Heart failure

• Breathlessness, at first on exertion and later at rest
• Difficulty lying flat, or needing extra pillows to sleep
• Waking at night breathless, needing to sit up or stand at a window
• Swelling of the ankles, feet and legs, worse towards the end of the day
• Rapid weight gain over days — fluid, not fat
• Fatigue and reduced exercise capacity
• A persistent dry cough, sometimes worse lying down
• Abdominal fullness or loss of appetite

• Previous heart attack, leaving scarred, non-contracting muscle
• Coronary artery disease without a discrete infarct
• Long-standing high blood pressure
• Diabetes
• Valve disease — a leaking or narrowed valve the heart has compensated for over years
• Cardiomyopathy, including viral, familial and post-partum forms
• Sustained fast heart rhythms, which can weaken the muscle over time
• Alcohol, and some chemotherapy agents
• Thyroid disease, and severe long-standing anaemia

• History and examination — jugular venous pressure, chest findings and peripheral swelling are genuinely informative here
• Echocardiography, which is the central test: it measures ejection fraction, shows which chambers are affected, assesses the valves and often reveals the cause
• ECG, which is rarely entirely normal in significant heart failure
• Blood tests including NT-proBNP where available, kidney function, electrolytes, haemoglobin, thyroid function and iron studies
• Chest X-ray, for congestion and to consider lung causes of the same symptoms
• Assessment for coronary disease, since it is the commonest underlying cause and may be treatable

• Treating the cause — revascularisation for coronary disease, blood pressure control, valve intervention, rhythm control, alcohol cessation
• Combination medical therapy, built up gradually to target doses; several of these medicines are proven to prolong life rather than only ease symptoms
• Diuretics to clear fluid and relieve breathlessness and swelling
• Daily weight monitoring at home, which detects fluid retention days before symptoms do
• Sensible salt and fluid guidance, individualised rather than blanket
• Supervised, gradual physical activity — deconditioning worsens symptoms
• Device therapy in selected patients: cardiac resynchronisation, or an implantable defibrillator where the risk of dangerous rhythms is high
• Iron correction, which improves symptoms in many patients even without anaemia

Doses are increased slowly and deliberately over several visits. Feeling no different after the first prescription is expected and is not a reason to stop.

• Treat high blood pressure early. It is the most preventable route into heart failure.
• Take a heart attack seriously in its aftermath — the medication started afterwards protects the remaining muscle.
• Manage diabetes actively; some diabetes medicines now used specifically reduce heart failure hospitalisation.
• Weigh yourself daily if you have been diagnosed, and report a gain of more than 2 kg over three days.