Heart failure: understanding the diagnosis and managing it well

What does heart failure actually mean?

Heart failure is a term that sounds final, but its clinical meaning is more specific and more hopeful than it sounds. The heart is still beating. The problem is that it pumps blood less efficiently than the body requires, either because the heart muscle has weakened and squeezes with less force, or because the heart squeezes reasonably well but cannot relax and fill properly between beats. Both patterns cause the same result: tissues receive less oxygen and nutrients than they need.

The body responds to this by retaining salt and water, which creates the fluid overload that causes the most visible symptoms: breathlessness as fluid accumulates in the lungs, and ankle swelling as it pools in the legs. This is not a flaw in the body's response but an attempt to compensate for reduced cardiac output that unfortunately overloads an already struggling heart.

Heart failure is one of the most common causes of hospital admission worldwide. A 2023 analysis in the Journal of the American College of Cardiology examining the global burden of cardiovascular diseases noted that diabetes and high blood pressure, both extremely prevalent across the Arab world, are among the leading causes of heart failure. Understanding your diagnosis is the first step in managing it actively rather than being managed by it.

With appropriate treatment, lifestyle adjustment and regular monitoring, many people with heart failure live comfortably and actively for many years. The partnership between you and your medical team is the single most important factor in how well you do.

Ejection fraction: the number that shapes your treatment

Ejection fraction (EF) is the percentage of the blood inside the left ventricle that is pushed out with each heartbeat, measured by an echocardiogram (heart ultrasound). A healthy heart typically ejects between 55% and 70% of the blood it contains. It does not empty completely with each beat, and this is normal.

When the ejection fraction falls below 40%, doctors call the condition heart failure with reduced ejection fraction, abbreviated HFrEF. The heart muscle itself has weakened and cannot squeeze with sufficient force. This is the form where the four main drug classes have the strongest evidence for improving survival. When EF sits between 40% and 49%, it is called mildly reduced. When EF is 50% or above but symptoms of heart failure are present, the condition is called heart failure with preserved ejection fraction, or HFpEF, meaning the heart squeezes adequately but has become too stiff to fill properly.

A 2024 review in The Lancet on heart failure with preserved ejection fraction found that this form now accounts for roughly half of all heart failure cases globally and is particularly common in women, older adults, those with diabetes and those with longstanding high blood pressure. Regional populations in the Arab world carry all these risk factors at high rates, which makes HFpEF highly relevant here.

The symptoms to recognise

Breathlessness on exertion is usually the first thing people notice. Initially it may appear only on climbing stairs or walking quickly, then progress over months to difficulty with lighter activities or even at rest. Lying flat makes breathlessness worse because fluid that has pooled in the legs during the day shifts towards the lungs when you lie down. This is why many people with heart failure prop themselves up on several pillows to sleep more comfortably.

Ankle swelling is the other hallmark symptom. The fluid is soft and leaves a temporary dent when you press it with a finger, a phenomenon doctors call pitting oedema. It tends to be worst at the end of the day and better in the morning after the fluid has had time to redistribute. In more advanced cases the swelling can involve the calves, thighs and abdomen.

Fatigue and weakness out of proportion to activity are very common and are caused by the muscles receiving less blood than they need. A persistent cough, especially when lying down, can be a sign of fluid in the lungs. Nausea and loss of appetite occur when fluid accumulates around the liver and gut. Waking at night with sudden breathlessness that improves when you sit or stand up, a pattern called paroxysmal nocturnal dyspnoea, is a specific symptom worth reporting to your doctor.

Daily weight monitoring: your early warning system

Weighing yourself every morning before eating and after your first visit to the bathroom, wearing the same light clothing each time, is the most powerful self-monitoring tool available to someone with heart failure. One kilogram of weight gained in 24 hours represents roughly one litre of fluid retained. This fluid accumulation typically precedes worsening breathlessness or swelling by one to two days, which means you have a window to act before a crisis develops.

Contact your cardiology team on the same day if your weight rises more than two kilograms in three days, or more than three kilograms in a week. Many heart failure clinics provide a direct phone number or messaging system for exactly this purpose. Do not wait for your next scheduled appointment.

A randomised trial published in the Journal of Medical Internet Research in 2024 followed heart failure patients using bluetooth-connected scales linked to a monitoring app. The study showed that systematic weight tracking combined with responsive medication adjustment significantly reduced hospital admissions compared with usual care. The principle is straightforward: detecting fluid accumulation early when a dose adjustment or an extra diuretic tablet can resolve it is far better than arriving at an emergency department in respiratory distress.

Salt, fluid and what actually makes the difference

Sodium causes the body to retain water. In heart failure, the kidneys are already operating under the stress of reduced cardiac output and retain sodium more aggressively than normal. Most heart failure guidelines recommend keeping sodium intake below 2 grams per day, which is less than half a teaspoon of table salt. This limit applies to salt added during cooking and eating, but equally to the sodium already present in processed foods.

The challenge in the Arab world is that sodium hides in many common foods: commercial bread, pickled vegetables, salted white cheese such as akkawi and halloum, canned goods, stock cubes and processed meats. Cooking fresh food at home and flavouring it with herbs, lemon, cumin and other spices rather than salt is the most effective practical strategy. Reading nutrition labels when buying packaged food and choosing low-sodium versions where available also helps.

Fluid restriction varies between patients and is not a universal rule for everyone with heart failure. In mild or well-controlled disease, no specific fluid limit is needed beyond reducing salt. In more advanced disease or when fluid overload recurs repeatedly, your doctor may set a daily fluid limit, typically 1.5 to 2 litres including all drinks and water in food. Ask your doctor whether a specific limit applies to you rather than assuming one direction or the other.

The four medicines that change the outcome

For heart failure with reduced ejection fraction specifically, the 2021 ESC guidelines and their 2023 update identified four drug classes that reduce mortality and hospitalisation, not just relieve symptoms. Getting to the target dose of all four is the goal, achieved gradually over weeks to months.

ACE inhibitors or ARBs (angiotensin receptor blockers) reduce the pressure the heart works against and protect the heart muscle from further remodelling. Beta-blockers slow the heart rate, reduce the harmful effects of the stress hormones that flood the system in heart failure, and lower the risk of dangerous rhythm problems. Mineralocorticoid receptor antagonists such as spironolactone or eplerenone reduce fluid retention and provide additional heart protection. SGLT2 inhibitors, originally developed for diabetes, were found to substantially reduce heart failure hospitalisations and death in people both with and without diabetes.

A 2025 review in American Family Physician confirmed that combining all four drug classes produces outcomes superior to any individual drug or pair. The critical point is not to stop any of these medicines based on how you feel on a good day. They are working even when you feel well, and their benefit accumulates over months and years.

Diuretics such as furosemide are the most immediately noticeable medicines because they reduce fluid and relieve breathlessness within hours. They are essential for comfort and safety but do not improve long-term prognosis the way the four disease-modifying drugs do. Your doctor adjusts the diuretic dose most actively, increasing it during periods of fluid accumulation and reducing it when you are dry and stable.

When to act urgently: the warning signs

Even people who manage their heart failure well will have periods of instability. Recognising the early signs and contacting your team promptly, before symptoms become severe, is what keeps you out of hospital and protects your heart from each additional episode of overload. Your cardiology team genuinely prefers an early phone call to seeing you in an acute state.

Contact your heart failure clinic or GP on the same day, not at the next scheduled appointment, if your weight rises rapidly, if your breathlessness worsens noticeably without an obvious cause such as a respiratory infection, if you develop new or worsening ankle swelling, or if you feel faint or notice an unusual change in your heart rate or rhythm.

Some symptoms require emergency care immediately, not a telephone call tomorrow.

Exercise, sleep and keeping active with heart failure

Complete rest is not the right approach. Regular moderate exercise improves the heart's efficiency, reduces symptoms, and improves quality of life for people with stable heart failure. Supervised cardiac rehabilitation programmes, where available, provide structured exercise under monitoring and education about self-management. Where these are not accessible, daily walking at a pace that allows conversation without gasping is a practical and effective starting point.

Start with whatever you can currently manage without causing breathlessness or chest discomfort, and build up the duration gradually over weeks. Aim for 20 to 30 minutes most days once you are stable. Avoid very heavy exertion, prolonged standing in extreme heat, and exercise immediately after large meals. In Gulf summers, early morning or late evening walks, or indoor walking in air-conditioned spaces, are sensible alternatives to midday exercise.

Sleep position matters. Elevating the head of the bed by 15 to 20 centimetres, using extra pillows, or using an adjustable base helps prevent the nocturnal breathlessness caused by fluid redistribution when lying flat. If you wake at night feeling as though you cannot breathe and it relieves when you sit up, record this and tell your doctor at your next visit.

Regular follow-up appointments, even when you feel well, are essential. They typically include weight check, blood pressure measurement, review of symptoms, and blood tests for kidney function, sodium and potassium, all of which are closely monitored in heart failure because the medicines affect them. Dose adjustments happen gradually based on your readings, not based on how you feel.

Sources

• McDonagh TA, Metra M, Adamo M et al: 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, European heart journal, 2021
• McDonagh TA, Metra M, Adamo M et al: 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, European heart journal, 2023
• Campbell P, Rutten FH, Lee MM et al: Heart failure with preserved ejection fraction: everything the clinician needs to know, Lancet (London, England), 2024
• Gauer RL, Rifaat A, Foulkrod AM et al: Heart Failure With Reduced Ejection Fraction: Medical Management, American family physician, 2025
• Mensah GA, Fuster V, Murray CJL et al: Global Burden of Cardiovascular Diseases and Risks, 1990-2022, Journal of the American College of Cardiology, 2023
• Yoon M, Lee S, Choi JY et al: Effectiveness of a Smartphone App-Based Intervention With Bluetooth-Connected Monitoring Devices and a Feedback System in Heart Failure (SMART-HF Trial), Journal of medical Internet research, 2024