Heart failure

What heart failure is

Despite the name, heart failure does not mean the heart has stopped working. It means the heart has become less efficient at pumping blood around the body, so organs and muscles may not receive all the oxygen and nutrients they need.

Heart failure sits within the group of structural heart issues, which are conditions that affect the physical structure of the heart, including the heart muscle, the chambers and the valves. These problems alter how blood flows through the heart or how effectively it pumps.

Treatment focuses on improving symptoms, slowing progression and reducing hospital admissions. Modern treatment approaches have significantly improved outcomes for people living with heart failure, particularly when the condition is diagnosed early.

Why heart failure develops

Heart failure can develop because of a number of underlying conditions, most commonly coronary artery disease, previous heart attacks, high blood pressure, or structural abnormalities of the heart muscle. Over time the heart may become weakened or stiff, making it harder to fill with blood or to pump it out.

Because the heart is less able to move blood forward, blood can back up in the veins and fluid begins to leak into the surrounding tissues. That is why heart failure so often shows itself as fluid on the lungs and swelling in the legs.

Not every form of heart failure involves a weakened pump. In heart failure with preserved ejection fraction, shortened to HFpEF, the heart pumps normally but does not fill properly. It is more common in women, particularly those with a history of high blood pressure or diabetes, and it can present quietly with fatigue, breathlessness and exercise intolerance.

• Coronary artery disease, where the arteries supplying the heart muscle become narrowed
• A previous heart attack, which leaves an area of heart muscle unable to pump properly
• Long standing high blood pressure, which over time can thicken the heart muscle and make it less efficient
• Cardiomyopathy and other diseases of the heart muscle that affect its size, shape or function
• Heart valve disease, where a narrowed or leaky valve disrupts normal circulation and can allow fluid to build up in the lungs
• Untreated obstructive sleep apnoea, which is itself a risk factor for high blood pressure, atrial fibrillation and heart failure

The symptoms you may notice

Common symptoms of heart failure include shortness of breath, fatigue, swelling in the legs or ankles, and reduced exercise tolerance. Some people also experience a persistent cough or a feeling of fullness caused by fluid retention.

Swelling linked to the heart usually develops gradually and is normally present in both legs, often worsening towards the end of the day. Many people notice it first as their shoes becoming tighter or their socks leaving deeper marks on the skin.

Fatigue is easy to dismiss. When the heart is not pumping blood as effectively as it should, the body receives less oxygen, particularly during physical activity, so tiredness tends to appear alongside breathlessness or swelling rather than on its own. A common pattern is that people focus on the swelling, and only when they think back do they recognise a gradual decline in what they can manage.

• Shortness of breath, particularly on exertion or when lying flat
• Fatigue and reduced energy levels
• Swelling in the legs or ankles, usually affecting both legs
• Reduced exercise tolerance
• A persistent cough
• A feeling of fullness caused by fluid retention
• Weight gain caused by fluid retention
• Waking at night feeling breathless

Breathlessness when you lie down

Two particular patterns of breathlessness are recognised warning signs of heart failure, and both are worth raising with a cardiologist. Orthopnoea is breathlessness when lying flat. Paroxysmal nocturnal dyspnoea, usually shortened to PND, is waking suddenly short of breath, often one to two hours after falling asleep.

The explanation lies in how the body handles fluid. During the day, gravity pulls fluid downwards into the legs. When you lie flat at night, that fluid gradually redistributes back into the chest and lungs. A healthy heart handles this without any noticeable difference, but when the heart is not pumping as efficiently as it should, the extra fluid volume can overwhelm the lungs, causing congestion and breathlessness.

With orthopnoea, people often notice they need two, three or even four pillows to sleep comfortably, or that they have started sleeping in a chair, and it typically eases within a few minutes of sitting up. PND is more sudden and more frightening, forcing you to sit up, get out of bed or go to a window for fresh air, and it takes longer to settle, typically 15 to 30 minutes.

These symptoms are not always cardiac. Obstructive sleep apnoea, acid reflux, anxiety, asthma and other lung conditions can produce something similar, and heart failure and sleep apnoea often coexist in the same patient. That is precisely why a proper assessment is worth having rather than piecing symptoms together online.

How heart failure is diagnosed

Diagnosis is usually made through a combination of clinical assessment, blood tests, an ECG, echocardiography and sometimes further imaging. The history and examination do much of the work, because the pattern of the breathlessness, the symptoms sitting alongside it and your background risk factors together give a strong indication before any test is run.

Dr Jogiya will usually arrange an echocardiogram, which is the single most useful test for investigating suspected heart failure, valve disease and structural causes of breathlessness. It gives a live picture of how well the heart is pumping, how the valves are working and whether there is any fluid or structural abnormality.

Blood tests typically include a natriuretic peptide, NT-proBNP, which is a marker of heart strain and can be very helpful in confirming or ruling out heart failure. Other blood tests look for anaemia, thyroid problems, kidney function and inflammatory markers. It is rarely one test that gives the answer. It is the combination of history, examination and investigations that identifies the cause.

• A 12 lead ECG, which records the electrical activity of the heart and can pick up rhythm problems, signs of a previous heart attack or evidence of strain
• An echocardiogram to assess how strongly the heart muscle is pumping and how the valves are working
• Blood tests, including NT-proBNP, kidney and liver function, thyroid function and inflammatory markers
• A chest X ray to look for fluid on the lungs, an enlarged heart or lung disease
• Further investigations such as a cardiac MRI, ambulatory ECG monitoring, a sleep study or an exercise test, where the initial results raise concern

How heart failure is treated

Management often includes medications such as diuretics to remove excess fluid, ACE inhibitors or ARBs to support heart function, and beta blockers to control heart rate and reduce strain on the heart. Mineralocorticoid receptor antagonists and SGLT2 inhibitors are also part of modern heart failure treatment. Diuretics in particular often ease breathlessness at night within days.

In some cases, devices such as pacemakers or cardiac resynchronisation therapy, known as CRT, may be required to improve heart function. CRT works by putting both ventricles back into a synchronised rhythm.

Where another condition is contributing, treating it directly matters just as much. Atrial fibrillation may need rate or rhythm control and anticoagulation to reduce stroke risk. Valve disease may need monitoring, or repair or replacement of the valve, often now through minimally invasive keyhole techniques. Obstructive sleep apnoea responds well to CPAP, and treating it also lowers cardiovascular risk in the longer term.

Lifestyle changes are an important part of managing heart failure and sit alongside medication rather than replacing it. Which combination is right for you is a decision for your own cardiologist, based on your test results and the cause of your heart failure.

• Reducing salt intake
• Maintaining a healthy weight
• Regular physical activity where it is appropriate for you
• Careful monitoring of symptoms so that any change is picked up early
• Elevating your legs when resting, and avoiding long periods sitting or standing in one position, where swelling is a problem

When to seek help

Some situations call for urgent assessment rather than an appointment. If you have severe, sudden breathlessness, chest pain, blue lips or a feeling of impending doom, call 999. This could be a heart attack, a serious rhythm disturbance or a clot on the lung.

Other symptoms are not emergencies, but they should not be explained away as stress or ageing either. They deserve a proper cardiology assessment.

The earlier these symptoms are properly investigated, the more straightforward the answers tend to be, and the more options there are for treatment. Dr Jogiya sees private patients across Kingston upon Thames, Wimbledon and central London, in person and virtually.

• Breathlessness that has been getting steadily worse
• Needing extra pillows to sleep, or having started sleeping in a chair
• New swelling in the ankles or legs, particularly when it affects both legs and comes with breathlessness
• A noticeable drop in your exercise tolerance
• Waking regularly gasping for breath
• Swelling that appears suddenly in one leg, which needs urgent assessment because it may suggest a blood clot