Heart Failure

Heart failure is a serious, chronic condition in which the heart muscle becomes too weak or too stiff to pump blood efficiently around the body. It does not mean the heart has stopped — it means the heart is not working as well as it should, causing fluid to build up in the lungs and other tissues. Heart failure can affect the left side, right side, or both sides of the heart. It affects millions of people worldwide and is increasingly common in Nigeria, driven by the high prevalence of uncontrolled hypertension, rheumatic heart disease (from repeated streptococcal infections), and cardiomyopathies. Heart failure is a life-altering but manageable condition — with proper treatment, many people live well for years.

Heart failure causes a characteristic pattern of symptoms that result from the heart's inability to pump adequately and the resulting fluid accumulation: • Shortness of breath (dyspnoea): – Initially only on exertion – Later occurring at rest – Orthopnoea — breathlessness that forces the person to sleep with extra pillows or sitting up – Paroxysmal nocturnal dyspnoea — waking at night gasping for air • Fatigue and weakness: even with minimal activity • Swollen ankles, feet, and legs (peripheral oedema): fluid accumulation; classically pits when pressed • Swollen or distended abdomen from fluid (ascites): in right heart failure • Rapid or irregular heartbeat (palpitations) • Persistent cough or wheeze: often producing white or pink frothy sputum • Rapid weight gain: from fluid retention; gaining more than 1–2 kg in a day or 2–3 kg in a week is a warning sign • Reduced urine output (nocturia: passing more urine at night may also occur) • Difficulty concentrating and confusion in severe cases

Heart failure is caused by conditions that damage or overwork the heart: Most common causes in Nigeria: • Hypertension (high blood pressure): the leading cause; chronically elevated pressure forces the heart to work harder until it weakens • Rheumatic heart disease: caused by repeated streptococcal throat infections in childhood leading to valve damage; very common in Nigeria • Coronary artery disease: blocked coronary arteries reduce blood supply to the heart muscle (heart attack) • Cardiomyopathy: disease of the heart muscle itself: – Dilated cardiomyopathy (weak, enlarged heart) – Peripartum cardiomyopathy — heart failure developing in the last month of pregnancy or within 5 months after delivery; important cause of maternal mortality in Nigeria – Hypertrophic cardiomyopathy Other causes: • Heart valve disease • Congenital heart defects • Severe anaemia • Viral myocarditis • Thyroid disease • Alcohol and substance abuse

• Uncontrolled or untreated hypertension: the most important modifiable risk factor in Nigeria • Previous heart attack • Coronary artery disease • Diabetes mellitus • Obesity • History of rheumatic fever in childhood • Alcohol misuse • Older age • Family history of cardiomyopathy • Pregnancy: peripartum cardiomyopathy • Untreated severe anaemia • Viral infections affecting the heart

• Acute decompensation: sudden worsening requiring emergency hospitalisation • Pulmonary oedema: dangerous fluid accumulation in the lungs causing severe breathlessness; life-threatening • Kidney failure: reduced cardiac output impairs kidney function • Liver damage (cardiac cirrhosis) from chronic congestion • Arrhythmias: abnormal heart rhythms, including sudden cardiac death • Stroke: blood clots can form in a weakened heart and travel to the brain • Malnutrition and severe weight loss (cardiac cachexia) in advanced disease • Depression and anxiety: very common in heart failure patients • Reduced quality of life and exercise capacity • Death

Primary prevention — prevent heart failure before it starts: • Control blood pressure to below 130/80 mmHg: take antihypertensive medication consistently • Treat streptococcal throat infections promptly with penicillin to prevent rheumatic fever • Maintain a healthy weight • Exercise regularly: at least 150 minutes of moderate activity per week • Eat a heart-healthy, low-salt diet • Do not smoke; limit alcohol • Control diabetes and high cholesterol Secondary prevention — for people diagnosed with heart failure: • Take all prescribed medications exactly as directed: diuretics (to remove excess fluid), ACE inhibitors or ARBs, beta-blockers, and aldosterone antagonists • Restrict dietary salt to less than 2 grams per day • Restrict fluid intake as directed by your doctor • Monitor your weight daily • Exercise at a level recommended by your cardiologist (regular gentle exercise actually helps heart failure) • Attend all clinic appointments • Avoid NSAIDs (ibuprofen, diclofenac): they cause fluid retention and worsen heart failure