Heart failure
Also called: congestive heart failure, CHF, cardiac failure, weak heart, HFrEF, HFpEF
Heart failure means the heart cannot pump blood around the body as well as it should. It does not mean the heart has stopped. It causes breathlessness, tiredness and swollen ankles. There is no cure, but modern medicines and good self-care help people feel better and live longer.
General health information for Pakistan. It does not give doses or brand advice. If you are worried, or symptoms are severe, see a doctor. When to see a doctor
Overview
Heart failure is a long-term condition in which the heart muscle is too weak or too stiff to pump blood properly. The name sounds frightening, but it does not mean the heart has stopped or is about to stop. Because blood is not moved forward well, fluid can build up in the lungs, legs and tummy. This causes breathlessness, swelling and tiredness.
Doctors describe heart failure by the ejection fraction (the share of blood the main pumping chamber pushes out with each beat). If it is 40% or less, this is heart failure with reduced ejection fraction (HFrEF, a weak pump). From 41% to 49% it is called mildly reduced, and 50% or more is preserved ejection fraction (HFpEF, a stiff heart that does not fill well). The type matters because the best medicines differ.
Heart failure often follows a heart attack, years of high blood pressure or coronary heart disease. It usually gets slowly worse over time, with spells when symptoms flare up and a hospital stay is needed. There is no cure, but current guidelines recommend a group of medicines that, used together, ease symptoms, keep people out of hospital and help them live longer. Taking these medicines every day, watching your weight and staying active are the keys to living well.
In Pakistan: what studies show
Hospital studies in Pakistan show heart failure is serious: in one Karachi hospital 11.7% of patients died during their stay, and at another Karachi centre 30.9% were back in hospital within 30 days. Not sticking to treatment was the most common reason for coming back (42.7%).
- At one tertiary hospital in Pakistan (Aga Khan University Hospital, Karachi), 172 of 557 people admitted with heart failure in 2020-2022 (30.9%) were readmitted within 30 days.[1] (cohort, data Jan 2020 - Dec 2022)
- In one hospital study at the National Institute of Cardiovascular Diseases in Karachi, 23 of 196 heart failure patients (11.7%) died during their hospital stay in 2022-2023.[2] (cross-sectional, data Jul 2022 - Jan 2023)
- In one hospital study in Abbottabad, 21% of people sent home after a heart failure flare-up were readmitted within 6 months, and 13% died before any readmission.[3] (cohort, data Apr 2023 - Aug 2023)
- At the National Institute of Cardiovascular Diseases in Karachi in 2021, the most common reason heart failure patients came back to hospital was not following their treatment (42.7%), followed by missing regular follow-up visits (39.4%).[4] (cross-sectional, data Feb 2021 - Aug 2021)
- In the same Karachi study of 307 heart failure patients in 2021, the average age was 59.20 years.[4] (cross-sectional, data Feb 2021 - Aug 2021)
- In one Peshawar hospital study of people admitted with worsening heart failure in 2011-2012, coronary artery disease (narrowed heart arteries) was the cause in 29.2%.[5] (cross-sectional, data Oct 2011 - Apr 2012)
- In the same Peshawar study, rheumatic heart disease (valve damage left by rheumatic fever) was the cause of heart failure in 13.7% of patients.[5] (cross-sectional, data Oct 2011 - Apr 2012)
- At one private hospital in Islamabad in 2013-2016, 248 of 336 heart failure patients who should have had a beta blocker (73.8%) were given one.[6] (cross-sectional, data Apr 2013 - Apr 2016)
What we do not know yet: No national heart failure registry or national survey for Pakistan was found, so all figures come from single hospitals, mostly in Karachi. Data on causes are more than ten years old, the only medicine-use data found predate the newest heart failure medicines, and readmission studies use different follow-up times, so they cannot be compared directly.
Pakistan studies cited
- Jitender K, Batool Z, Sethi SM, et al. Clinical Predictors of 30-Day Readmission after Heart Failure Hospitalization in a Low- and Middle-Income Country. Cardiology (Karger) 2026;published online 10 Jul 2026. doi:10.1159/000553526. Open source
- Sohail H, Khaliq K, Irfan G, et al. Comparison of In-Hospital Outcomes between Heart Failure Patients with Reduced and Preserved Ejection Fraction: A Single-Center Cross-Sectional Study. Pakistan Heart Journal 2024;57(01):33-37. doi:10.47144/phj.v57i1.2598. Open source
- Shams S, Khan MI, Afsar R, et al. The Rate and Time to First Readmission in Patients Discharged with a Diagnosis of Acute Decompensated Heart Failure Admitted to the Cardiology Department, Ayub Teaching Hospital, Abbottabad. Journal of Ayub Medical College Abbottabad 2024;36(4):686-691. doi:10.55519/JAMC-04-13550. Open source
- Lal D, Bai B, Bai P, et al. Factors Contributing to Re-Hospitalization in Heart Failure Patients at a Tertiary Care Center in Karachi, Pakistan. Pakistan Heart Journal 2024;57(3):219-224. doi:10.47144/phj.v57i3.2529. Open source
- Iqbal MA, Rauf MA, Khan N, et al. Frequency of etiological and precipitating factors in patients with acute de-compensated heart failure. Pakistan Heart Journal 2013;46(03):172-177. Open source
- Zafar R, Haris M, Assad S, et al. Core Measures for Congestive Heart Failure in a Tertiary Care Setting in Pakistan. Cureus 2016;8(8):e728. doi:10.7759/cureus.728. Open source
Symptoms
- Breathlessness during everyday activity, or more breathless than expected when you exercise
- Breathlessness when lying flat, so you need extra pillows or have to sit up at night
- Feeling very tired, weak or light-headed, especially after moving about
- Dizziness
- Swelling of the feet, ankles, legs or tummy, or feeling bloated
- Sudden weight gain over a few days, caused by fluid building up in the body
- A cough at night, or coughing up frothy pink phlegm (mucus)
Causes and risk factors
Causes
- Coronary heart disease (narrowed heart arteries), which reduces blood supply to the heart muscle
- A heart attack, which damages part of the heart muscle and can cause heart failure suddenly
- Long-term high blood pressure, which makes the heart work too hard for years
- Heart valve disease and cardiomyopathy (disease of the heart muscle itself)
- Heart rhythm problems, such as atrial fibrillation (an irregular, often fast heartbeat)
- Other illnesses that strain the heart, such as chronic kidney disease, anaemia, thyroid problems, haemochromatosis (too much iron in the body) or a serious infection
What makes it more likely
- Being aged 65 or over
- High blood pressure
- Diabetes
- Coronary heart disease or a past heart attack
- Being overweight or obese
- Smoking
- Drinking a lot of alcohol or using cocaine
- Pregnancy, which puts extra strain on the heart
Complications
Heart failure tends to come in waves, with flare-ups that often need a hospital stay. In Pakistan, missing medicines and chest infections are common triggers for these admissions. Fluid can fill the lungs suddenly (pulmonary oedema), which is an emergency. Irregular heart rhythms are common and can cause sudden death or blood clots. The kidneys may be affected, both by the heart failure and by some of its medicines, so blood salts such as potassium and sodium can go too high or too low. Many people also have iron deficiency or anaemia, which makes tiredness worse. Severe heart failure can affect memory and mood, and it shortens life, which is why early treatment matters.
When to see a doctor
- Severe difficulty breathing, such as gasping, choking or being unable to finish a sentence: get emergency help now
- Lips or skin that look pale, blue or grey (on darker skin, check the palms, soles of the feet or gums): get emergency help now
- Fainting, or someone who has collapsed and is not responding normally: get emergency help now
- Coughing up frothy pink phlegm
- New breathlessness when lying flat or during everyday activity
- Sudden weight gain over a few days or swelling that is getting worse: see your doctor the same day
Diagnosis
If heart failure is suspected, the first step is usually a blood test called NT-proBNP (a hormone the heart releases when it is under strain). A normal level makes heart failure unlikely. A raised level means you should see a heart specialist and have an echocardiogram (an ultrasound scan of the heart). UK guidance says this should happen within two weeks if the level is very high and within six weeks if it is moderately raised. The echocardiogram shows how well the heart pumps, measures the ejection fraction and checks the heart valves.
Other tests look for the cause and for things that make it worse. These usually include an ECG (heart tracing), a chest X-ray, blood tests for kidney, liver and thyroid function, blood count, iron levels, cholesterol and blood sugar, and a urine test. Breathing tests (spirometry or peak flow) help rule out lung disease. Some people need a heart MRI scan or other specialist tests.
Treatment
- Confirm the diagnosis and the type of heart failure with a blood test and an echocardiogram, and treat the cause, such as high blood pressure, blocked arteries, a valve problem or an irregular heartbeat.
- Use a water tablet (loop diuretic) to clear extra fluid and ease breathlessness and swelling. Your doctor adjusts it up or down depending on your weight and symptoms.
- For heart failure with reduced ejection fraction, start the main medicine groups together rather than one at a time: a renin-angiotensin blocker (an ACE inhibitor, an ARB, or sacubitril with valsartan), a beta blocker, a mineralocorticoid receptor antagonist (MRA) and an SGLT2 inhibitor. Your doctor decides which medicines and the dose, and raises the dose slowly.
- For mildly reduced or preserved ejection fraction, your doctor may use an SGLT2 inhibitor and an MRA, and sometimes the other medicine groups, while treating blood pressure, diabetes and atrial fibrillation.
- Have regular blood tests for kidney function and potassium, and blood pressure checks, after starting or changing these medicines and every few months when stable. Iron deficiency is checked and may be treated with iron given through a drip.
- If symptoms continue, a heart specialist may add other medicines such as ivabradine, hydralazine with a nitrate, or digoxin, or suggest a device such as a special pacemaker (cardiac resynchronisation therapy) or an implantable defibrillator (ICD).
- Join a cardiac rehabilitation (exercise and education) programme. For advanced heart failure, options include specialist referral, a heart pump or transplant, and palliative care to control symptoms.
Medicines in Pakistan
Medicines a doctor may use, by group. Each link opens our page for that medicine, with every brand and its official DRAP price. Your doctor decides which medicine and dose are right for you.
| Group | Role | Medicines |
|---|---|---|
| ACE inhibitors and angiotensin receptor blockers (ARBs) | core medicine for reduced ejection fraction; relax blood vessels and protect the heart. An ARB is used if an ACE inhibitor is not tolerated, and a specialist may switch to sacubitril with valsartan | Enalapril (37 brands), Lisinopril (21 brands), Ramipril (7 brands), Candesartan Cilexetil (4 brands), Valsartan (9 brands), Losartan (129 brands) |
| Beta blockers | core medicine for reduced ejection fraction; slow the heart so it works less hard. Started at a low dose and increased slowly by the doctor | Bisoprolol fumarate (127 brands), Carvedilol (13 brands) |
| Mineralocorticoid receptor antagonists (MRAs) | core medicine for reduced ejection fraction, also considered in other types; needs regular potassium and kidney checks | Spironolactone (11 brands) |
| SGLT2 inhibitors | core medicine for reduced ejection fraction and also used in mildly reduced and preserved ejection fraction; helps with or without diabetes | Dapagliflozin (14 brands), Empagliflozin (162 brands) |
| Loop diuretics (water tablets) | relieve breathlessness and swelling by removing extra fluid; used at the lowest dose that keeps fluid under control | Furosemide (35 brands) |
| Specialist add-on medicines | started on specialist advice: hydralazine with a nitrate if renin-angiotensin blockers cannot be used, and digoxin for severe symptoms despite other treatment | Hydralazine (5 brands), Isosorbide dinitrate (13 brands), Digoxin (10 brands) |
Also used (not yet in our price list): sacubitril with valsartan (an angiotensin receptor-neprilysin inhibitor, ARNI), ivabradine, intravenous iron
Self-care and prevention
Self-care
- Take your heart failure medicines every day, even when you feel well, and do not stop any of them without talking to your doctor
- Weigh yourself regularly and tell your doctor about a sudden rise, which can mean fluid is building up
- Stay active, and ask about a cardiac rehabilitation programme to learn how to exercise safely
- Eat a balanced diet and keep a healthy weight; ask your doctor whether you need to limit salt or fluids, as this depends on your situation
- Do not use potassium-based salt substitutes, because some heart failure medicines already raise potassium
- Stop smoking and avoid alcohol or keep it low
- Get a flu vaccine every year and a one-off pneumococcal (pneumonia) vaccine
- Show every doctor and pharmacist your medicine list, because some medicines, such as verapamil and diltiazem, are avoided in heart failure with reduced ejection fraction
Prevention
- Keep blood pressure under control
- Manage diabetes and cholesterol to protect the heart arteries
- Do not smoke, and avoid heavy drinking and cocaine
- Keep a healthy weight and stay physically active
- If you already have heart failure, take your medicines regularly and get vaccinated, since missed medicines and chest infections are common reasons for hospital stays
Common questions
Does heart failure mean my heart is about to stop?
No. Heart failure means the heart is not pumping as well as it should. It does not mean the heart has stopped or will stop soon. With treatment, many people live active lives for years.
Can heart failure be cured?
In most cases it cannot be cured, but it can be controlled. Guideline medicines ease symptoms, reduce hospital stays and help people live longer. If the cause can be treated, such as a valve problem or a very fast heart rhythm, the heart may improve, but medicines are usually still continued.
Why do I need so many medicines?
Each main medicine group protects the heart in a different way, and studies show they work best together. Your doctor starts them at low doses and builds them up over weeks. If a side effect bothers you, tell your doctor so the dose or medicine can be adjusted rather than stopped.
Should I stop drinking water or stop eating salt?
Not always. UK guidance does not advise routine strict limits on salt or fluid for everyone with heart failure. Your doctor may ask you to limit them if your blood sodium is low or you take in a lot. Avoid potassium-based salt substitutes.
Why should I weigh myself regularly?
A sudden rise in weight is often a sign that fluid is building up in the body, sometimes before you feel more breathless. Spotting it early lets your doctor adjust your water tablet and may prevent a hospital stay.
Sources
- NICE. Chronic heart failure in adults: diagnosis and management (NG106) (2018, updated 2025).
- ESC. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (2023).
- ACC. 2022 AHA/ACC/HFSA Heart Failure Guideline: Key Perspectives - American College of Cardiology (2022).
- NHS. Heart failure - NHS (2026 (accessed)).
- Pakistan Heart Journal. Factors Associated with Admission of Heart Failure Patients (2019).
- Journal of Cardiac Failure (Aga Khan University eCommons). Prognosis of hospitalized new-onset systolic heart failure in Indo-Asians--a lethal problem (2007).
Prepared from the sources listed below by the MedInfoBase team. Last reviewed 16 October 2026. This page is general health information, not medical advice. It gives no doses and does not replace a doctor: talk to your doctor or pharmacist before starting, stopping or changing any medicine. How we write and check our pages.
Related conditions
High blood pressure (hypertension)Coronary artery disease (angina)Atrial fibrillationType 2 diabetes mellitusIron-deficiency anaemia