Heart failure: the symptoms that get mistaken for getting older

Heart failure means the heart cannot deliver enough blood to meet the body's needs at normal filling pressures. It affects roughly 1 to 2 per cent of adults in developed countries and more than 10 per cent of those over seventy. Despite substantial treatment advances, prognosis after diagnosis remains worse than for several common cancers, which very few patients are told.

The two kinds, which are genuinely different diseases

Heart failure with reduced ejection fraction (HFrEF) means the ventricle contracts weakly — ejection fraction of 40 per cent or less. The commonest causes are prior myocardial infarction, long-standing hypertension, and cardiomyopathy. This is the version with excellent evidence-based drug therapy.

Heart failure with preserved ejection fraction (HFpEF) means the ventricle contracts normally but is stiff and fills poorly. It now accounts for roughly half of all heart failure, is more common in older adults, in women, and in people with hypertension, obesity, diabetes and atrial fibrillation.

HFpEF was for years a diagnosis of exclusion with no proven treatment, and it is the harder of the two to recognise because an echocardiogram showing normal pumping function is easily reported as reassuring.

What it feels like

The symptoms are non-specific enough that attributing them to age is genuinely tempting.

Breathlessness on exertion, developing gradually — the stairs that used to be fine, the walk to the shop that now needs a pause.

Orthopnoea — breathlessness lying flat, relieved by sitting up. The characteristic history is a gradual increase in the number of pillows used, which people rarely mention because they do not connect it to anything.

Paroxysmal nocturnal dyspnoea — waking abruptly at night gasping, needing to sit up or open a window. This one is fairly specific and worth reporting.

Ankle and leg swelling, worse through the day, better overnight.

Fatigue, often the dominant symptom and the least specific.

Weight gain over days — fluid, not fat. Two kilograms in three days is fluid retention until proven otherwise.

In older adults the presentation can be atypical: confusion, reduced appetite, abdominal discomfort from liver congestion, or simply a decline in function without any respiratory complaint at all.

Treatment for reduced ejection fraction

This is one of the genuine success stories of modern cardiology. Four drug classes — sometimes called the four pillars — each independently reduce mortality, and together produce substantial gains:

• ACE inhibitors or ARBs, or increasingly sacubitril/valsartan, which outperformed enalapril in the PARADIGM-HF trial.
• Beta blockers — bisoprolol, carvedilol, or metoprolol succinate specifically.
• Mineralocorticoid receptor antagonists — spironolactone or eplerenone.
• SGLT2 inhibitors — dapagliflozin or empagliflozin, which reduce hospitalisation and death regardless of whether the patient has diabetes. This was a genuine surprise when the trials reported.

Diuretics relieve symptoms and are essential for comfort, but do not improve survival. Devices — implantable defibrillators and cardiac resynchronisation — help selected patients.

The commonest failure in practice is under-dosing. Patients are started on low doses and never titrated up, and much of the mortality benefit in the trials came from reaching target doses.

Treatment for preserved ejection fraction

Long a therapeutic desert, this has changed. SGLT2 inhibitors showed benefit in the EMPEROR-Preserved and DELIVER trials and are now recommended. Beyond that, treatment focuses on the contributors — blood pressure control, weight, atrial fibrillation, sleep apnoea — and on diuretics for congestion.

The self-management that actually changes outcomes

Weigh daily, first thing, after urinating, before dressing. A rise of 2 kg over two or three days means fluid is accumulating, and most patients can be given a plan to adjust their diuretic dose in response. This single habit prevents a substantial number of admissions.

Restrict salt moderately, which reduces fluid retention.

Fluid restriction if advised — this is one of the situations where general hydration advice does not apply and the cardiology team's instruction governs.

Exercise. Cardiac rehabilitation improves symptoms, quality of life and hospitalisation rates in heart failure. It is consistently under-referred and under-attended, and the old advice to rest has been thoroughly overturned.

Avoid NSAIDs, which cause fluid retention and worsen kidney function. This matters because they are bought without prescription for the aches that heart failure patients also have.

The conversation that should happen and often does not

Heart failure has a trajectory of gradual decline punctuated by acute deteriorations, and prognosis is genuinely poor — worse than many cancers at equivalent stage. Yet discussions about what happens later, about preferences, about resuscitation and about palliative input happen late or never.

Palliative care alongside active treatment improves symptom control and quality of life in heart failure, and is not a withdrawal of treatment. It is reasonable, and increasingly recommended, to raise it early rather than at the end.