Heart failure — when the pump weakens

Heart failure ( congestive cardiac failure ) — syndrome where heart cannot pump sufficiently to meet body’s needs OR does so only at elevated filling pressures.

Not cardiac arrest — heart still beating — inefficiently.

~1 million UK — rising — better MI survival + ageing.

Symptoms

Left-sided (pulmonary congestion):

  • breathlessness — exertion → rest
  • orthopnoea
  • PND — wake gasping
  • dry cough

Right-sided (systemic congestion):

  • peripheral oedema — ankles
  • ascites
  • JVP raised

General:

  • fatigue
  • reduced exercise tolerance

Acute decompensation:

  • pulmonary oedema — pink frothy sputum — 999

Types

HFrEF — reduced ejection fraction (<40%)

Systolic failure — post-MI, cardiomyopathy

HFmrEF — mildly reduced (41–49%)

HFpEF — preserved EF (≥50%)

Diastolic dysfunction — stiff ventricle — elderly, hypertensive, obese, AF common

Diagnosis

  1. History and examination — bibasal crackles, oedema, JVP, displaced apex
  2. NT-proBNP — elevated — exclude if very low in primary care
  3. Echocardiogram — EF, valves, diastolic function
  4. ECG — ischaemia, LVH, AF
  5. Chest X-ray — cardiomegaly, Kerley B lines, pleural effusions

Causes

Treatment — HFrEF pillar drugs

Four pillars improve survival (NICE):

  1. ACEi/ARB/ARNI
  2. Beta-blocker — bisoprolol, carvedilol, nebivolol
  3. MRA — spironolactone/eplerenone
  4. SGLT2 inhibitor — dapagliflozin/empagliflozin — even without diabetes

Diuretics — symptom relief — furosemide — not mortality benefit alone

Titrate to target doses — specialist nurse support

Devices:

  • ICD — arrhythmia risk
  • CRT — LBBB wide QRS

HFpEF

  • SGLT2i — benefit shown
  • diuretics
  • treat BP, AF, obesity
  • no proven ACEi mortality benefit like HFrEF

Self-management

  • daily weights
  • fluid/salt moderation
  • cardiac rehabilitation
  • flu/pneumococcal vaccines
  • report deterioration early — IV diuretic outpatient some centres

Prognosis

Variable — 5-year mortality ~50% historically — improving with modern therapy

Advanced HF — palliative care, transplant, LVAD — specialist

Breathless climbing stairs worsening over months — GP + BNP + echo — not age alone.

Common questions about heart failure

What are the symptoms of heart failure?
Breathlessness on exertion progressing to rest, orthopnoea (need extra pillows), paroxysmal nocturnal dyspnoea, fatigue, ankle or leg swelling, bloating, reduced exercise tolerance. Some present with acute pulmonary oedema — medical emergency.
What causes heart failure?
Coronary artery disease and previous heart attack (commonest), hypertension, cardiomyopathy, valve disease, atrial fibrillation, alcohol, viral myocarditis, chemotherapy toxicity. Left ventricular damage reduces pump function — fluid backs up in lungs and periphery.
Is heart failure curable?
Often manageable not curable — some causes reversible (valve replacement, tachycardiomyopathy if rhythm controlled). HFrEF medicines and devices improve ejection fraction in many. HFpEF — treat comorbidities — hypertension, AF, obesity. Heart transplant selected end-stage cases.
What medicines treat heart failure?
HFrEF — ACE inhibitor or ARB (or ARNI sacubitril/valsartan), beta-blocker (bisoprolol, carvedilol), MRA (spironolactone), SGLT2 inhibitor (dapagliflozin), diuretics (furosemide) for congestion. Device therapy — ICD, CRT if broad QRS — specialist. HFpEF — SGLT2i, treat BP, diuretics.
What should I limit with heart failure?
Fluid restriction if advised (usually 1.5 to 2 litres daily in severe cases), moderate salt reduction, alcohol minimal especially if alcohol cardiomyopathy, weigh daily — report 2kg gain in 3 days. Stay active within limits — cardiac rehab programmes help.

Sources