More than 60 million people worldwide live with heart failure. The name sounds terrifying, but heart failure does not mean the heart has stopped. With modern treatment and good self-care, many people live active, fulfilling lives for years.
Imagine being told after months of breathlessness and swollen ankles that you have heart failure. You hear the word “failure” and assume the worst. Then a heart failure nurse sits down with you, explains what it means, and shows you how to weigh yourself every morning. Six months later, you are walking to the shops again.
What heart failure is
Heart failure means the heart is not pumping blood around the body as well as it should, or is not filling properly between beats. As a result, the body does not get enough oxygen-rich blood, and fluid can build up in the lungs, legs and abdomen.,Heart failure is usually a long-term condition that develops gradually, though it can also appear suddenly, for example after a heart attack. It is common in older people, but it can affect people of any age.
Common causes
- Coronary heart disease and previous heart attacks
- High blood pressure, especially if poorly controlled for years
- Cardiomyopathy: diseases of the heart muscle, some inherited
- Heart valve disease
- Atrial fibrillation and other abnormal heart rhythms
- Heavy alcohol use
- Some cancer treatments
- Viral infections affecting the heart (myocarditis)
- Rheumatic heart disease, still common in many low- and middle-income countries
- Pregnancy-related cardiomyopathy (peripartum cardiomyopathy)
- Untreated thyroid disease, severe anaemia and some lung conditions
Symptoms
- Breathlessness, particularly with activity or when lying flat
- Waking at night breathless, needing to sit up
- Swollen ankles, legs or abdomen
- Rapid weight gain from fluid
- Tiredness and reduced ability to exercise
- Persistent cough or wheeze
- Feeling dizzy or light-headed
- Loss of appetite and feeling full quickly
- Palpitations
Types of heart failure
Healthcare providers describe heart failure using the ejection fraction (EF), the percentage of blood pumped out of the main pumping chamber with each beat, measured on an echocardiogram.,Heart failure with reduced ejection fraction (HFrEF), usually an EF of 40% or below, means the heart muscle is weak and pumps poorly. Heart failure with preserved ejection fraction (HFpEF), usually an EF of 50% or above, means the heart pumps normally but is stiff and does not fill properly. Heart failure with mildly reduced ejection fraction lies in between. The type matters because some treatments work very differently depending on it.
How heart failure is diagnosed
Diagnosis usually starts with a blood test called NT-proBNP or BNP, which rises when the heart is under strain. If it is raised, an echocardiogram, an ultrasound scan of the heart, confirms the diagnosis and shows the type. Other tests include an ECG, chest X-ray, and blood tests for kidney function, anaemia, thyroid and diabetes. Some people need further tests, such as an MRI scan or coronary angiogram, to find the cause.
The four pillars of treatment for HFrEF
For heart failure with reduced ejection fraction, four groups of medicines have been shown in large trials to reduce hospital admissions and help people live longer. They are often called the “four pillars”.,They are: an ACE inhibitor, angiotensin receptor blocker (ARB) or, increasingly, sacubitril/valsartan (an ARNI); a beta-blocker such as bisoprolol, carvedilol or metoprolol succinate; a mineralocorticoid receptor antagonist (MRA) such as spironolactone or eplerenone; and an SGLT2 inhibitor such as dapagliflozin or empagliflozin. Guidelines now recommend starting all four as soon as safely possible, rather than one at a time over many months.
Why doses are increased slowly
Beta-blockers and some other heart failure medicines are started at a low dose and increased gradually, often every couple of weeks, to the highest dose you can tolerate. This “up-titration” matters because higher doses give greater benefit.,During dose changes, you may feel more tired or light-headed for a while, which usually settles. Blood tests check kidney function and potassium. Heart failure nurses often manage this process, adjusting doses based on your blood pressure, heart rate, symptoms and blood results.
Diuretics (water tablets)
Diuretics such as furosemide and bumetanide help remove excess fluid, easing breathlessness and swelling. They relieve symptoms but do not change the long-term course of the disease in the way the four pillars do. Your dose may be adjusted depending on your weight and symptoms. Many people learn to adjust their diuretic dose themselves, within limits agreed with their heart failure team.
Treatment for HFpEF
For heart failure with preserved ejection fraction, the main treatments are diuretics to control fluid, treating causes and related conditions such as high blood pressure, atrial fibrillation, diabetes, obesity and sleep apnoea, and SGLT2 inhibitors, which have been shown to reduce hospital admissions. Some people with HFpEF and obesity may benefit from weight-loss medicines such as semaglutide. Research in this area is moving quickly.
Daily weights: your early warning system
Weighing yourself every morning is one of the simplest and most effective things you can do. Do it at the same time each day, after using the toilet, before eating or drinking, and wearing similar clothes. Write it down or use an app.,A sudden increase, often 2 kg (about 4 lb) in three days, or more than about 1 kg in a day, can mean fluid is building up, even before you feel more breathless. Contact your heart failure team or follow your self-management plan if this happens. Acting early can prevent a hospital admission.
Salt and fluid
Too much salt makes the body hold on to fluid, worsening swelling and breathlessness. Aim to keep salt low, generally under 5 g a day, by cooking from fresh ingredients and limiting processed foods, takeaways, stock cubes, salty snacks and sauces.,Most people with heart failure do not need to restrict fluids strictly. However, if you have significant fluid retention or low sodium levels, your heart failure team may advise a fluid limit, often around 1.5 to 2 litres a day. Follow individual advice, and remember that soups, jelly, ice cream and fruit with high water content count towards fluid intake.
Physical activity and cardiac rehabilitation
It might seem logical to rest if your heart is weak, but regular, appropriate activity improves symptoms, fitness and quality of life in heart failure. Cardiac rehabilitation programmes designed for people with heart failure provide supervised exercise, education and support.,Walking, cycling, gentle swimming and strength exercises are often recommended, building up gradually. You should be able to talk while exercising. Stop and seek advice if you get chest pain, severe breathlessness, dizziness or palpitations.
Devices and procedures
- Implantable cardioverter defibrillator (ICD): monitors heart rhythm and delivers a shock to correct dangerous rhythms, for people at high risk of sudden death
- Cardiac resynchronisation therapy (CRT): a special pacemaker that helps both sides of the heart beat together, for some people with HFrEF and specific ECG patterns
- Valve repair or replacement: including keyhole procedures such as TAVI or mitral valve clips
- Treating blocked arteries: with stents or bypass surgery where appropriate
- Left ventricular assist devices and heart transplants: for selected people with advanced heart failure
- Atrial fibrillation: rate or rhythm control and anticoagulation to prevent stroke
- High blood pressure
- Diabetes, where some medicines also benefit the heart
- Iron deficiency, which is common and can be treated with intravenous iron, improving symptoms
- Sleep apnoea
- Kidney disease
- Depression and anxiety
Vaccines and infections
Infections such as flu, pneumonia and COVID-19 can trigger worsening heart failure. Annual flu vaccination, pneumococcal vaccination and other recommended vaccines are important. Seek help early if you develop a chest infection.
Medicines to avoid or use with caution
- Anti-inflammatory painkillers such as ibuprofen, naproxen and diclofenac, which cause fluid retention and can worsen heart failure
- Some diabetes medicines, such as pioglitazone
- Some calcium channel blockers, such as diltiazem and verapamil, in HFrEF
- Some antiarrhythmic medicines
- Decongestants and some herbal remedies
- Always check with a pharmacist before buying medicines
Recognising worsening heart failure
- Weight gain of about 2 kg in three days
- More breathlessness than usual, or breathlessness at rest
- Needing more pillows to sleep, or waking breathless at night
- More swelling in the legs, ankles or abdomen
- Feeling more tired or dizzy
- Reduced urine output
- Contact your heart failure team early if you notice these
When to call for emergency help
- Severe breathlessness at rest
- Chest pain
- Fainting or collapse
- Coughing up frothy or pink sputum
- A very fast or irregular heartbeat with feeling unwell
- Call your local emergency number
Living well: practical tips
Many people with heart failure find that pacing activities, planning rest, and spreading tasks through the day help them conserve energy. Sleeping propped up can ease breathlessness at night. Small, frequent meals may be easier than large ones.,Keeping a simple diary of weight, symptoms and medicines, and bringing it to appointments, helps your team adjust treatment. Taking medicines as prescribed every day is crucial; if side effects are a problem, talk to your team rather than stopping.
Alcohol and smoking
Alcohol can weaken the heart muscle and interact with medicines. In alcohol-related cardiomyopathy, stopping drinking completely can lead to significant improvement. For others, keeping alcohol low is usually advised. Smoking damages the heart and blood vessels; stopping is one of the most beneficial things you can do.
Sex and relationships
Many people with stable heart failure can have a normal sex life. Sexual activity is similar in effort to climbing a couple of flights of stairs. If you can manage that without severe symptoms, sex is usually safe. Some heart medicines can affect erections or libido; talk to your healthcare provider, as alternatives exist. Do not take medicines such as sildenafil if you use nitrate medicines.
Driving, work and travel
Many people with heart failure continue to drive and work, sometimes with adjustments. Driving rules vary by country and may depend on symptoms, devices such as ICDs, and recent procedures. Check with your healthcare provider and licensing authority.,When travelling, take enough medicines and a list of them, keep diuretics timed so they do not disrupt journeys, avoid very hot climates if they worsen symptoms, and check insurance. On long flights, move regularly and stay hydrated within any fluid limits.
Emotional health
A diagnosis of heart failure can bring fear, sadness and uncertainty. Depression and anxiety are common and can make it harder to manage the condition. Breathlessness itself can cause anxiety.,Talk to your heart failure team about how you feel. Cardiac rehabilitation, support groups, counselling and, where needed, medicines can all help. Many people find meeting others living with heart failure especially reassuring.
The role of heart failure nurses
Specialist heart failure nurses play a vital role in many countries. They monitor symptoms, adjust medicines, teach self-care, support people after hospital discharge and help prevent readmissions. If you have heart failure and have not been offered contact with a specialist nurse or heart failure service, ask whether one is available in your area.
Heart failure in women
Heart failure affects women and men, but the causes and types can differ. Women are more likely to have HFpEF and may be diagnosed later because symptoms such as breathlessness and fatigue are attributed to other causes. Peripartum cardiomyopathy can occur late in pregnancy or in the months after birth; breathlessness, swelling and fatigue that seem worse than expected after childbirth should be checked.
Rheumatic heart disease
In many low- and middle-income countries, rheumatic heart disease remains a major cause of heart failure in young people. It follows untreated strep throat infections that trigger rheumatic fever, which can damage heart valves. Prompt treatment of sore throats with antibiotics where appropriate, and long-term penicillin for those who have had rheumatic fever, can prevent further damage. Valve surgery can help some people.
Planning ahead and palliative care
Heart failure can be unpredictable, with periods of stability and episodes of worsening. Thinking about the future while you are well gives you more control. This may include discussing your wishes about treatment, resuscitation, ICD deactivation if you have one, and where you would prefer to be cared for.,Palliative care is not only for the last days of life. It can help at any stage with breathlessness, fatigue, low mood and planning, alongside heart treatments. Many heart failure services work closely with palliative care teams.
Questions to ask your heart failure team
- What type of heart failure do I have, and what is my ejection fraction?
- Am I on all the recommended medicines at the right doses?
- What should my target weight be, and what should I do if it rises?
- Should I limit salt or fluids, and by how much?
- Can I join cardiac rehabilitation?
- Would I benefit from a device such as an ICD or CRT?
Understanding your echocardiogram report
Your echocardiogram report will usually mention your ejection fraction and may describe the size and thickness of your heart chambers, how well the valves open and close, and whether there are signs of raised pressure in the lungs.
If your EF is reduced, it may be repeated after several months of treatment. Many people see their EF improve on the four pillars of treatment, sometimes back to near-normal levels. This is called heart failure with improved ejection fraction. Even if this happens, medicines are usually continued, because stopping them can lead to deterioration.
Iron deficiency in heart failure
Iron deficiency is very common in heart failure, even in people who are not anaemic, and it contributes to tiredness and breathlessness. Guidelines recommend checking iron levels (ferritin and transferrin saturation). If iron is low, intravenous iron can improve exercise capacity and quality of life and reduce hospital admissions. Iron tablets are less effective in heart failure because absorption is often poor.
A day in the life: managing well
A typical day of good self-care might include weighing yourself on waking, taking morning medicines, eating a breakfast low in salt, taking a short walk, pacing household tasks with rest breaks, keeping an eye on ankles and breathing, taking evening medicines, and sleeping propped up if needed. None of these steps is dramatic on its own, but together they keep many people well and out of hospital.
After a hospital admission
The weeks after leaving hospital with worsening heart failure are a high-risk time for readmission. Good follow-up, ideally within one to two weeks, helps catch problems early and adjust medicines, which are often changed during an admission.
Before leaving hospital, make sure you understand your new medicines, your target weight, your diuretic plan, and who to contact. Ask for a copy of your discharge letter. If you have not been contacted by a heart failure team within a couple of weeks, follow it up.
Caring for someone with heart failure
Family members and carers can make a big difference by helping with daily weights, noticing changes in breathlessness or swelling, supporting healthy low-salt cooking, encouraging activity and helping with medicines. Caring for someone with a long-term condition can be tiring and worrying, so carers should look after their own health and seek support, such as carer assessments, respite and support groups.
Heart failure around the world
Heart failure is a growing global problem as populations age and conditions such as high blood pressure and diabetes become more common. In many regions, access to echocardiography, specialist teams and newer medicines is limited. Simple, effective steps, such as controlling blood pressure, treating rheumatic heart disease, and making the core heart failure medicines available and affordable, could save many lives.
Sleep and heart failure
Breathlessness when lying flat and waking at night breathless are classic signs of fluid build-up and should be reported. Many people sleep better propped up on pillows. Sleep apnoea, both obstructive and central types, is common in heart failure and can worsen the heart’s function; if you snore loudly or your partner notices pauses in your breathing, ask about a sleep study.
Myths about heart failure
- “Heart failure means I will die soon.” Many people live for many years with good treatment
- “I should rest as much as possible.” Appropriate activity improves symptoms
- “I can stop my tablets when I feel better.” Feeling better usually means they are working
- “Salt does not matter if I take water tablets.” Too much salt still causes fluid build-up
Your heart, your team
Living well with heart failure is a partnership between you, your family and your healthcare team. You notice the daily changes; they adjust the treatment. Speak up early about symptoms, side effects or worries, and keep asking questions until you understand your plan. Small, consistent actions every day add up to more good days, fewer hospital stays and a better life.
Keeping track of your numbers
- Your daily weight
- Your blood pressure and pulse, if you have a home monitor
- How far you can walk before getting breathless
- How many pillows you need to sleep
- Any changes in ankle swelling
Frequently asked questions
Does heart failure mean my heart is going to stop?
No. It means the heart is not pumping as well as it should. With treatment, many people live for many years.
Can heart failure improve?
Yes. In some people, especially with HFrEF and good treatment, heart function improves significantly.
Should I avoid exercise?
No. Appropriate regular exercise is beneficial. Ask about cardiac rehabilitation.
Why do I need so many tablets?
Each of the main medicines works in a different way, and together they give the greatest benefit.
Can I drink coffee?
Moderate amounts are usually fine for most people. Ask if you have palpitations or rhythm problems.
But I feel worse when my doses go up
That can happen for a short time. Tell your heart failure team rather than stopping; they can adjust the pace. The long-term benefits of reaching target doses are substantial.
Your next step: Start weighing yourself every morning this week, write it down, and ask your heart failure team what change in weight should prompt you to contact them.
Related: BNP test and heart failure · Echocardiogram · Beta-blockers · SGLT2 inhibitors
Sources: European Society of Cardiology heart failure guidelines (2021, 2023 update), American Heart Association/American College of Cardiology/Heart Failure Society of America guideline (2022), National Institute for Health and Care Excellence (NG106), British Heart Foundation, World Heart Federation.
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