15,000 – R35,000 |
| Moderate HF on Entresto + cardiologist + echo + HF nurse programme | R35,000 – R70,000 |
| Advanced HF with device therapy (ICD/CRT) + specialist management | R50,000 – R120,000 |
Gap Cover Relevance
Gap cover is relevant for: - Hospital admissions for decompensated heart failure (cardiologist inpatient shortfall) - ICD or CRT device implantation (in-hospital procedure; specialist shortfall) - Coronary angiography or intervention for ischaemic cardiomyopathy
Key Questions to Ask Your Scheme
- Are all my CDL comorbidities (hypertension, diabetes, dysrhythmia) properly registered? Correct CDL registration is the most important step to reduce OOP costs.
- Is Entresto on my formulary, and if not, what is the non-formulary motivation process?
- Is my cardiologist on your DSP panel? Regular specialist visits are a significant cost if shortfalls apply.
- Is echocardiography covered under my radiology or cardiology benefit? Annual or biannual echo is standard for HF monitoring.
- Does my plan have a chronic disease management programme for heart failure? Some schemes have dedicated heart failure nurse programmes (Dis-Chem Home Care, Netcare Heart, etc.) that provide medication support and monitoring — ask about this.
Talk to Eldon
Heart failure management costs are minimised by correct CDL registration of all comorbidities and access to specialist cardiology. The Check shows what each plan on our panel pays for this, side by side, and Eldon advises from there.
See which plans pay for heart failure management →