Heart failure

What is heart failure?

Heart failure means the heart isn’t pumping efficiently enough to meet the body’s needs. It does not mean the heart has stopped—many people live well for years with the right plan. 

There are two main patterns:

  • Systolic heart failure (HFrEF): the heart’s pumping strength is reduced (low ejection fraction).

  • Diastolic heart failure (HFpEF): the pumping strength may be normal, but the heart is stiff and doesn’t fill properly.

Symptoms

Common symptoms include:

  • shortness of breath (especially with exertion or lying flat)

  • fatigue and reduced exercise tolerance

  • ankle/leg swelling, weight gain from fluid

  • waking at night breathless, cough, abdominal bloating

Symptoms fluctuate—often driven by fluid balance, rhythm issues, blood pressure, infections, and medication changes.

How we confirm the diagnosis

Key tests typically include:

  • Echocardiogram (to measure ejection fraction, valve function, pressures)

  • ECG (rhythm, conduction delay such as bundle branch block)

  • Blood tests (including natriuretic peptides, kidney function, iron studies when relevant)

  • Additional testing (CT/MRI/angiography) depending on cause and risk.

Treatment goals

We focus on three outcomes:

  1. You feel better (breathlessness, energy, exercise tolerance)

  2. Fewer hospitalisations

  3. Longer-term protection (slowing progression and reducing sudden cardiac death risk)

Treatment for systolic heart failure (HFrEF): the “four pillars”

For HFrEF, modern guidelines emphasise starting and optimising four core medication classes (as tolerated), because together they improve symptoms and reduce hospitalisation and mortality. 

The four pillars commonly include:

  • an ARNI (or ACE inhibitor/ARB, depending on suitability)

  • a heart-failure beta blocker

  • a mineralocorticoid receptor antagonist (MRA)

  • an SGLT2 inhibitor 

Other medicines may be added for fluid control (diuretics), heart rate/rhythm, blood pressure, and specific situations (e.g., iron deficiency treatment when appropriate). 

Key point: this is usually a stepwise process—we start evidence-based therapy early and adjust over time based on blood pressure, kidney function, potassium, symptoms, and your priorities.

Diastolic heart failure (HFpEF): what’s different?

HFpEF is common, especially with ageing, hypertension, obesity, sleep apnoea, diabetes, and atrial fibrillation. Treatment focuses on:

  • controlling fluid retention and blood pressure

  • managing AF and other contributing conditions

  • improving fitness and cardiometabolic health

    SGLT2 inhibitors now have strong guideline support in HFpEF/HFmrEF to reduce HF hospitalisation (and improve outcomes), even though the overall strategy differs from HFrEF.

Device and pacing therapies

Not everyone with heart failure needs a device—but for selected patients, devices can be life-changing.

ICD (Implantable Cardioverter-Defibrillator)

An ICD monitors for dangerous ventricular arrhythmias and can deliver a shock or pacing to prevent sudden cardiac death. It’s considered in selected patients with persistently reduced ejection fraction despite optimal medical therapy, depending on cause and overall prognosis. 

CRT (Cardiac Resynchronisation Therapy)

In some people with HFrEF, the problem is partly electrical—especially left bundle branch block—which causes the ventricles to contract out of sync. CRT (biventricular pacing) can improve symptoms, heart function, and outcomes in appropriately selected patients. 

Conduction system pacing (CSP)

CSP aims to pace the heart in a more physiological way by directly engaging the heart’s natural conduction system (e.g., His bundle pacing or left bundle branch area pacing). It’s increasingly used as an alternative to traditional right-ventricular pacing, and in selected scenarios may be used as a CRT strategy or when pacing needs and heart failure overlap. 

How we decide between CRT vs CSP: it depends on your ECG pattern (e.g., LBBB), pacing needs, anatomy, prior devices, symptom profile, and likelihood of response—this is personalised rather than one-size-fits-all.