Heart Failure Symptoms and the Warning Signs to Watch

Heart failure means the heart muscle cannot pump, or cannot fill, well enough to meet the body's needs. It does not mean the heart has stopped. Blood backs up and fluid collects, which causes breathlessness, swollen ankles and tiredness. It is a long-term condition, and treatment controls it well.

What are the symptoms of heart failure?

The three main symptoms are breathlessness, swelling and fatigue. Breathlessness comes first with effort, later on lying flat. Swelling starts at the ankles and can climb to the abdomen. The fatigue is out of all proportion to what you did, and ordinary tasks leave you drained.

Patients describe it in familiar words:

• Breathlessness on walking or climbing stairs
• Needing two or three pillows to sleep, or waking at night gasping for air
• Swollen feet and ankles that pit when you press them
• A tight, full abdomen and no appetite
• Constant tiredness and weakness
• A dry cough that gets worse at night
• Weight climbing quickly over a few days without eating any more

The pattern matters as much as the symptom itself. Breathlessness that is worse lying down, or swelling that builds through the day, points to the heart rather than to the lungs or to simple weight gain.

What causes heart failure, and who is at risk?

Heart failure is the end result of another heart problem rather than a disease that begins on its own. The commonest routes to it are damage from a heart attack, years of untreated high blood pressure, a diseased valve, or a rhythm disturbance that has been running fast for months.

Causes and risk factors we see often in our patients:

• A previous heart attack, which leaves scar where working muscle used to be.
• Long-standing high blood pressure, which thickens and stiffens the heart muscle.
• Diabetes, extremely common in Pakistani families and a direct risk factor for heart failure.
• Heart valve disease, including rheumatic valve damage, which remains common in Pakistan.
• Arrhythmia, especially atrial fibrillation running fast for a long time.
• Cardiomyopathy, meaning disease of the heart muscle itself, sometimes after a viral illness or around childbirth.
• Anaemia, thyroid disease and kidney disease, which all worsen an already struggling heart.

The World Health Organization counts cardiovascular disease as the leading cause of death worldwide, and heart failure is where much of that disease finally shows itself. Because South Asians develop coronary artery disease earlier, as the American Heart Association describes, heart failure here often arrives at a younger age than clinicians expect.

Why does daily weight and fluid tracking matter so much?

Because sudden weight gain in heart failure is water, not fat, and water collects before you can feel it. Two kilograms of retained fluid can pile up over two or three days while you still feel reasonably well. Catching it at that stage usually means a small medicine adjustment instead of a hospital admission.

How to track weight properly:

1. Weigh yourself every morning, after going to the toilet and before breakfast.
2. Use the same scale, on the same hard floor, in similar clothing.
3. Write the number down every day. Memory is not good enough for this.
4. Tell your cardiologist if you gain about 2 kg (roughly 4.5 lb) in two to three days, or about 2.5 kg in a week.

Fluid awareness runs alongside it. Count everything liquid: water, chai, doodh, lassi, shorba, juice, and the water you take with medicines. Some patients need a set daily limit and others do not. Bring your weight diary to every visit. For a lot of people it changes the prescription more than any test does. Our guide to daily weight and fluid tracking covers the routine in more detail.

What are the warning signs that heart failure is getting worse?

A worsening episode, what doctors call decompensation, usually announces itself days before it turns dangerous. The early signs are all fluid-related and they build gradually. Weight, swelling, pillows and stamina all change before you become severely breathless. A patient who checks daily can act while a phone call is still enough.

When should you go to the Emergency?

Go immediately. Call 1122 or go straight to DHQ Hospital Abbottabad Emergency if you are breathless while sitting still, if you wake gasping and cannot settle, if you have chest pain, if you cough pink frothy sputum, or if you faint. None of these wait until morning.

Do not drive yourself, and do not take an extra dose of your water tablet on your own to try to fix it at home. Extra diuretic without supervision can dehydrate you and harm your kidneys. Routine worsening, the creeping weight and the extra swelling, belongs in a prompt clinic appointment. The symptoms above belong in the Emergency.

How is heart failure diagnosed?

Diagnosis combines your symptoms and examination with an ECG, blood tests, and above all an ultrasound of the heart. The ultrasound measures the ejection fraction, the percentage of blood the main pumping chamber pushes out with each beat, which separates the main types of heart failure and guides treatment.

Tests your cardiologist may arrange include:

• Echocardiography, the central test, showing pumping strength, chamber size and valve function.
• Blood tests for kidney function, salts, blood count, sugar, thyroid and, where available, natriuretic peptide.
• Holter monitoring if the pulse is irregular or a rhythm problem is suspected.
• An ETT (Exercise Tolerance Test) in selected patients, to assess exercise capacity or possible ischaemia.
• Angiography when blocked coronary arteries are the likely cause and treatment could change.
• 24-hour blood pressure monitoring when hypertension is driving the problem.

Dr. Muhammad Ali Khan, Consultant Cardiologist, runs structured heart failure management in Abbottabad, with heart failure care among his main clinical interests.

How is heart failure treated?

Treatment has two halves: medicines that protect and strengthen the heart over the long term, and medicines that clear excess fluid so you feel better now. European Society of Cardiology guidelines describe combinations of tablets that ease symptoms, reduce hospital admissions and improve survival when the doses are built up properly.

• ACE inhibitors, ARBs or ARNI reduce the workload on the heart and protect the muscle.
• Beta-blockers slow the heart and, over months, often improve its pumping strength.
• Mineralocorticoid receptor antagonists and SGLT2 inhibitors add further protection in suitable patients.
• Diuretics, the water tablets, relieve swelling and breathlessness. They treat the symptom rather than the weakness underneath it.
• Devices such as an ICD or a CRT pacemaker help a selected group, decided after specialist assessment.
• Treating the cause, whether that means opening blocked arteries, repairing a valve, controlling blood pressure or slowing atrial fibrillation, can improve heart function substantially.

Doses start low and rise step by step at each review, with blood pressure, pulse and kidney tests checked as they climb. That is deliberate, not slow.

How do you live with heart failure?

Well-managed heart failure allows a full daily routine: work, family, prayer, gentle walking. What holds it together are the daily habits. The patients who do best are the ones who take medicines without gaps, watch their weight, and speak up early when something changes.

Day-to-day priorities:

• Take every medicine daily, including on the days you feel strong. Feeling well is the treatment working.
• Weigh yourself every morning and keep the diary.
• Go easy on salt. Achar, papar, namkeen, packaged masalas and salty snacks all pull fluid back in.
• Walk regularly at a comfortable pace, and rest when you need to.
• Avoid regular anti-inflammatory painkillers and unlabelled herbal products, which can cause fluid retention. Ask before starting anything new.
• Ask before fasting in Ramadan, since fluid and diuretic timing need planning for each patient individually.
• Keep every follow-up appointment. Doses are meant to be adjusted over time, not fixed forever.

Low mood and anxiety are common with heart failure, and both are treatable. Mention them at your review. They affect how well you manage everything else.