Contributed by Dr Hong Rilong, Associate Consultant, Cardiology

Heart failure (HF) is a condition where inefficient pumping of the heart results in an inability to meet metabolic demands of the body. This may be due to structural damage or reduction in functional efficacy of the heart. In short, the heart has failed as the "engine of the body". It can lead to symptoms such as breathlessness (particularly during physical activity or even at rest), leg swelling, fluid retention and even sudden cardiac death.

HF affects about 4.5% of Singaporeans, more than twice the rate seen in the United States and Europe (1%–2%), making it a significant public health concern¹.

Upon hearing their HF diagnosis, many patients often view it as a "death sentence", expecting rapid health deterioration. While HF is a serious condition, it is manageable with proper treatment and lifestyle changes. The overall trajectory depends on a multitude of factors. In fact, in patients with chronic stable HF, the mortality rate is just 5.9% at 1-year compared to up to 27.7% in cases of worsening HF².

Figure: 1-Year Mortality in Different Heart Failure Presentations

Patients with worsening HF had the highest 1-year mortality at 27.7%, while those with new-onset acute HF had a 19.2% rate. In contrast, individuals with chronic stable HF experienced significantly better outcomes, with a 1-year mortality of only 5.9%. Data adapted from the IN-HF Outcome Registry (Tavazzi et. al., Circ Heart Failure. 2013)

Early Treatment Makes a Difference

Early treatment is crucial for patients with HF. This includes both guideline recommended medical therapy and treatment of the underlying cause of HF.

Common causes of HF include ischaemic heart disease, hypertensive heart disease, and valvular heart disease. Many of these share common risk factors such as smoking, diabetes, high cholesterol levels, high blood pressure - most of which should be carefully managed through regular check-ups with general practitioners. Smoking, in particular, should be stopped completely. For conditions such as coronary artery disease, heart rhythm disorders, heart valve disease, or heart muscle disease (cardiomyopathies), patients should work with their cardiologists for specialised care.

Treatment options have expanded significantly in the past decade. Therapy for HF with reduced ejection fraction (HFrEF), where the heart's pumping strength is reduced, has demonstrated clear reduction in mortality and morbidity. For these patients, four foundational therapies³ which include angiotensin receptor-neprilysin inhibitors (ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 (SGLT2) inhibitors are now used routinely as a part of standard care, as recommended by major international cardiac societies. These medications help relax blood vessels, slow the heart rate, remove excess fluid, and protect against further heart damage. Further progress has also been made in the field of artificial cardiac support, protein and gene modification that target specific cardiac conditions.

Managing Daily Life with Heart Failure

Staying Active

Exercise is especially important for patients with chronic medical conditions like HF. For those with stable HF, the general recommendation is 150 minutes per week of moderate intensity exercise. The right intensity can be gauged by a simple rule: being able to talk but not sing while exercising.

Keeping to a healthy diet

A balanced diet with daily salt intake kept under 2000mg is recommended (average Singaporeans consume around 3,620mg of sodium daily⁴). The best way to control salt intake is through home cooking. Familiarising oneself with local foods high in salt helps with making better choices – for instance, sliced fish beehoon, mee soto and curry contain a lot of salt!

Monitoring weight regularly

Self-monitoring of weight and fluid intake can help prevent unnecessary hospital visits. Daily weight checks help track water retention – a common issue in HF. A sudden weight increase usually indicates fluid retention rather than dry weight gain. Patients can learn to adjust their fluid intake or water pills (diuretic) accordingly. Monitoring signs such as lower limb swelling also helps manage the condition.

Know When to Seek Help

Recognising when to seek medical help is important, even with good daily self-care. Signs to watch out for would include worsening fluid retention that does not improve despite the above self-adjustments. For mild symptoms such as manageable breathlessness (able to take short walk) or lower-limb swelling, a visit to a general practitioner may be sufficient. However, if breathlessness occurs even at rest, prevents one from performing simple daily tasks, or is accompanied by persistently low blood pressure, these are signs that more urgent care is required at the hospital.

While HF is a serious condition affecting many people in Singapore, proper management through collaboration between patients and physicians can help control its symptoms, allowing many patients to continue to live long and fulfilling lives.

REFERENCES

1. Lam CSP. Heart failure in Southeast Asia: facts and numbers.ESC Hear Fail. 2015;2(2):46-49.doi:10.1002/ehf2.12036
2. Tavazzi L, Senni M, Metra M, Gorini M, Cacciatore G, ChinagliaA, Di Lenarda A, Mortara A, Oliva F, Maggioni AP; IN-HF(Italian Network on Heart Failure) Outcome Investigators.Multicenter prospective observational study on acute andchronic heart failure: one-year follow-up results of IN-HF(Italian Network on Heart Failure) outcome registry. Circ HeartFail. 2013 May;6(3):473-81. doi: 10.1161/CIRCHEARTFAILURE.112.000161. Epub 2013 Mar 8. PMID: 23476054.
3. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, ColvinMM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC,Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, KhazanieP, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC,Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW;ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSAGuideline for the Management of Heart Failure: A Reportof the American College of Cardiology/American HeartAssociation Joint Committee on Clinical Practice Guidelines.Circulation. 2022 May 3;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063. Epub 2022 Apr 1. Erratum in:Circulation. 2022 May 3;145(18):e1033. doi: 10.1161/CIR.0000000000001073. Erratum in: Circulation. 2022 Sep27;146(13):e185. doi: 10.1161/CIR.0000000000001097. Erratumin: Circulation. 2023 Apr 4;147(14):e674. doi: 10.1161/CIR.0000000000001142. PMID: 35363499.
4. Health Promotion Board. (2022). National Population HealthSurvey (NPHS).