What Is Heart Failure?
Heart failure — sometimes called congestive heart failure — is a condition in which the heart muscle is too weak or too stiff to pump enough blood to meet the body's needs. It doesn't mean the heart has stopped or is about to stop. It means it's not working as well as it should.
When the heart can't pump efficiently, blood can back up into the lungs (causing shortness of breath) or into the legs and feet (causing swelling). The kidneys respond by retaining salt and water, which worsens the fluid buildup.
Two main types:
HFrEF (reduced ejection fraction): The heart muscle is weak and doesn't squeeze well. Also called "systolic" heart failure.
HFpEF (preserved ejection fraction): The heart squeezes normally but is too stiff to fill properly. Also called "diastolic" heart failure. More common in older adults, women, and those with obesity or diabetes.
Heart failure affects about 6.7 million Americans and is a leading cause of hospitalization, especially in adults over 65. But with proper treatment, many people live active, full lives.
Normal Heart vs Weakened Heart
Normal Heart Function
Heart Failure
Result: Blood backs up into the lungs and body, causing swelling, shortness of breath, and fatigue.
Symptoms
Symptoms of heart failure develop gradually and can be easy to dismiss as "just getting older." Key warning signs include:
- Shortness of breath — especially with activity, when lying flat, or waking you at night
- Swelling (edema) in the legs, ankles, or feet
- Rapid weight gain from fluid retention (more than 2–3 lbs in a day)
- Persistent fatigue or weakness
- Reduced ability to exercise or do daily activities
- Persistent cough or wheezing, sometimes with white or pink-tinged mucus
- Decreased appetite or nausea
- Difficulty concentrating or decreased alertness
- Rapid or irregular heartbeat
If you have heart failure, weighing yourself every morning is one of the most important things you can do. A sudden gain of 2–3 pounds in 24 hours often signals fluid buildup — call your doctor before it becomes an emergency.
How Is It Diagnosed?
Diagnosing heart failure involves a combination of your history, physical exam, and tests:
- Echocardiogram ("echo"): The most important test. An ultrasound of the heart that shows how well it's pumping and measures the ejection fraction (EF) — the percentage of blood pumped out with each beat. Normal EF is 55–70%.
- BNP or NT-proBNP blood test: A protein released by the heart when it's under stress. Elevated levels strongly suggest heart failure.
- Chest X-ray: Can show an enlarged heart or fluid in the lungs.
- EKG: Checks heart rhythm and looks for prior heart attacks.
- Blood tests: Check kidney function, electrolytes, thyroid, blood count, and iron levels — all of which affect heart function.
- Stress test or cardiac catheterization: May be ordered to look for underlying coronary artery disease as a cause.
Treatment Options
Heart failure is a chronic condition, but it's highly treatable. The goals are to relieve symptoms, slow progression, reduce hospitalizations, and extend life.
Medications (The Foundation)
For HFrEF, guideline-directed medical therapy (GDMT) includes four key medication classes proven to extend life:
- ACE inhibitors or ARBs / ARNIs (e.g., lisinopril, sacubitril/valsartan): Reduce strain on the heart
- Beta-blockers (e.g., carvedilol, metoprolol succinate): Slow the heart and improve its efficiency
- Mineralocorticoid receptor antagonists (MRAs) (e.g., spironolactone): Reduce fluid and have heart-protective effects
- SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin): Originally diabetes drugs now proven to dramatically reduce heart failure hospitalizations and death
- Diuretics (e.g., furosemide): Help remove excess fluid and relieve swelling and breathlessness
Devices
- ICD (implantable cardioverter-defibrillator): Prevents sudden cardiac death in patients with significantly reduced EF
- CRT (cardiac resynchronization therapy): A special pacemaker that coordinates the heart's contractions and can significantly improve function
Lifestyle Changes
- Low-sodium diet (less than 2,000–2,300 mg/day) to prevent fluid buildup
- Daily weight monitoring
- Fluid restriction if recommended by your doctor
- Cardiac rehabilitation — supervised exercise shown to improve outcomes
- Avoiding alcohol, which weakens the heart muscle
📺 Video Resources
Watch Dr. Pollock explain heart failure, how to manage it, and what warning signs to watch for.
When to Seek Care
- Sudden severe shortness of breath or inability to breathe lying down
- Pink, foamy mucus when coughing
- Chest pain or pressure
- Fainting or near-fainting
- Rapid weight gain (3+ lbs overnight) with worsening breathing
Call your doctor (don't wait) if: you gain 2–3 lbs in a day, your legs are more swollen than usual, you're more short of breath than normal, or you're feeling significantly more fatigued. Early intervention prevents hospitalizations.