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Heart Failure

Heart Failure - What it is

​Heart failure happens when the heart loses its ability to pump enough blood, leaving the organs and tissues with insufficient oxygen and nutrients to function properly. This could be due to a weak or stiff heart. In congestive heart failure, there is a build-up of fluid in the tissues (an oedema).

heart failure conditions & treatments

While heart failure can occur at any age, it tends to occur more frequently in elderly patients. In comparison to the Western population, the onset of heart failure in Singapore occurs earlier and at a younger age. The average age of onset is at 50 years old in Singapore, as compared to 60 years old in the West. A significant number of heart failure patients also have pre-existing medical conditions such as diabetes mellitus.

Classifying Heart Failure

Heart failure can be classified into two main groups: heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). The left ventricle ejection fraction, which measures how much blood gets pumped out per cardiac cycle, is an indicator of how well the heart is pumping and can be used to help classify heart failure and subsequently guide treatment. The assessment of the heart function can be performed using transthoracic echocardiogram or cardiac magnetic resonance imaging.

In HFrEF, the pump function of the heart is weak, and patients usually have a left ventricle ejection fraction of less than 40%. This could be due to coronary artery disease or hereditary conditions. In HFpEF, the systolic heart function is normal (left ventricle ejection fraction of 50% and above) but the heart muscle is stiff. Consequently, there is ineffective filling up and pumping of blood around the body. Stiffness of heart muscle can occur due to a variety of reasons such as ageing, long-standing high blood pressure or obesity.

Heart Failure - Symptoms

The symptoms of heart failure include:
  • Shortness of breath at rest or on exertion
  • Difficulty in breathing when lying flat
  • Persistent coughing or wheezing
  • Waking up breathless at night with dry hacking cough
  • Swollen ankles, legs or abdomen
  • Sudden weight gain
  • Tiredness and giddiness
  • Loss of appetite or nausea
  • Palpitation (increased heart rate)

Heart Failure - How to prevent?

Heart failure is highly preventable, and many of its common causes can be avoided with simple lifestyle changes.

Adopt a healthy lifestyle to prevent and control risk factors (diabetes mellitus, hypertension, hyperlipidemia, smoking and obesity) for coronary artery disease which is the commonest cause for heart failure. The risk of developing heart failure can also be lowered a healthy diet and regular exercise.

Other ways to prevent heart failure include:
  • Maintain a healthy weight: Target to have a BMI (Body Mass Index) between 18.3 to 22.9 kg/m2, and a waist circumference of equal or less than 80cm (for women) and 90cm (for men)
  • Eat a balanced diet which is rich in fresh fruits and vegetables
  • Reduce salt intake
  • Avoid excessive alcohol intake
  • Keep your cholesterol, blood pressure and blood sugar levels at healthy levels. Read more on cholesterol management and high blood pressure (hypertension) management,
  • Quit smoking (if you are a smoker)
  • Go for regular medical check-ups
  • Keep chronic conditions in check
  • Manage your stress levels

Heart Failure - Causes and Risk Factors

The most common causes of heart failure are:

  • Coronary heart disease and heart attack (which may be “silent”): In coronary heart disease, the arteries supplying blood to the heart become narrowed or blocked. A heart attack happens when blood flow to an area of the heart is completely blocked. The heart muscle suffers damage when its blood supply is reduced or blocked. If the damage affects the heart’s ability to pump blood, heart failure develops.
  • Cardiomyopathy (disease of the heart muscles): It may be caused by coronary artery disease and various other heart problems. It can weaken the heart muscle, leading to heart failure.
  • High blood pressure (hypertension): Hypertension, a common cause, makes the heart work harder to pump blood. When it cannot keep up, heart failure symptoms develop.
  • Other causes: heart valve disease and postchemotherapy complications: Defects of the heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure.

Heart failure can be precipitated by several events. The common precipitating factors are:

  • Poor compliance to salt restriction, fluid restriction or medications
  • Heart attack
  • Worsening heart valves condition
  • Abnormal heart rhythm
  • Medical stress from infection, surgery or anemia

Heart Failure - Diagnosis

The diagnosis of heart failure is based on:

  • Symptoms: Symptoms can provide important clues to the presence of heart failure. Shortness of breath while engaging in activities and episodes of shortness of breath during sleep are classic symptoms of heart failure

  • Physical examination: The physician listens to the heart and lungs with a stethoscope for tell-tale signs of heart failure, such as irregular heart sounds, a rapid heart rate and murmurs of the heart valves. If there is fluid in the lungs, crackling sounds may be heard. Rapid breathing or other changes in breathing may also be present. Patients with heart failure may also have a rapid pulse.

    By pressing on the abdomen, the physician can feel if the liver is enlarged. The skin of the fingers and toes may have a bluish tint and feel cool if not enough oxygen is reaching them.

  • Chest radiograph: Chest radiographs can show if there is fluid in the lungs or if the heart is enlarged. Abnormalities of heart valves and other structures also may be seen.

  • Electrocardiogram (ECG; also called EKG): An electrocardiogram gives information on the heart rhythm and and evidence of previous heart attack.

  • Other imaging tests:
    • Echocardiography can show if the heart wall or chambers are enlarged and if there are abnormalities of the heart valves. An echocardiogram can be used to find out how much blood is being pumped out of the heart chambers.
    • Magnetic Resonance Imaging can supplement the finding of echocardiogram and is excellent for cardiac tissue characterisation.

  • Cardiac catheterisation: is used to measure pressure in the heart and the amount of blood pumped by the heart. This test can help find abnormalities of the coronary arteries, heart valves, heart muscle, and other blood vessels. Combined with echocardiography and other tests, cardiac catheterisation can help find the cause of heart failure.

Heart Failure - Treatments

Heart failure is usually treated with lifestyle changes and medicines.

Lifestyle changes

Dietary changes to maintain proper weight and reduction of salt intake may be needed. Reducing salt intake helps to lessen swelling in the legs, feet and abdomen. Other lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption and not using harmful drugs.

Appropriate exercise such as walking, cycling, swimming, or low-impact aerobic exercises may be recommended, but it is important that heart failure patients only begin an exercise programme with the advice of their doctors. The National Heart Centre Singapore offers good Cardiovascular Rehabilitation and Preventive Cardiology Programme for patients identified to have multiple risk factors for heart disease or who have just undergone open-heart surgery.

Heart surgery

Surgery may be needed to correct abnormalities of the heart or heart valves that cause heart failure. Congenital heart defects and abnormal heart valves can be repaired with surgery. Blocked coronary arteries can usually be treated with angioplasty or coronary artery bypass surgery.

Heart devices or transplants

Severe or end-stage heart failure may result in heart muscles so damaged that available treatments will not help. When all other treatments do not work, patients are usually considered for mechanical assist devices and heart transplantation.

National Heart Centre Singapore (NHCS) Heart Failure Clinic

The clinic adopts a team approach to treat heart failure through a structured outpatient programme to prolong survival, improve quality of life and reduce hospital admissions. A specialist nurse clinician is on hand to provide phone consultations to patients.

Learn more on our Heart Failure Programme here.

Heart Failure - Preparing for surgery

Heart Failure - Post-surgery care

Heart Failure - Other Information

What happens in advanced heart failure?

Advance Care Planning is important for heart failure patients to make plans about their future health care, especially when they are not in a position to make or communicate their healthcare choices. Shared decision-making among patients, their families, and the medical team in establishing the goals of care should be initiated early.

Unlike cancer patients, some heart failure patients can experience an unpredictable pattern of decline. Learn more on Advance Care Planning at NHCS here.


Videos on heart failure:


Living with Heart Failure



心脏衰竭患者 / Living with Heart Failure (Chinese version)


Health Management Guide for Heart Failure

Read our guide here.

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