Heart failure means the heart is not pumping or filling with blood as well as it should, so the body does not get the circulation it needs. It does not mean the heart has stopped or is about to stop. Most people with heart failure notice breathlessness, tiredness and swelling in the ankles or legs, and these symptoms usually build up gradually over weeks or months. More than a million people in the UK are living with heart failure, according to the British Heart Foundation.
Heart failure is managed with a combination of medicines that protect the heart muscle, diuretic tablets that clear excess fluid, treatment of the underlying cause and, for some people, a specialised pacemaker or defibrillator. There is no cure for most types, but treatment has improved enormously. In more than 20 years as a Consultant Cardiologist at Kingston Hospital NHS Trust, I have watched heart failure change from a diagnosis with few options to one where many patients go back to work, travel and live full lives for many years.
What happens in the heart when it fails
The heart has two jobs with every beat. It squeezes to push blood out, and then it relaxes to fill again. Heart failure can affect either part of that cycle.
Cardiologists describe the pumping strength of the main chamber using the ejection fraction, which is the percentage of blood pushed out with each beat. A healthy heart usually ejects more than half. The British Heart Foundation describes three main types of heart failure based on this figure.
- Reduced ejection fraction. The muscle is weakened and pumps less forcefully, with an ejection fraction of 40% or less.
- Mildly reduced ejection fraction. The pumping is moderately weakened, with an ejection fraction of around 41% to 49%.
- Preserved ejection fraction. The heart squeezes normally but the muscle has become stiff, so it does not relax and fill properly. The ejection fraction is 50% or more.
The type matters because the treatments that work best are different. Preserved ejection fraction heart failure is particularly common in older people, women and those with long-standing high blood pressure, diabetes or kidney disease. It was once thought of as a milder condition, but it causes the same symptoms and needs the same careful management.
What causes heart failure
Heart failure is almost always the result of something else that has strained or damaged the heart over time. The NHS lists the most common causes as coronary heart disease, previous heart attacks, high blood pressure, heart valve problems, cardiomyopathy and irregular heart rhythms such as atrial fibrillation. Heavy drinking, some chemotherapy drugs and viral infections affecting the heart muscle can also be responsible.
From working with patients across Kingston, Wimbledon and London, I’ve found that long-standing high blood pressure is the cause most often overlooked. Hypertension was the focus of my research during my specialist training at St George’s, and I still see patients whose blood pressure has been mildly raised for a decade before their heart muscle finally thickens and stiffens. Finding the cause is not an academic exercise, because treating it can halt and sometimes partly reverse the damage.
The symptoms that should prompt a check
The three classic symptoms are breathlessness, fatigue and swelling. In practice, the pattern is often more subtle.
- Breathlessness walking up stairs or hills that you would previously have managed easily.
- Needing more pillows at night, or waking up breathless and having to sit up.
- Swelling around the ankles that is worse at the end of the day and leaves a dent when pressed.
- Unexplained weight gain over a few days, which is usually fluid rather than fat.
- A persistent cough or wheeze, particularly when lying down.
- Tiredness that does not improve with rest.
Many of these have other causes, from chest problems to medication side effects. That is why breathlessness that is new or getting worse deserves a proper assessment rather than being put down to age or fitness. Ankle swelling in particular is very common and is only sometimes caused by the heart, so it needs to be looked at alongside your other symptoms.
If you develop sudden severe breathlessness, chest pain, or you cough up pink frothy sputum, call 999.
How heart failure is diagnosed
The first step is usually a blood test called NT-proBNP, which measures a hormone released when the heart is under strain. A normal result makes heart failure unlikely. NICE guidance recommends that people with a raised level are seen by a specialist and have a heart scan, with the most urgent cases assessed within two weeks.
The key test is an echocardiogram, an ultrasound scan of the heart. It shows how strongly the heart squeezes, how well it relaxes, whether the valves are working properly and whether the walls of the heart are thickened. Echocardiography has been a central part of my career, and I am a member of both the British and American Societies of Echocardiography. In heart failure, the echo does more than confirm the diagnosis. It usually points to the cause and tells me which treatments are likely to help most.
I also carry out a 12 lead ECG during the consultation, which can show signs of a previous heart attack, thickened heart muscle or a rhythm problem. Depending on the findings, further tests might include a CT coronary angiogram to look for narrowed arteries, a heart rhythm monitor or a cardiac MRI. You can read more about each of these on my heart tests page.
How heart failure is managed
Treatment depends on the type of heart failure and its cause, but most plans involve several elements working together.
Medicines that protect the heart. For heart failure with a reduced ejection fraction, there is now strong evidence for four groups of medicines taken together. These are an ACE inhibitor or similar drug, a beta blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Each one reduces the risk of hospital admission and improves survival, and the benefits add up when they are combined. SGLT2 inhibitors, which were first developed for diabetes, are also now used in heart failure with a preserved ejection fraction.
Diuretics. Often called water tablets, diuretics clear excess fluid and ease breathlessness and swelling quickly. They make people feel better but do not protect the heart muscle in the same way, so they are used alongside the medicines above rather than instead of them.
Treating the cause. This might mean controlling blood pressure, treating narrowed coronary arteries, repairing or replacing a faulty valve, or controlling an irregular rhythm such as atrial fibrillation.
Devices. Some people with a weak heart muscle benefit from an implantable cardioverter defibrillator, which protects against dangerous heart rhythms. Others are offered cardiac resynchronisation therapy, a specialised pacemaker that helps both sides of the heart beat in time.
Cardiac rehabilitation. The NHS says everyone diagnosed with heart failure should be offered cardiac rehabilitation, a structured programme of exercise and education. Regular, appropriate activity improves symptoms and quality of life, and the old advice to rest has been firmly replaced.
In my experience, getting each medicine up to the right dose matters as much as starting it. Many patients are started on low doses and never increased, often because their symptoms improve early on. The full benefit comes from reaching the target dose of each medicine where it is tolerated, and that usually needs several reviews over a few months, with blood tests to check kidney function and potassium.
Living well with heart failure
The day to day habits that make the most difference are simple, but they need to become routine.
- Weigh yourself every morning, after using the toilet and before breakfast, and write it down.
- Take your medicines exactly as prescribed, even when you feel well.
- Keep salt intake low and follow any fluid advice your team gives you.
- Stay active within your limits, and ask about cardiac rehabilitation.
- Limit alcohol and stop smoking.
- Have your annual flu vaccine and stay up to date with COVID-19 and pneumococcal vaccines.
In my experience, a daily weight check works better than watching for ankle swelling because the body can hold a significant amount of extra fluid before any swelling is visible. A steady rise on the scales over two or three days is often the earliest warning that fluid is building up, and it gives time to adjust treatment before breathlessness sets in. Most heart failure teams ask patients to get in touch if their weight goes up by around 2kg over three days, but follow the specific advice you have been given.
I trained and qualified as a GP before specialising in cardiology, and that experience shapes how I manage heart failure. Good care depends on the cardiologist, the GP, the heart failure nurses and the patient working from the same plan. I write to GPs with clear dose targets and blood test intervals so that treatment keeps moving forward between appointments.
What is the outlook?
The outlook varies widely. It depends on the type and cause of heart failure, how early it is found and how well treatment is tolerated. When the cause can be treated, such as a valve problem, an uncontrolled heart rhythm or blood pressure that has been left too high, the heart muscle can sometimes recover a great deal. Even when it cannot, modern medicines have made a substantial difference to both symptoms and life expectancy.
What I’ve found makes the biggest difference is an early, accurate diagnosis. A raised NT-proBNP, a clear echocardiogram and a treatment plan put in place promptly give patients the best chance of staying well.
Getting your heart checked
If you have breathlessness, swelling or tiredness that is new or getting worse, or you have already been told your heart is not pumping as well as it should, please contact me, Dr Arvind Vasudeva, for a full assessment. I see patients at Parkside Hospital in Wimbledon, The New Victoria Hospital in Kingston, Cleveland Clinic London and Heartsure in Kingston, and you can book an appointment at whichever location suits you best.