Written by Dimitrios Vrachatis, Specialist Cardiologist, PhD, National and Kapodistrian University of Athens.
What is heart failure?
Heart failure is a syndrome involving:
- Signs: objective findings such as raised jugular venous pressure, lung crackles or peripheral swelling
- Symptoms: experiences such as breathlessness or fatigue
It results in increased pressures within the heart and/or an inability to maintain adequate cardiac output, the volume pumped per minute, at rest or during exercise.
How common is it?
Heart failure can result from many conditions and has been described as a silent epidemic. It affects more than 10% of people over 70. European incidence is estimated at three per 1,000 person-years overall and five per 1,000 person-years in adults.
What happens in heart failure?
Symptoms and signs result from impaired structure or function of the myocardium, valves or pericardium, causing reduced output or raised chamber pressures at rest or during exertion.
Neurohormonal activation, including increased sympathetic activity and renin–angiotensin system activation, oxidative stress and inflammation are involved.
The heart cannot effectively fulfil its central role: receiving venous blood, sending it to the lungs for oxygenation, then pumping it through the arteries.
Are there different categories?
Classification uses left ventricular ejection fraction, expressed as a percentage:
- Reduced: below 40%, HFrEF
- Mildly reduced or intermediate: 40–50%, HFmrEF
- Preserved: 50% or more, HFpEF
How is it diagnosed?
Ejection fraction is measured by echocardiography, but this alone does not establish the diagnosis: signs and symptoms must also be present.
For heart failure with preserved ejection fraction, further evidence is needed:
- Raised blood natriuretic peptides, BNP or NT-proBNP, and/or
- Additional echocardiographic findings, such as diastolic dysfunction, thickened walls or left atrial enlargement
What causes heart failure?
Common causes include:
- Uncontrolled or undiagnosed hypertension
- Coronary artery disease
- Valve disease, such as aortic stenosis or mitral regurgitation
Other causes include:
- Toxins: excessive alcohol, appetite suppressants, chemotherapy, heavy metals or radiation
- Infections: for example viral myocarditis
- Autoimmune disease: lupus or rheumatoid arthritis
- Genetic conditions: hypertrophic, dilated or restrictive cardiomyopathy, laminopathies and muscular dystrophies
- Infiltrative disease: amyloidosis, haemochromatosis or sarcoidosis
- Metabolic conditions: diabetes, thyroid disease, Cushing’s syndrome or phaeochromocytoma
- Kidney failure
- Tachycardia-induced cardiomyopathy
- Peripartum cardiomyopathy
Can it be prevented?
Some underlying causes can be prevented. In general, follow healthy habits, avoid smoking and excessive alcohol, and arrange regular health monitoring and primary prevention with your cardiologist before problems develop.
What are the symptoms?
Symptoms vary in intensity. Their gradual onset can lead people to reduce activity substantially and mistakenly believe they have none. This can delay intervention, and the first recognised episode may be severe or even sudden death.
Typical symptoms include:
- Breathlessness during activity
- Waking at night with breathlessness
- Fatigue or slow recovery after exertion
- Needing several pillows when sleeping
- Leg swelling
Less typical symptoms include:
- Night-time cough
- Weight loss
- Loss of appetite or wasting
- Palpitations or a rapid heartbeat
- Depression
- Fainting
- A feeling of fullness
- Confusion
- Bendopnoea: breathlessness when bending to tie shoelaces
How is heart failure treated?
Medicines central to chronic heart failure treatment include:
- ACE inhibitors and beta-blockers
- Mineralocorticoid receptor antagonists (MRAs)
- Angiotensin receptor–neprilysin inhibition (ARNI)
- SGLT2 inhibitors, diabetes medicines with demonstrated benefits in heart failure
Depending on the clinical picture, treatment may also include:
- Diuretics, such as furosemide
- Ivabradine for a rapid heart rate, only in sinus rhythm
Devices may:
- Prevent fatal arrhythmias: implantable defibrillators (ICDs)
- Improve cardiac function: cardiac resynchronisation therapy (CRT)
For selected patients, mechanical circulatory support or heart transplantation is a final option.
How is my treatment chosen?
The treating doctor escalates medication and other treatments according to the clinical picture.
Device implantation follows internationally defined criteria and applies only to patients with specific characteristics.
Ideally, assessing the effect of a dose change or new medicine requires sufficient time, approximately one to two weeks, with systematic follow-up and communication.
Alongside medication, follow advice on:
- Regular weight monitoring
- Stopping smoking
- Reducing salt
- Limiting alcohol
- Weight loss
- Gentle daily exercise
- Keeping vaccinations up to date
Can heart failure worsen?
Chronic heart failure can involve flare-ups and acute episodes requiring urgent intravenous medication or admission, for example with pulmonary oedema.
Close follow-up aims to minimise these episodes, which worsen overall health and can affect other organs, including the kidneys.
When should I contact the doctor?
Patients and their carers are an important part of treatment.
Contact your cardiologist promptly for new or worsening symptoms, such as breathlessness, cough, swollen legs or rapid weight gain of more than 2 kg in 1–2 days. Timely treatment adjustments can help avoid hospital admission.