Heart failure means the heart is not pumping or filling well enough to meet the body’s demands. It is a diagnosis with a reputation far worse than its modern reality — the drug therapy available today changes the trajectory of this condition substantially when it is delivered at full dose.
Recognising it
Breathlessness on exertion, progressing to breathlessness lying flat or waking at night. Swelling of the ankles and legs. Fatigue out of proportion to activity. Reduced exercise tolerance that has crept up over months.
Diagnosis rests on echocardiography to assess pumping function and filling pressures, blood tests including natriuretic peptides, and an assessment of the underlying cause — coronary disease, hypertension, valve disease, rhythm disturbance or cardiomyopathy.
Reduced versus preserved ejection fraction
In heart failure with reduced ejection fraction, the pumping strength itself is impaired. This form has the strongest drug evidence in all of cardiology, and treatment follows a defined regimen built on four pillars, each of which independently improves survival.
In heart failure with preserved ejection fraction, the heart pumps normally but fills poorly. It is common, frequently under-diagnosed, and closely tied to hypertension, diabetes and obesity — which is where the treatment focus lies.
Why stenting is usually not the answer
Where heart failure coexists with coronary disease, the instinct is often to open the arteries in the hope that pumping function will recover. REVIVED-BCIS2 (2022) tested precisely this in 700 patients with ejection fraction of 35% or below and viable heart muscle. Over a median 41 months, adding PCI to medical therapy did not reduce death or heart-failure hospitalisation, and the improvement in ejection fraction did not appear.
The implication is not that these patients need less treatment. It is that the treatment which changes their outcome is the full, correctly titrated heart-failure drug regimen, and that effort is better spent there.
Living with it day to day
Daily weight monitoring to catch fluid retention early. Salt and fluid awareness. Taking every dose, including on days when you feel well — these drugs work by remodelling the heart over months, not by relieving symptoms that afternoon. Prompt review if weight rises by more than two kilograms in three days, or if breathlessness worsens.
Written and medically reviewed by Dr. Gurbir Singh Gill — Interventional Cardiologist & Diabetologist, Oxford Hospital.
Last reviewed: 1 September 2026