Congestive Heart Failure
Heart failure occurs when the heart cannot pump effectively — causing breathlessness, leg swelling, and fatigue. Modern treatment with SGLT2 inhibitors, ARNIs, and device therapy significantly improves survival and quality of life when diagnosed and managed by a specialist. This can happen suddenly (acute heart failure)—after a heart attack, for example—or it can sneak up over months or years (chronic heart failure). Either way, the heart struggles to supply enough oxygen and nutrients to support your organs, muscles, and daily energy needs.
Heart recovery takes time
Heart failure is a clinical syndrome in which the heart is unable to pump sufficient blood to meet the body's metabolic demands, or can only do so at elevated filling pressures. It is a common and serious condition — affecting an estimated 1–2% of the adult population in Singapore — and a leading cause of hospitalisation and cardiovascular mortality. Despite its name, heart failure does not mean the heart has stopped; it means cardiac function is impaired and progressive without appropriate management. Early specialist diagnosis and evidence-based treatment significantly improve survival and quality of life.
Types of Heart Failure
- Heart failure with reduced ejection fraction (HFrEF) — defined as an ejection fraction below 40% — occurs when the heart muscle is weakened and cannot contract effectively. It is most commonly caused by coronary artery disease, prior myocardial infarction, or dilated cardiomyopathy, and responds well to guideline-directed medical therapy.
- Heart failure with preserved ejection fraction (HFpEF) — ejection fraction 50% or above — occurs when the heart muscle is stiff and cannot relax adequately, impairing ventricular filling. It is more prevalent in older patients, women, and those with hypertension, obesity, diabetes, and atrial fibrillation. HFpEF is increasingly common and carries significant morbidity despite a normal pumping function on echocardiography.
- Heart failure with mildly reduced ejection fraction (HFmrEF) — ejection fraction 40–49% — represents an intermediate phenotype with overlapping features and management considerations from both groups.
Symptoms & Functional Classification
Symptoms arise from fluid congestion and reduced cardiac output. Common presentations include breathlessness on exertion or at rest, orthopnoea (breathlessness lying flat), paroxysmal nocturnal dyspnoea, ankle and leg swelling, fatigue, reduced exercise tolerance, and persistent cough. Severity is clinically staged using the NYHA functional classification — from Class I (no symptoms with ordinary activity) to Class IV (symptoms at rest) — which guides treatment intensity and prognosis assessment.
Causes & Risk Factors
The most common causes of heart failure in Singapore include coronary artery disease, hypertension, valvular heart disease, cardiomyopathy, and atrial fibrillation. Diabetes, obesity, chronic kidney disease, and obstructive sleep apnoea are important comorbidities that both precipitate and worsen heart failure. Acute decompensation — a sudden worsening requiring hospitalisation — is commonly triggered by uncontrolled hypertension, arrhythmia, infection, medication non-adherence, or dietary sodium excess.
Diagnosis
Diagnosis combines clinical assessment, biomarkers, and imaging. Elevated BNP or NT-proBNP confirms cardiac origin of symptoms and quantifies haemodynamic stress. Echocardiography is the cornerstone investigation — providing ejection fraction measurement, assessment of diastolic function, valve morphology, and wall motion. ECG identifies arrhythmias, conduction disease, and evidence of prior myocardial infarction. Chest X-ray assesses pulmonary congestion and cardiac silhouette. Cardiopulmonary exercise testing objectively quantifies functional capacity and guides advanced therapy decisions.
Treatment
- For HFrEF, the four pillars of guideline-directed medical therapy are an ACE inhibitor or ARNI (sacubitril/valsartan), a beta-blocker, a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and an SGLT2 inhibitor (dapagliflozin or empagliflozin). Each pillar independently reduces mortality and hospitalisation; combination therapy provides additive benefit. Sacubitril/valsartan and SGLT2 inhibitors represent the most significant pharmacological advances in heart failure management in the past decade and are now recommended as standard of care.
- For HFpEF, SGLT2 inhibitors have demonstrated mortality and hospitalisation benefit and are now recommended. Management additionally focuses on aggressive treatment of underlying comorbidities — hypertension, atrial fibrillation, diabetes, and obesity.
- Device therapy — cardiac resynchronisation therapy (CRT) for patients with reduced ejection fraction and bundle branch block, and implantable cardioverter-defibrillators (ICD) for those at high risk of sudden cardiac death — provides significant mortality benefit in selected patients. Diuretics manage fluid overload across all phenotypes.
- Advanced therapies — ventricular assist devices (VADs) and cardiac transplantation — are considered for end-stage heart failure refractory to optimal medical and device therapy.
Monitoring & Long-Term Care
Heart failure requires regular specialist follow-up to optimise medication doses, monitor renal function and electrolytes, assess volume status, and respond to symptom changes. Patients are educated to monitor daily weight — a weight gain of more than 2kg over two days signals fluid accumulation requiring prompt review. Cardiac rehabilitation improves functional capacity, reduces hospitalisation rates, and is recommended for stable heart failure patients.
Experiencing breathlessness, leg swelling, or recently diagnosed with heart failure? Dr. Peter Chang consults at Paragon Medical Centre, Orchard Road. Book a specialist assessment today.