What is heart failure?

Heart failure can develop gradually and slowly (chronic or slow-onset heart failure) or suddenly and rapidly (acute heart failure). Acute heart failure is often a result of exacerbation of chronic heart failure, requiring immediate medical attention.

There are many risk factors for heart failure, including other diseases and lifestyle behaviours. Disease and conditions that are risk factors for heart failure include atrial fibrillation (a quivering or irregular heartbeat), coronary artery disease, diabetes, heart attack, high cholesterol, hypertension (high blood pressure) and obesity. Lifestyle behaviours that may contribute to heart failure include smoking and recreational drug use, alcohol consumption, an inactive lifestyle and lack of exercise, and an unhealthy diet.

Heart failure may also be caused by other factors – for example, by a virus that attacks the heart or as a result of heart problems that arise during pregnancy (peripartum cardiomyopathy). These underlying causes of heart failure are not preventable and can occur in people of any age.

Current guidelines from the European Society of Cardiology (2021) distinguish three types of heart failure based on the left ventricular ejection fraction (LVEF):

• HF with reduced ejection fraction (HFrEF)
• HF with mildly reduced ejection fraction (HFmrEF)
• HF with preserved ejection fraction (HFpEF).

Left ventricular ejection fraction (LVEF) is the proportion of oxygenated blood in the heart that is pumped out by the left ventricle to the rest of the body with each heartbeat. In HFrEF, the LVEF is below 40%, while in HFpEF, it is at least 50%. HFmrEF, which was first introduced in the 2016  guidelines, refers to heart failure with an LVEF between 40% and 49%, inclusive. This was initially considered a ‘grey area’ between HFrEF and HFpEF, and is now starting to be seen as a group with a clinical and risk profile closer to HFrEF based on clinical trials and retrospective sub-group analyses of previous studies. There is ongoing discussion regarding the LVEF cut-offs currently used to distinguish types of HF, so it is possible that definition criteria may change in the future.

Heart failure symptoms are similar to symptoms of other health conditions. The three ‘red flag’ symptoms are:

• extreme fatigue
• breathlessness
• swelling, especially in the lower limbs, caused by fluid retention.

Other symptoms may include rapid weight gain (again, caused by fluid retention), reduced exercise capacity and, in severe cases, fluid in the lungs (pulmonary oedema). Symptoms may vary based on a person’s age and weight.

These symptoms are often hard for people to identify, so they may not recognise the need to see a healthcare professional. Heart failure symptoms are often dismissed as signs of ageing or other health conditions. This can delay diagnosis and access to treatment.

The timely and appropriate diagnosis of heart failure helps people achieve the best possible outcomes through early access to support and effective management.

Multiple tests are used to establish a definitive heart failure diagnosis, including:

• clinical history
• physical examination
• NP testing (blood tests to assess natriuretic peptides, which are hormones produced by the heart)
• chest X-ray
• electrocardiogram (ECG, a test that checks the heart’s rhythm and electrical activity)
• echocardiogram (a scan that provides a detailed overview of the heart).

Heart failure diagnosis is a team effort. People with heart failure typically present with symptoms in primary care or emergency rooms, and healthcare professionals working in these settings should collaborate with specialists, such as cardiologists and heart failure nurses, to ensure prompt initiation of care.

Heart failure is a lifelong condition that requires continuous monitoring and care. The aims of heart failure care include managing symptoms, preventing disease progression, maximising heart capacity, preventing hospitalisations and improving quality of life and survival. Best-practice multidisciplinary and integrated heart failure care that adheres to guidelines can achieve these aims.

Comprehensive care may be delivered in heart failure management programmes that support the person with heart failure throughout their entire care journey, from diagnosis to end-of-life care. They should include:

• prescription, review and optimisation of medication and cardiac devices
• access to transplantation
• cardiac rehabilitation
• post-discharge care
• regular monitoring of risk factors, signs, symptoms, quality of life, functional status and comorbidities
• education on self-care (patient empowerment)
• psychosocial support
• advance care planning
• a comprehensive care plan outlining essential information.

These programmes are not always available due to lack of resources (funding and staff), national guidance and administrative support.

Preventing heart failure is important because the syndrome can have a significant impact on a person’s quality of life, health and wellbeing. It also benefits society as a whole, as the growing prevalence of heart failure is contributing to an increase in associated healthcare costs.

Heart failure can be prevented or delayed by addressing risk factors – medical conditions, diseases and lifestyle behaviours that can result in HF. Maintaining a healthy lifestyle, for example by exercising regularly and refraining from smoking, significantly reduces the risk of HF.

Guidelines recommend that people at risk of heart failure should limit their alcohol intake, exercise for at least 2.5 hours per week at moderate intensity and avoid or stop recreational drug use and smoking.

People with heart failure have an essential role in improving their own health outcomes, because heart failure must be managed on a daily basis – away from hospitals, doctors and nurses. This type of care is referred to as self-care: behaviours and activities that each person with heart failure can engage in to manage their own condition. People with heart failure who are empowered and adequately supported in self-care are at a lower risk of hospital readmission and depression.

Self-care involves learning how to monitor one’s own symptoms, prevent heart failure from worsening and contact the care team for help if/when needed. Self-care behaviours include:

• daily weighing to monitor fluid retention
• monitoring blood pressure and heart rate
• eating a healthy diet, including plenty of fruit and vegetables and limiting salt intake
• adhering to the medication plan
• exercising regularly
• quitting smoking
• limiting alcohol consumption
• seeking mental health support to maintain emotional and psychological wellbeing
• seeking social welfare support and financial help, if required.

Maintaining self-care behaviours can be difficult. The care team should help people with heart failure develop their own strategies to remain motivated and engaged with their care. Heart failure nurses are especially well-placed to provide self-care education to people with heart failure.