Medically Reviewed By: Dr Paul Lim – MBBS, M.Med (Int Med), MRCP (UK), FAMS (Cardiology)
Heart failure means the heart is not pumping as well as it should, not that it has stopped or is about to. Just been told your heart is weak, or your ejection fraction is low? Sit down with Dr Paul Lim, who will take you through your results at your own pace and set out what treatment can do.
Dr Paul Lim Chun Yih
Senior Consultant Cardiologist & Electrophysiologist
Senior Consultant Cardiologist & Cardiac Electrophysiologist
Dr Paul Lim subspecialises in the heart’s electrical system, which matters in heart failure more than people expect. Rhythm problems such as atrial fibrillation can weaken the heart, and a weakened heart is prone to dangerous rhythms. He implants the devices used in heart failure, defibrillators and resynchronisation pacemakers, where they are needed. He completed advanced fellowship training at Barts Heart Centre, London under Singapore’s HMDP award.
Heart failure is when the heart cannot pump blood around the body as well as it should. It does not mean the heart has stopped working, or is about to. The muscle has become weaker, or stiffer, so less blood reaches your organs and muscles with each beat and pressure builds up behind it.
Congestive describes that build-up. Fluid the heart cannot move on collects in the lungs, which makes you breathless, and in the legs and abdomen, which swell. Congestive heart failure, CHF and cardiac failure all name the same condition.
The pump can fail in two broad ways:
A smaller group falls between the two, with mildly reduced ejection fraction.
Doctors also talk about the side affected. Left-sided failure backs fluid up into the lungs; right-sided failure backs it up into the body, which is where swollen ankles come from. Many people have both.
A heart attack is a blocked artery cutting off blood to part of the heart muscle. A cardiac arrest is the heart suddenly stopping. Both are emergencies, and both need 995. Heart failure is a longer-term weakness of the pump, though the three are linked: a heart attack is one of the commonest causes of heart failure, usually through coronary artery disease.
Ejection fraction (EF, or LVEF) is the share of blood the main pumping chamber pushes out with each beat. It is measured on an echocardiogram and printed on the report as a percentage. A healthy heart does not empty completely: pushing out half or more is normal.
| Ejection fraction | Category | What it means |
|---|---|---|
| 50% or more | Normal range. HFpEF if you also have heart failure symptoms and signs | The squeeze is fine; the problem is a stiff heart that fills poorly |
| 41 to 49% | Mildly reduced (HFmrEF) | Between the two, and often treated along the lines of reduced EF |
| 40% or less | Reduced (HFrEF) | The pump is weak. This is where medicines have the strongest evidence |
| Was 40% or less, now above | Improved (HFimpEF) | The heart has recovered some strength, usually with treatment that still needs continuing |
These are the ejection fraction categories used to classify heart failure. An EF of 35% or less is also the level at which a protective device comes into the discussion.
The symptoms of a failing heart usually build up over weeks or months, and they are easy to put down to age or being unfit. Most come from the same two things: too little blood reaching the body, and fluid backing up behind the heart.
Breathlessness has many causes besides the heart. If it is your main symptom, the shortness of breath guide covers the others.
Do not wait for an appointment if you have:
Arrange a review soon if:
Worth mentioning at a routine visit:
Not sure which column you fall into? Speak to a cardiologist rather than wait and see.
Told your heart is weak? Talk to our friendly Dr Paul Lim about what your echo shows.
Two scales describe heart failure. The NYHA class measures how much symptoms limit you day to day, and it can improve with treatment. The ACC/AHA stage describes how far the condition has developed.
| NYHA class | When symptoms appear | In everyday terms |
|---|---|---|
| Class I | Only with more than ordinary activity | Normal life, symptoms on real exertion |
| Class II | With ordinary activity | Breathless climbing stairs or walking briskly |
| Class III | With minimal activity | Breathless dressing or walking across a room |
| Class IV | At rest | Symptoms even sitting still |
The ACC/AHA stages run in one direction, from risk to advanced disease:
Stage B is worth dwelling on. It shows up on an echocardiogram before any symptoms appear, and treatment started then aims to keep them away.
Heart failure is the end result of something else that has strained or damaged the heart. Finding that cause matters, because some of them can be treated directly.
More than one cause is common, particularly in older people: high blood pressure, narrowed arteries and atrial fibrillation often arrive together.
Cardiomyopathy is the general term for diseases of the heart muscle, where the chamber walls become stretched, thickened or stiff. It is one of the main routes into heart failure, and several types run in families.
Two things set cardiomyopathy apart. Several types raise the risk of dangerous heart rhythms, so part of the assessment is judging whether a defibrillator is needed for protection. And because most types are inherited, a diagnosis in one person is a reason to check close relatives, who can then be monitored early.
Cardiomegaly, or an enlarged heart, is often first mentioned on a chest X-ray. It is a description rather than a diagnosis: the heart shadow looks larger than expected, which can reflect a stretched chamber, thickened walls, fluid around the heart, or simply how the picture was taken. An echocardiogram settles which, and whether the heart is pumping normally.
The aim is to answer three questions: is it heart failure, which type is it, and what caused it.
How far you can walk, how many pillows you sleep on, and whether your ankles swell. Fluid in the lungs and legs is often audible and visible, and every medicine you take is reviewed.
The key test. An ultrasound scan of the heart that measures the ejection fraction, the thickness of the walls, the size of the chambers and how the valves are working. It is painless and takes under an hour.
NT-proBNP is a hormone the heart releases when it is under strain. It helps tell a heart cause of breathlessness from other causes, though it runs higher with age, kidney disease and atrial fibrillation, and lower with obesity. Kidney function, thyroid, blood count and sugar are checked alongside it.
Shows the rhythm, signs of a past heart attack, and whether a bundle branch block is present. A left bundle branch block matters here, because it is one of the findings that makes a resynchronisation device worth considering.
Shows fluid in or around the lungs and the size of the heart shadow.
Depending on what the first tests show: a CT coronary angiogram or stress test to look at the arteries, a Holter monitor to catch a rhythm problem, or a cardiac MRI to look at the muscle itself.
The ECG, blood tests and echocardiogram are all done in clinic. Book a review with Dr Paul Lim.
Heart failure usually cannot be cured, but treatment helps: it eases symptoms, keeps people out of hospital and helps them live longer. Most people need several of the approaches below together.
Less salt, so the body holds on to less fluid. Weighing yourself every morning, since a rise over a few days is the earliest sign of fluid building up. Regular exercise, which improves how much you can do. Stopping smoking and keeping alcohol low.
For reduced EF, four groups lower the risk of death and of hospital admission: an ARNI (sacubitril-valsartan) or an ACE inhibitor or ARB, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, which helps whether or not you have diabetes. They are started low and built up over weeks. Never stop one on your own account.
Diuretics clear excess fluid from the lungs and legs, so they ease breathlessness and swelling quickly. The dose is adjusted to your weight and symptoms, which is where the daily weigh-in earns its keep.
If the EF stays at 35% or less despite several months of full medical treatment, an ICD guards against a dangerous rhythm by delivering a shock if one occurs. Where the ECG also shows a QRS of 130 ms or more with left bundle branch block, cardiac resynchronisation therapy (CRT) paces both sides of the heart back into step, which can improve symptoms and strength, with the strongest benefit seen at 150 ms or more. These are the devices Dr Lim implants, and the decision rests on your full picture, not one number.
When a fast rhythm is weakening the heart, controlling it, sometimes with catheter ablation, can let the muscle recover. Narrowed arteries or a faulty valve are treated too, with the appropriate specialist where a procedure or surgery is needed.
For the small number whose heart failure stays severe despite everything else, a pump that assists the heart (a left ventricular assist device) or a heart transplant is considered at a specialist centre.
Much of what keeps heart failure stable happens at home, between appointments.
See Dr Paul Lim about breathlessness, swelling or a low ejection fraction, and what can be done about it.
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By Appointment Only
Heart failure means the heart cannot pump blood around the body as well as it should. It does not mean the heart has stopped, or is about to. The muscle has become weaker or stiffer, so less blood reaches the body with each beat and fluid can build up in the lungs and legs. It is also called congestive heart failure (CHF) or cardiac failure.
No. A heart attack is a blocked artery cutting off blood to part of the heart muscle, and a cardiac arrest is the heart suddenly stopping. Both are emergencies: call 995. Heart failure is a longer-term weakness of the pump. The three are linked, because a heart attack is one of the commonest causes of heart failure, and a weakened heart is more prone to dangerous rhythms.
Both are heart failure, sorted by the ejection fraction on your echocardiogram. In heart failure with reduced ejection fraction (HFrEF) the EF is 40 per cent or less, because the muscle squeezes weakly. In heart failure with preserved ejection fraction (HFpEF) the EF is 50 per cent or more: the heart squeezes normally but is stiff and fills poorly. Mildly reduced EF, at 41 to 49 per cent, sits between them. The type matters because the medicines with the strongest evidence differ.
Two scales are used. The ACC/AHA stages run from A (at risk, with no symptoms or heart damage yet) through B (changes in the heart but no symptoms) and C (symptoms) to D (advanced heart failure despite treatment). The NYHA classes, I to IV, describe how much symptoms limit you, from breathlessness only with more than ordinary activity to symptoms at rest. Your NYHA class can improve with treatment.
Heart failure usually cannot be cured, but treatment works: it relieves symptoms, lowers the chance of a hospital admission and helps people live longer. Some causes can be reversed. When a fast rhythm such as atrial fibrillation has weakened the heart, controlling the rate often lets the muscle recover. The ejection fraction can also climb with medicines, which is recorded as heart failure with improved ejection fraction.
That depends on the cause, the type of heart failure, how advanced it is and how well it responds to treatment. Medicines and devices that lower the risk of death are now standard care, and many people live with heart failure for years. Your own results are the best guide, so ask your cardiologist to go through what your echocardiogram shows and what it means for you.
Cut down on salt, which makes the body hold on to fluid. Much of it comes from sauces, stock and eating out rather than the salt shaker. Keep alcohol low, since it can weaken the heart muscle directly. Some people are asked to limit how much they drink in total when fluid keeps building up. That is individual advice, so follow the amount your own doctor gives you rather than a general rule.
For most people it is, and it helps: regular exercise improves how much you can do and your quality of life. Start gently and build up, ideally through a supervised cardiac rehabilitation programme. Stop and seek help if activity brings on chest pain, dizziness or breathlessness well beyond your usual. Your cardiologist can tell you what level suits you.
When the heart cannot move blood on, pressure backs up into the lungs and fluid seeps into them. Lying flat lets more fluid shift towards the chest, so breathlessness is often worse in bed. People prop themselves up on extra pillows, and some wake at night gasping or coughing. A cough bringing up frothy, pink-tinged phlegm means fluid in the lungs and needs emergency care: call 995.
Yes, and the two often travel together. A fast, irregular heartbeat can weaken the heart muscle over time, and a weakened, stretched heart is more likely to go into atrial fibrillation. When the rhythm is the main driver, controlling it can let the heart recover. Treatment for atrial fibrillation is covered in its own guide.
Heart failure is diagnosed and managed by a cardiologist. Dr Paul Lim is a Senior Consultant Cardiologist and Electrophysiologist who assesses heart function with an echocardiogram, looks for rhythm problems that can weaken the heart, and implants the ICDs and resynchronisation devices used in heart failure. He sees patients at Orchard and Jurong.
