Heart failure
Also called: Congestive heart failure, CHF, HFrEF, HFpEF
The heart cannot pump enough blood for the body's needs, or can only do so at high filling pressures. Fluid backs up into the lungs and legs, causing breathlessness, fatigue and swelling.
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About 1–2% of adults, rising to over 10% of people over 70.
What happens in the body
In heart failure with reduced ejection fraction (HFrEF) the left ventricle is weak and dilated; in preserved ejection fraction (HFpEF) it is stiff and fills poorly. Hormonal systems (renin–angiotensin–aldosterone, sympathetic) retain salt and water, which initially helps but eventually worsens congestion.
Causes
- Coronary artery disease and previous heart attack
- Long-standing high blood pressure
- Heart valve disease
- Cardiomyopathies (genetic, alcohol, chemotherapy, viral)
- Arrhythmias such as atrial fibrillation
- Diabetes and obesity (especially HFpEF)
Risk factors
- Hypertension
- Coronary disease
- Diabetes
- Obesity
- Age
- Heavy alcohol use
- Certain cancer treatments
Symptoms
- Breathlessness on exertion, then at rest
- Breathlessness lying flat or waking at night gasping
- Swollen ankles and legs
- Tiredness and reduced exercise capacity
- Rapid weight gain from fluid
- Cough, sometimes with frothy sputum
Diagnosis — tests and examinations
- NT-proBNP or BNP blood test
- Echocardiogram (ejection fraction, valves, wall motion)
- ECG and chest X-ray
- Blood tests for kidney function, electrolytes, thyroid, anaemia
- Cardiac MRI or angiography to find the cause
Treatment
Medicines and medical treatment
- Diuretics (furosemide) to clear fluid
- For HFrEF, the four pillars: ACE inhibitor/ARB or sacubitril–valsartan, beta-blocker, mineralocorticoid antagonist (spironolactone), SGLT2 inhibitor (dapagliflozin/empagliflozin)
- SGLT2 inhibitors also help HFpEF
- Treat the cause: blood pressure, ischaemia, valves, rhythm
Operations and procedures
- Implantable cardioverter-defibrillator (ICD) to prevent sudden death
- Cardiac resynchronisation therapy (biventricular pacemaker)
- Valve repair or replacement
- Left ventricular assist device or heart transplantation in advanced disease
Self-care, home remedies and lifestyle
- Weigh daily; report a gain of more than 2 kg in 3 days
- Limit salt; follow fluid advice if given
- Stay active with a supervised exercise programme
- Vaccination against influenza and pneumococcus
- Avoid NSAIDs such as ibuprofen, which retain fluid
Possible complications
- Arrhythmias and sudden death
- Kidney impairment
- Hospital admissions for fluid overload
- Blood clots
- Muscle wasting (cardiac cachexia)
Prevention
- Control blood pressure, diabetes and cholesterol
- Prompt treatment of heart attacks
- Limit alcohol; avoid smoking
Outlook
Serious, but modern combination therapy has greatly improved survival and symptoms; many people live well for years.
When to see a doctor
See a doctor for new breathlessness or ankle swelling. Seek urgent care for breathlessness at rest, chest pain or fainting.
Sources and further reading
These sources cover this condition. They have not been checked against every statement on this page.
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