Overview
Heart failure is a chronic, progressive condition in which the heart cannot pump enough blood and oxygen to meet the body's needs. There are approximately 1 million heart failure patients in our country; its frequency significantly increases with age.
It does not mean the heart has completely "stopped"; it works inadequately. With proper treatment, quality of life and lifespan can be significantly increased.
Types
Left heart failure:
- HFrEF (reduced ejection fraction): EF <40%, systolic dysfunction
- HFmrEF (mid-range): EF 40-49%
- HFpEF (preserved ejection fraction): EF ≥50%, diastolic dysfunction
Right heart failure:
- Due to left failure or after pulmonary hypertension
Stages (NYHA):
- Class I: Asymptomatic
- Class II: Symptoms with mild exertion
- Class III: Symptoms with little exertion
- Class IV: Symptoms even at rest
Symptoms
- Shortness of breath (first with exertion, then at rest)
- Shortness of breath when lying down (orthopnea) - need for pillows
- Shortness of breath waking from sleep (paroxysmal nocturnal dyspnea)
- Extreme fatigue, weakness
- Swelling of ankle, leg, abdomen (edema)
- Rapid, irregular heartbeat
- Dry, persistent cough (especially when lying down)
- Pink-frothy sputum
- Decreased daytime urine output, frequent night urination
- Abdominal distension, loss of appetite
- Nausea
- Difficulty concentrating, confusion
- Palpitations
- Rapid weight gain (fluid retention)
Causes
Most common causes:
- Coronary artery disease and history of heart attack (70%)
- High blood pressure
- Diabetes
- Heart valve diseases
- Cardiomyopathies (genetic, viral, alcoholic)
- Arrhythmia (especially atrial fibrillation)
- Congenital heart diseases
- Thyroid disorders
- Anemia
- Severe infections (myocarditis)
- Cancer treatments (chemotherapy, radiotherapy)
- Toxins: alcohol, cocaine
Risk Factors
- Coronary artery disease, history of heart attack
- High blood pressure
- Diabetes
- Obesity
- Smoking
- High cholesterol
- Sleep apnea
- Age (over 65)
- Family history
- Some medications (NSAIDs, some chemotherapy)
- Excessive alcohol
- Arrhythmias
- Thyroid diseases
Complications
- Kidney damage/failure
- Liver damage
- Heart valve problems
- Arrhythmias (especially atrial fibrillation)
- Sudden cardiac death
- Thromboembolism (clot)
- Acute pulmonary edema
- Heart attack
- Death
When to See a Doctor
Scheduled:
- New-onset shortness of breath (with exertion)
- Ankle swelling
- Unexplained weight gain (more than 2 kg in 3 days)
- Extreme fatigue
- Shortness of breath waking from sleep at night
- Frequent palpitations
Emergency:
- Severe, sudden shortness of breath
- Pink-frothy sputum
- Chest pain
- Fainting
- Change in consciousness
- Blue lips, nails
- Severely swollen feet/legs
- Suddenly worsening symptoms
Diagnosis and Treatment
Diagnosis:
- Physical examination
- Echocardiography (EF calculated, critical test)
- ECG
- Chest X-ray
- Blood tests: BNP/NT-proBNP (elevated), creatinine, electrolytes, troponin, thyroid, anemia
- Exercise test
- Cardiac MRI
- Coronary angiography (to exclude ischemic cause)
- Right heart catheterization
Treatment:
1. Medication (foundation for HFrEF - quadruple therapy):
- ACE inhibitors / ARB / ARNI: Sacubitril-valsartan, lisinopril, losartan
- Beta blockers: Bisoprolol, carvedilol, metoprolol
- Aldosterone antagonists: Spironolactone, eplerenone
- SGLT2 inhibitors: Dapagliflozin, empagliflozin (cardioprotective)
Other medications:
- Diuretics: Furosemide, torsemide (to remove fluid)
- Digoxin (in selected patients)
- Ivabradine (for high heart rate)
- Vericiguat (new)
- Anticoagulants (if arrhythmia present)
2. Device therapies:
- ICD (implantable cardioverter defibrillator): Prevents sudden cardiac death
- CRT (cardiac resynchronization therapy): Pacemaker that synchronizes the pump
- LVAD (left ventricular assist device): Bridge or destination therapy
3. Surgery:
- Coronary bypass
- Heart valve surgeries
- Heart transplant (end-stage)
4. Lifestyle (very important):
- Salt restriction (<5 g/day, <2 g in severe cases)
- Fluid restriction (if needed, 1.5-2 L per day)
- Daily weight monitoring (2 kg increase in 3 days is warning)
- Cardiac rehabilitation (exercise)
- Alcohol restriction
- Quit smoking
- Heart-healthy diet (Mediterranean)
5. Vaccines:
- Annual flu
- Pneumococcal
- COVID-19
Prevention
Control risk factors:
- Control your blood pressure
- Manage your diabetes
- Lower your cholesterol
- Quit smoking
- Maintain a healthy weight
- Exercise regularly (150 min per week)
- Eat a Mediterranean-style diet
- Avoid excessive salt, saturated fat, and sugar
- Limit alcohol
- Manage stress
- Get enough sleep (7-8 hours)
- Have sleep apnea treated if present
- Regular health check-ups (yearly over age 40)
- Secondary prevention if you have had a heart attack
- Early screening if family history exists