Heart Failure: Symptoms, Diagnosis and Treatment

What is heart failure?

Heart failure is a clinical syndrome in which the heart cannot supply the body's needs adequately, or can do so only at abnormally high filling pressures. It does not mean that the heart has stopped. It may result from impaired contraction, impaired relaxation or other structural heart abnormalities.

Common complaints include breathlessness, fatigue, leg swelling and reduced exercise capacity. Early diagnosis and appropriate treatment can control symptoms and improve outcomes.

What are the symptoms?

• Breathlessness while walking or climbing stairs.
• Fatigue and reduced exercise tolerance.
• Ankle and leg swelling.
• Difficulty breathing when lying flat.
• Waking at night short of breath.
• Abdominal swelling or rapid weight gain.
• Palpitations.
• In advanced disease, breathlessness at rest.

Cough, reduced appetite and frequent urination at night may also occur.

What causes heart failure?

Causes include coronary artery disease, previous myocardial infarction, hypertension, valve disease, dilated or hypertrophic cardiomyopathy, myocarditis, atrial fibrillation and other arrhythmias, inherited heart muscle disorders and some cancer treatments. More than one cause may contribute.

What are the main types?

Left ventricular ejection fraction (EF), measured by imaging, helps classify heart failure:

• Reduced EF (HFrEF): EF of 40% or less.
• Mildly reduced EF (HFmrEF): EF of 41–49%.
• Preserved EF (HFpEF): EF of 50% or more, with evidence supporting the diagnosis. A normal EF does not exclude heart failure.
• Improved EF: Previously reduced EF that improves with treatment. Improvement does not automatically mean treatment can be stopped.

How is it diagnosed?

Clinical assessment looks for symptoms and signs of congestion. An ECG identifies rhythm or conduction abnormalities and possible evidence of previous myocardial injury.

Echocardiography evaluates EF, chamber size, valve function and filling characteristics. BNP or NT-proBNP blood tests can support assessment, but results are interpreted with age, kidney function, obesity and other clinical factors.

Other blood tests may assess kidney function, electrolytes, blood count, thyroid function and iron status. Cardiac MRI or coronary assessment is used when indicated by the suspected cause.

How is it treated?

Medication

For HFrEF, four major treatment groups can improve outcomes: an ARNI or an ACE inhibitor/ARB when appropriate, an evidence-based beta blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Diuretics relieve fluid retention and breathlessness.

SGLT2 inhibitors are also important treatment options for eligible patients with mildly reduced or preserved EF. Drug selection and doses depend on blood pressure, kidney function, potassium and tolerance.

Treating the underlying condition

Coronary disease, hypertension, valve abnormalities and arrhythmias require appropriate management. Iron deficiency and other accompanying conditions may also need treatment.

Devices and advanced therapies

An ICD may protect selected patients from dangerous ventricular arrhythmias. Cardiac resynchronisation therapy can help selected patients whose ventricles do not contract in electrical synchrony. These devices are not needed by everyone. Advanced cases may require assessment for mechanical support or transplantation.

Daily life and follow-up

• Take prescribed medicines regularly.
• Monitor weight and report rapid changes as advised.
• Discuss salt intake and individual fluid requirements with your clinician.
• Remain physically active at an appropriate level.
• Avoid smoking and attend follow-up appointments.
• Monitor symptoms, blood pressure and pulse as instructed.

Increasing swelling or breathlessness may indicate fluid accumulation. Some patients recover substantial heart function when the cause is reversible, while others need lifelong treatment. Do not discontinue medication solely because you feel better.

When is it an emergency?

Severe breathlessness at rest, chest pain, fainting, confusion or pink frothy sputum requires immediate medical assessment. Call 112.

Assoc. Prof. Sezen Bağlan Uzunget, MD — Cardiologist

This information is educational. Heart failure diagnosis and treatment are individualised.

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