Heart Failure
The heart hasn’t stopped; it just isn’t pumping or filling well enough to keep up with the body. Modern medicines have changed the outlook dramatically, especially when they’re started early.
Quick answer: Heart failure means the heart can’t pump or fill well enough, causing breathlessness, tiredness and swollen ankles. It’s grouped by ejection fraction: reduced (HFrEF, 40% or less), mildly reduced, or preserved (HFpEF, 50% or more). For HFrEF, four medicine groups together cut deaths and hospital stays. Daily weighing helps catch fluid build-up early.
How common. About 1 to 2 in 100 adults in high-income countries, rising to more than 1 in 10 people over 70.
Causes. Most often coronary heart disease or a past heart attack, and long-term high blood pressure. Others: atrial fibrillation, heart valve disease, cardiomyopathy (heart muscle disease, sometimes inherited), heavy alcohol use, some cancer treatments, diabetes, obesity, thyroid disease and rheumatic heart disease, which remains common in some First Nations communities and lower-income countries.
Types
The ejection fraction (EF) is the share of blood the main pumping chamber pushes out with each beat, measured on a heart ultrasound (echocardiogram). A normal EF is about 50 to 70%. Per the ESC 2021 guidelines:
- HFrEF (reduced EF), 40% or less: the heart muscle squeezes weakly. This type has the strongest evidence for medicines.
- HFmrEF (mildly reduced EF), 41 to 49%: in between; often treated like HFrEF.
- HFpEF (preserved EF), 50% or more: the heart squeezes normally but is stiff and fills poorly. More common in older women and people with high blood pressure, obesity, diabetes or atrial fibrillation.
Symptoms. Breathlessness on exertion, then with less activity; breathlessness lying flat (needing more pillows) or waking breathless at night; tiredness; swollen ankles, legs or tummy; quick weight gain from fluid; a cough at night; poor appetite; and dizziness.
How it’s diagnosed. A blood test for natriuretic peptides (BNP or NT-proBNP): a normal result makes heart failure unlikely. Then an echocardiogram, an ECG, a chest X-ray, and blood tests for kidney function, blood count, thyroid and iron. Iron deficiency is common in heart failure, and an iron infusion can improve symptoms.
Medicines: the four pillars
For HFrEF, the ESC 2021 guidelines and their 2023 update recommend all four groups, started early and built up to target doses. One analysis estimated that for a 55-year-old, all four together could add about 6 years of life compared with older two-medicine treatment.
- Pillar 1 · PrescriptionARNI, ACE inhibitor or ARBSacubitril with valsartan (an ARNI), or an ACE inhibitor or ARB if that isn’t suitable.
- Works
- Lower risk of death and hospital admission; the ARNI did better than an ACE inhibitor in the PARADIGM-HF trial
- Watch for
- Low blood pressure, dizziness, potassium and kidney changes; a dry cough with ACE inhibitors. Never take an ACE inhibitor within 36 hours of sacubitril with valsartan.
- Pillar 2 · PrescriptionBeta-blockerBisoprolol, carvedilol, metoprolol (slow-release) or nebivolol. See beta-blockers.
- Works
- Lower risk of death and sudden cardiac death
- Watch for
- Tiredness and a slow pulse at first; started at a low dose and increased slowly.
- Pillar 3 · PrescriptionMineralocorticoid receptor antagonist (MRA)Spironolactone or eplerenone.
- Works
- Lower risk of death and hospital admission
- Watch for
- High potassium and kidney changes, so regular blood tests; breast tenderness with spironolactone.
- Pillar 4 · PrescriptionSGLT2 inhibitorDapagliflozin or empagliflozin. See SGLT2 inhibitors.
- Works
- Fewer hospital admissions and deaths in HFrEF; also recommended for HFmrEF and HFpEF since the ESC 2023 update, mainly to cut hospital admissions
- Watch for
- Genital thrush; pause on sick days.
- As neededDiuretics, devices and moreFluid tablets such as furosemide relieve breathlessness and swelling. Some people need a defibrillator (ICD) or a pacemaker that resynchronises the heart (CRT), or valve repair.
- Works
- Diuretics ease symptoms but don’t lengthen life on their own; devices help selected people
- Watch for
- Dizziness and dehydration with diuretics; your dose may change with your weight.
HFpEF. Treatment focuses on an SGLT2 inhibitor, diuretics for fluid, and treating the causes: blood pressure, atrial fibrillation, diabetes and weight. In people with obesity, GLP-1 medicines have improved symptoms in trials.
Self-care
- Weigh yourself every morning, after the toilet and before breakfast. Tell your heart team if you gain more than about 2 kg over 2 to 3 days, or the amount on your action plan.
- Cut back on salt: skip added salt and limit processed and takeaway food.
- Fluids: only restrict them if your team asks you to, usually when fluid builds up despite medicines.
- Keep moving: cardiac rehabilitation and regular exercise improve quality of life and reduce hospital admissions.
- Vaccines: flu, COVID-19 and pneumococcal vaccines protect against infections that often trigger worsening. See flu and COVID-19.
- Medicines: avoid anti-inflammatory painkillers such as ibuprofen, which hold on to fluid. Check with a pharmacist before buying any medicine or supplement.
- Don’t smoke, keep alcohol low, and have sleep apnoea treated if you have it.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Heart energy supplementsProducts such as coenzyme Q10 and hawthorn aren’t recommended by heart failure guidelines; the evidence is limited and some interact with heart medicines.
See your GP if
- You’re breathless with everyday activity, need more pillows, or have new ankle swelling
- You have heart failure and your weight is rising, swelling is worse, or you’re more breathless than usual
- You feel dizzy or faint, or have side effects from your medicines
- You haven’t had a heart failure review or action plan in the past year
Call 000 (Australia) or your local emergency number for severe breathlessness at rest, chest pain, fainting, coughing up pink frothy phlegm, new confusion, or a fast, irregular heartbeat with dizziness.
Outlook. Varies with the cause, type and how early treatment starts. Many people live well for years, and in some the ejection fraction improves with treatment. Keep taking your medicines even if you feel better. World Heart Day is on 29 September and Heart Week (Australia) is in May: see our health days calendar.
Common questions
What is the difference between HFrEF and HFpEF?
In HFrEF the heart squeezes weakly (ejection fraction 40% or less). In HFpEF it squeezes normally (50% or more) but is stiff and fills poorly. Both cause breathlessness and fluid build-up.
What are the four pillars of heart failure treatment?
For reduced ejection fraction: an ARNI, ACE inhibitor or ARB; a beta-blocker; a mineralocorticoid receptor antagonist; and an SGLT2 inhibitor. Together they lower the risk of death and hospital admission.
What is a normal ejection fraction?
About 50 to 70%. Heart failure with reduced ejection fraction is 40% or less; 41 to 49% is mildly reduced.
What are the stages of heart failure?
The ACC/AHA stages run from A (at risk) and B (heart changes without symptoms) to C (symptoms) and D (advanced). The NYHA classes I to IV describe how much symptoms limit daily activity.
Can heart failure be reversed?
Sometimes the ejection fraction improves with treatment, especially when a cause such as fast atrial fibrillation or alcohol is treated. Medicines usually need to continue.
How much weight gain is a warning sign?
More than about 2 kg over 2 to 3 days usually means fluid build-up. Contact your heart team, or follow your action plan.
Is heart failure the same as a heart attack?
No. A heart attack is a blocked artery damaging heart muscle. Heart failure is the heart not pumping or filling well, and a heart attack is one cause of it.
What should I avoid with heart failure?
Anti-inflammatory painkillers, too much salt, smoking and heavy drinking. Check with a pharmacist before taking new medicines or supplements.
Evidence and more information
- McDonagh et al, ESC 2021 Guidelines for the diagnosis and treatment of heart failure
- McDonagh et al, ESC 2023 Focused update of the heart failure guidelines
- Atherton et al, NHFA/CSANZ 2018 Australian heart failure guidelines
- Vaduganathan et al, Lancet 2020: Comprehensive disease-modifying therapy in HFrEF
- Long et al, Cochrane 2019: Exercise-based cardiac rehabilitation for heart failure
- Heart Failure Matters (ESC): Rapid weight gain
- NHS: Heart failure
maladywise.com/heart-failure/