Weak Heart Muscle (Heart Failure): Symptoms & Treatment

A weak heart muscle is what doctors call heart failure: the muscle no longer pumps enough blood to meet the body's needs. It is serious, and it is treatable. This page explains the symptoms, the causes, the ejection fraction, and when the condition becomes dangerous.

It is one of the most common heart conditions, and many people who have it live a near-normal life, provided it is picked up early and they stay on their treatment and keep their follow-up appointments. What it will not tolerate is neglect, because it can get worse within hours. So this page sets out how it is diagnosed and how it is treated, and sets out just as plainly the signs that mean the situation is an emergency, one that must not wait for a clinic appointment.

The first thing a patient and their family need is the correct name for the condition, because it is the same name they will find written on the echocardiogram report and on the prescription, and the same name they will hear from the cardiologist.

What is a weak heart muscle?

The heart is a muscular pump: with every beat the left ventricle fills with blood and then squeezes to push it out to the rest of the body. When the heart muscle is weak, this pump works less efficiently, so the organs receive less blood than they need and fluid builds up in the lungs and the legs. That is where most of the symptoms come from: breathlessness, swelling and fatigue.

The medical name for the condition

What people call a weak heart muscle is what doctors call heart failure. On a report or a prescription you may also see it written as congestive heart failure (CHF), cardiac failure, or cardiac insufficiency. The word "failure" frightens people far more than it should: it does not mean the heart has stopped, and it does not mean the heart is about to stop. It means the heart is not pumping as strongly as the body needs.

Heart failure is, at root, a description of what happens when the heart cannot pump enough for the body's needs, rather than the name of one single disease. Weak pumping is sometimes picked up on an echocardiogram before the person has complained of anything at all, and that situation needs treatment and follow-up too. It is not left alone simply because the person "does not feel anything".

If the root of the problem is a disease of the heart muscle itself, and not the arteries, the valves or blood pressure, your doctor will call it a cardiomyopathy. Put more simply: heart failure describes what the heart's performance has become, and a cardiomyopathy is one of the causes behind it.

Keep hold of both names. They are what let you read your own medical report, understand what is written on your prescription, and look up reliable information about your own condition rather than about heart disease in general.

Ejection fraction (EF): the number written on your echocardiogram report

During an echocardiogram (an ultrasound scan of the heart) the doctor measures how much of the blood in the left ventricle is pushed out with each beat, compared with how much blood had filled it beforehand. That proportion is called the ejection fraction, shortened to EF, and it is the same thing people mean when they ask about "the heart's pumping percentage" or "the efficiency of the heart muscle". No heart empties itself completely with any single beat, even a healthy one, which is why a normal EF is not 100%.

• Most reports give the normal range as roughly 55% to 70%, and 50% or above still counts as preserved pumping. Every report carries its own reference range, so read your number against the range printed on your own copy.
• A number below normal means the muscle is pushing out less blood with each beat, and this is what is usually meant by a weak heart muscle.
• Doctors sort the condition by this number into three groups: reduced ejection fraction (around 40% or less), mildly reduced (between 41% and 49%), and preserved (50% or above). This grouping identifies which type you have and which treatment plan follows from it. It is not a grade of how dangerous the condition is for you.
• A normal or near-normal number does not rule out heart failure. One form of it happens with the ejection fraction preserved, and that form is explained just below.
• No single number can be called "dangerous" on its own. Your doctor reads the number together with your symptoms, the cause of your condition, the rest of your tests, and the direction the number has been moving over time.
• The number does not decide how you feel. Some people have a low number and get through the day with barely a complaint; others have a near-normal number and obvious breathlessness.
• The number is not a final verdict. In many cases it improves once you stay on your treatment and the cause is brought under control, and that improvement can take months to show. In other cases the number stays where it is, and treatment is still worth taking because it eases the symptoms and protects against getting worse.
• And if the number does improve, that is not permission to stop your medication. Stopping treatment after the number improves is a well-known reason for the weakness to come back, and the decision to change any medicine belongs to your doctor alone.
• A small difference between one echo and the next — a few points — may be a difference in measurement between one machine or one operator and another rather than a real change in your condition, so do not make a decision of your own on the strength of it.

What is the difference between a weak heart muscle and a stiff heart muscle?

Confusing the two is very common — so common that many people use the two names as though they meant one thing. They do not. The difference is essentially the difference between a pump that pushes weakly and a pump that does not fill as it should:

• A weak heart muscle: the problem is in the squeeze, that is, in pushing the blood out. The muscle contracts with less force, so less blood leaves the ventricle with each beat and the ejection fraction is low. Doctors call this heart failure with reduced ejection fraction (HFrEF).
• A stiff heart muscle, which patients often call a "relaxed" or "lax" heart muscle: the problem is in the filling. The muscle becomes stiffer and less elastic, so it does not relax properly between beats and does not fill with enough blood, while the ejection fraction stays normal or close to normal. The everyday name is misleading: it points at the relaxation phase between beats, and the problem is precisely that the muscle does not relax in that phase as it should. On an echocardiogram report you will most often see it written as diastolic dysfunction, and when it comes with symptoms doctors call it heart failure with preserved ejection fraction (HFpEF).

The everyday word "relaxed" is not precise: some people use it to mean enlarged heart chambers with a weak squeeze, which is the first condition and not the second. So this is not settled by a name you heard from someone else. It is settled by what is written on your echocardiogram report and by your doctor's reading of it.

Both are forms of heart failure, and finding a "relaxation" problem does not mean the condition is milder or that it needs no follow-up. The symptoms a patient complains of can be exactly the same in both — breathlessness, swelling and fatigue — so neither a description of the symptoms nor a blood test separates them. The echocardiogram is the test that tells them apart, alongside your doctor's reading of the rest of the clinical picture.

This distinction is not a theoretical detail: the treatment and follow-up plan differ between the two, and what helps a weak squeeze is not the same as what helps a stiff muscle. That decision belongs to the cardiologist after seeing the echocardiogram report.

And watch out for a third term that is often mixed up with the two above: a lax or prolapsing heart valve is something entirely different. It concerns one of the heart valves and not the heart muscle, and it has its own assessment and its own follow-up.

What are the symptoms of a weak heart muscle?

Most of the symptoms of a weak heart muscle — what doctors call heart failure — come back to one simple explanation: the muscle can no longer push blood forward with enough force, so blood banks up behind it and fluid leaks out of the vessels into the lungs, the legs and the abdomen. The kidneys make it worse, because they respond to the weak pumping by holding on to salt and water, so the volume of fluid in the body rises further, while the muscles and the brain still receive less oxygen-carrying blood than they need. Understanding why each symptom happens is not just theory: a patient who knows what is going on in their own body describes it accurately to the doctor, and an accurate description gets you to the diagnosis faster.

It matters to know that almost exactly the same symptoms appear in the other condition, the one people call a “relaxed” heart muscle, in which the muscle becomes stiff and cannot fill with blood rather than being unable to pump it out. In other words, you cannot tell the two apart from your symptoms alone. What separates them is an echocardiogram (an ultrasound scan of the heart), which measures how well the heart is pumping — and the difference between the two is explained separately elsewhere in this guide.

The symptoms do not all appear at once. They usually build slowly over weeks or months, until you get used to them and put them down to getting older or to being worn out by work. So compare yourself today with yourself six months ago, not with the people around you.

Breathlessness on exertion, and later at rest

This is the best known symptom and usually the first to appear. It is caused by fluid collecting in the blood vessels of the lungs behind the weakened heart, which makes it harder for oxygen to reach the blood. The clearest way to keep track of it is to follow how much effort it takes to bring it on:

• Early on: breathlessness with relatively heavy effort, such as climbing two flights of stairs, carrying heavy bags, or walking at a brisk pace.
• As the condition progresses: the same breathlessness appears with far less effort — walking on level ground, getting dressed, or taking a shower.
• In the advanced stages: breathlessness while you are sitting or lying down, with no effort at all. If breathlessness at rest appears for the first time, see your doctor the same day; and if it is severe, or it stops you finishing a full sentence, it is an immediate emergency, as set out in the section that follows.

Breathlessness when lying flat, and waking at night gasping for air

When you lie down, the fluid that has pooled in your legs returns to the circulation and to the chest, and the lungs become more congested. So you find that you now need an extra pillow, then two, and eventually you sleep almost sitting up. You may wake an hour or two after falling asleep, gasping and feeling as though you are suffocating, and have to sit up or stand by an open window. It does not pass straight away: your breathing usually takes around half an hour to settle, and that detail in particular is one a cardiologist will ask you about. The number of pillows you sleep on is important information for your doctor, so tell them, and tell them as well if that number has gone up recently.

Swollen feet and ankles, and a bloated abdomen

Fluid the heart cannot push forward leaks into the tissues, and gravity collects it in the lower parts of the body. These are signs you can look for yourself at home:

• Swelling of the feet, ankles and legs that gets worse by the end of the day and settles after a night's sleep.
• Press your thumb into the shin bone for a few seconds and it leaves a dent that is slow to fill back in.
• Shoes that used to be comfortable now feel tight, or a sock leaves a deep mark on the leg that is still there after you take it off.
• A bloated abdomen, or a heavy, full feeling under the ribs on the right side, from fluid congesting the liver.
• In someone who spends most of the day in bed, the swelling may show over the lower back instead of the feet.

Other symptoms that are often misread

• Tiredness and a drop in what you can manage: the muscles are not getting the blood they need, so the legs feel heavy and the tiredness is not lifted by rest or by sleep.
• Palpitations or an irregular heartbeat: a struggling heart tries to compensate by beating faster, and the weak muscle itself makes rhythm disturbances more likely.
• A persistent cough or a wheeze in the chest: caused by congestion in the lungs. It often gets worse at night or on lying down, and is frequently misread as a chest allergy or as repeated colds. A persistent dry cough can also sometimes be a well-recognised side effect of one class of heart medicines (the angiotensin-converting enzyme inhibitors, written ACE inhibitors on most prescriptions and reports) — in that case tell your doctor, so that they can decide on an alternative; do not stop the medicine yourself.
• Poor appetite and feeling full after a few mouthfuls: fluid congesting the liver and the intestines presses on the stomach, and it may come with nausea or discomfort after eating.
• Passing urine often at night: lying down returns the fluid from the legs to the circulation, so more blood reaches the kidneys, they produce more urine, and you wake repeatedly to go to the bathroom.
• Dizziness or trouble concentrating: from reduced blood flow to the brain, and the dizziness is worse when you stand up suddenly. It can sometimes come from the heart or blood pressure medicines themselves, and the right response is to show it to your doctor so the treatment can be adjusted — not to stop the medicine yourself.
• A sudden gain in weight over a few days: this is retained fluid, not fat. It is the earliest warning available to you, and how to track it is set out in the daily weight section below.

In older people the picture can be completely different: breathlessness may not be obvious at all, and what shows instead is confusion, drowsiness, repeated falls, going off food, or a general decline in activity. An older person who is going downhill for no clear reason deserves to have the heart assessed, rather than having it all put down to age.

One symptom on its own does not necessarily mean the heart muscle is weak, since breathlessness and swelling have many other causes. But several of them together — particularly breathlessness on exertion, breathlessness when lying flat, and swollen feet — call for a visit to a cardiologist for the necessary tests.

When is a weak heart muscle an emergency?

A weak heart muscle — or heart failure, as doctors call it — is a long-term condition you can live with for many years with regular follow-up. But it can also deteriorate suddenly, within hours, as the lungs fill rapidly with fluid. That kind of acute deterioration is not managed at home and does not wait for a clinic appointment, and delay is exactly what turns a treatable situation into a critical one. Read the signs below before you need them, and show them to whoever lives with you, because a patient who is deteriorating may not be in any state to judge their own condition.

Go to the nearest emergency department at once — or call an ambulance — if any of the following happens:

• Severe breathlessness while you are sitting or resting, or being unable to finish a full sentence without stopping for breath.
• A cough that brings up frothy sputum, or sputum that is pink or streaked with blood.
• Pain, pressure or heaviness in the chest, or pain that spreads to the arm, the neck, the jaw or the back.
• Fainting, or a strong feeling that you are about to lose consciousness.
• A very fast or irregular heartbeat that does not settle after rest.
• Sudden confusion, difficulty rousing the patient, or unusual drowsiness and lethargy.
• Cold skin with a clammy sweat, pallor and a racing pulse.
• Blue lips or fingertips.
• Sudden weakness down one side of the body, a drooping face, or slurred speech — heart patients are at higher risk of stroke, and that too is an emergency that cannot wait.
• If you have an implanted defibrillator and it delivers a shock while you are having symptoms, or delivers more than one shock.

Do not drive yourself in any of these situations, do not wait for the morning or for your clinic appointment, and do not take an extra dose of any medicine on your own in the hope that the symptoms will settle. Take your current medication list and your most recent heart reports with you if you have them, because they save the medical team a great deal of time.

Signs that are not an emergency but do mean seeing your doctor early

• A rapid gain in weight, or a clear increase in swelling of the feet or bloating of the abdomen.
• Needing an extra pillow to sleep, or waking at night short of breath after your sleep had been settled.
• Breathlessness with an effort you were managing easily only a few weeks ago.
• Repeated dizziness, or a clear drop in your ability to move about and get through your normal day.
• A new cough, or a persistent wheeze without an obvious cold.

These are signs of a gradual decline, and dealing with them early with your doctor is usually what keeps you out of the emergency department altogether.

Daily weight: the most important habit for anyone with a weak heart muscle

The body starts holding on to fluid two or three days before the breathlessness appears, and the scales show it before you feel anything at all — because every litre of retained fluid registers as one kilogram on the scales. That is what makes a daily weight, written down, the simplest and most useful form of home monitoring in heart failure — the doctors' name for a weak heart muscle — and it costs you one minute every morning.

How to weigh yourself properly

• At the same time every morning, straight after you wake up.
• After going to the toilet, and before eating or drinking anything.
• In roughly the same clothes — or as little clothing as you can — and with no shoes on.
• On the same scales and in the same place, on a hard, level floor rather than on a carpet.
• Write the number down with the date in a small notebook or on your phone, and take that record with you to every visit to the doctor.

When does a gain become a warning?

What matters is a rapid gain, not a slow one over months. A gain of more than one kilogram in a single day, or of more than two kilograms over three days, means your body is retaining fluid, even if you feel perfectly well. When that happens, see your doctor early: do not wait for your follow-up appointment and do not wait until the breathlessness starts, because fluid retention is far easier to deal with at the beginning than after the chest has filled. Equally, a rapid drop in weight together with dizziness, a dry mouth or a clear reduction in the amount of urine you pass is worth reporting to your doctor too, because it may mean the body has lost more fluid than it should have.

Common reasons for a sudden gain like this include: too much salt, pickles and processed food; drinking more fluid than your doctor has allowed; or taking the ordinary painkillers that belong to the non-steroidal anti-inflammatory class (NSAIDs), which are sold over the counter without a prescription, cause fluid retention, raise blood pressure and blunt the effect of heart medicines. Be aware, too, that this same class is hidden inside many cold and flu remedies, back and joint pain medicines and painkilling injections, so ask your doctor or your pharmacist about a painkiller that is safe for your heart before you buy anything on your own.

And whatever the scales read, do not change the dose of any medicine and do not stop it on your own, not even if you feel completely well — the improvement you feel is the medicine working, and stopping heart medicines suddenly can lead to a rapid deterioration. Adjusting doses is a medical decision, and the only exception is where your doctor has already given you specific written instructions about your diuretic (water tablet) for when your weight goes up. And remember that diuretics reduce the fluid and the symptoms and make breathing easier, but they do not strengthen the heart muscle in themselves; real improvement in how well the muscle works comes from the other core medicines your doctor prescribes, and from taking them faithfully every day.

Causes of a weak heart muscle

A weak heart muscle is the everyday name for the condition doctors call heart failure, and you may also see it written on your report as congestive heart failure. The word “failure” frightens people far more than it should: it does not mean the heart has stopped, and it does not mean it is about to stop. It means the force with which the heart pumps is no longer enough for what the body needs. When the problem lies in the heart muscle itself — not in the arteries, the valves or the blood pressure — the condition is called a cardiomyopathy, which is one of the routes to heart failure rather than another name for it.

What matters most is that heart failure is not a single, standalone disease. It is where the heart ends up after years of being overworked by something else, or after an injury that damages it quickly. That is why the first question a cardiologist asks is not only “is the muscle weak?” but “what weakened it?” The treatment plan changes with the cause, and some causes, treated early enough, can be followed by a marked improvement in the efficiency of the muscle.

These are the most common causes.

• Narrowed coronary arteries and a previous heart attack: the first and commonest cause. When the artery that feeds the heart muscle narrows, or blocks suddenly, part of the muscle loses its blood supply and turns into scar tissue that no longer contracts; the rest of the muscle then carries the whole load, and the pumping efficiency falls. A heart attack can sometimes pass without obvious pain — which happens often in people with diabetes, in older people and in women — so its mark is only discovered later, when the heart is examined for some other reason.
• Long-standing, uncontrolled high blood pressure: this forces the heart to pump against high resistance every day for years. The wall of the heart thickens and stiffens first, so the muscle finds it harder to relax and fill, and the strength of its squeeze may fall later on. It is the commonest route to the stiff-muscle pattern of heart failure, in which the muscle fills poorly while the ejection fraction stays normal or near normal. The danger is that high blood pressure usually causes no symptoms at all, so many people reach the doctor only after the pressure has already left its mark on the muscle.
• Heart valve disease: a narrowed valve makes the heart push blood out through an opening smaller than it should be, and a leaking valve sends part of the blood backwards with every beat. Either way the heart works under an extra load that wears it down over the years. Many of these problems can be treated by surgery or by a catheter procedure, and timing is what makes the difference: treating the valve at the right moment often protects the strength of the muscle, while some weakness can remain even after the valve is repaired or replaced if the delay has been a long one.
• Viral inflammation of the heart muscle (myocarditis): a passing viral infection can reach the muscle itself, inflaming and weakening it over days or weeks, and this can happen to a young person who has never had any heart trouble. Many of these cases improve with time, treatment and follow-up; some leave behind a weakness that needs long-term treatment. A few begin severely and move fast, which is why severe breathlessness, chest pain, fainting or a fast, irregular pulse after a viral illness is not something to wait out — it needs to be assessed immediately.
• Cardiomyopathy of pregnancy and childbirth (peripartum cardiomyopathy): uncommon, but important. It appears in the last month of pregnancy or during the first months after delivery. The difficulty is that its symptoms — breathlessness, swollen feet, overwhelming tiredness — overlap with the ordinary complaints of late pregnancy and the weeks after birth, so the diagnosis is delayed. Breathlessness on lying flat, swelling that increases instead of settling after delivery, or exhaustion that blocks the simplest task deserves an assessment of the heart rather than being explained away as normal tiredness. Two things should always be said. First, the choice of medicines is different during pregnancy and breastfeeding, and a woman must tell every doctor treating her that she is pregnant or breastfeeding before any medicine is dispensed. Second, the condition can return in a later pregnancy, so a new pregnancy is planned with the cardiologist and the obstetrician together beforehand, not afterwards.
• Diabetes: it damages the large and the small arteries alike, and it acts directly on the cells of the heart muscle and on their ability to contract and to relax. A person with diabetes is more likely to develop heart failure even without ever having had a heart attack, particularly when the diabetes has been present for many years and the blood sugar is not well controlled.
• Thyroid disease: an overactive thyroid keeps the heart racing until it is worn out, while an underactive thyroid slows the pulse and weakens the force of the squeeze. This cause is missed surprisingly often, even though a simple blood test reveals it, and bringing the thyroid back under control can return a good part of the muscle’s efficiency.
• Heart rhythm disorders: a fast pulse that continues for weeks or months — as in uncontrolled atrial fibrillation — drains the muscle and weakens it gradually. This is one of the causes that responds best to treatment: in many cases the pumping efficiency improves once the rhythm is restored or the rate is slowed.
• Alcohol and certain toxic substances: drinking heavily for years poisons the cells of the heart muscle and weakens it directly, and so do some stimulant recreational drugs, which raise the blood pressure, speed the pulse and damage the muscle even at a young age. The same goes for anabolic steroids and the muscle-building injections and powders traded in gyms without any medical supervision, which are a known cause of cardiomyopathy in young people who were perfectly healthy beforehand.
• Some cancer treatments: chemotherapy drugs of the anthracycline class, some targeted therapies, and radiotherapy to the chest area can all affect the heart muscle, either during treatment or years afterwards. This is never a reason to refuse treatment or to stop it on your own. It is a reason to have an echocardiogram before treatment starts and follow-up scans afterwards, and to make sure your cardiologist knows your history of chemotherapy or radiotherapy even if years have passed.
• Inherited and family causes: some types of cardiomyopathy run in families. More than one relative with a weak heart muscle, or a sudden death at a young age in the family, is reason enough to have first-degree relatives screened even when they have no symptoms at all.
• Less common causes that still occur: severe, persistent anaemia; chronic kidney disease; iron overload in the body; amyloid protein deposited in the muscle; sarcoidosis; sleep apnoea left untreated for years; congenital heart defects; and chronic lung disease, which loads the right side of the heart.
• Cases with no identified cause: in a fair proportion of patients no cause is found even after the full set of tests, and the condition is then called idiopathic cardiomyopathy. That does not make it mysterious or untreatable: treatment and follow-up run on exactly the same lines even when the cause is never pinned down.

More than one cause can be present in the same person — high blood pressure together with diabetes and a previous heart attack, for example — and in practice this is the usual picture. That is why the treatment plan is built on the whole picture and not on a single cause.

Risk factors for a weak heart muscle

A risk factor is not a direct cause, but it raises the chance that the muscle will weaken, or that it will get worse faster once it already has. They fall into two groups here, because you deal with them differently: one group you can genuinely change, starting this week, and one you cannot change at all — but knowing about it is what makes your follow-up regular instead of occasional.

Risk factors you can do something about

• Uncontrolled high blood pressure: the most important of them all, and the one that responds best to treatment and regular follow-up.
• Uncontrolled diabetes: keeping blood sugar in range protects more than the nerves and the kidneys; it protects the heart muscle too.
• High cholesterol and blood fats: they pave the way to narrowed coronary arteries, and narrowed coronary arteries are in turn the leading cause of a weak heart muscle.
• Smoking in every form: cigarettes, the waterpipe (shisha) and e-cigarettes alike. All of them damage the lining of the arteries and cut the oxygen reaching the muscle.
• Excess weight and inactivity: both add to the load on the heart, and both push up blood pressure, blood sugar and blood fats at the same time.
• Too much salt: in processed food, pickles, tinned food, stock cubes and instant soup. Salt increases fluid retention and raises blood pressure, and it is one of the quickest of these factors to respond when you change it, and one of the clearest in its effect.
• Alcohol: drinking heavily and continuously weakens the heart muscle directly — it can do so on its own, with no other cause present.
• Anabolic steroids and sports performance enhancers: bought and used with no medical supervision at all, they damage the heart muscle and raise blood pressure — and they do so at a young age, in people who look to be at the peak of their fitness.
• Sleep apnoea: suspect it if there is loud snoring, gasping or choking during sleep, and heavy daytime sleepiness. It is common and it is treatable, and leaving it alone loads the heart night after night.
• Painkillers of the non-steroidal anti-inflammatory class: these are the ordinary painkillers bought in Egypt without a prescription and used for back pain, joint pain, headache, period pain and colds. They make the body hold on to salt and water, they raise blood pressure, they add load to a heart that is already weak, they blunt the benefit the heart gets from some of its own medicines — the diuretics among them — they strain the kidneys, and they can push someone with a weak heart muscle into a sudden deterioration with increased swelling and breathlessness. The practical rule is this: do not take any painkiller — tablets, effervescent sachets, injections, or even some of the creams and gels rubbed on the skin, and likewise the combined cold and flu remedies — before you ask your doctor which alternative is right for you.
• Stopping or adjusting your medicines yourself: a great many people stop their treatment when they start feeling better. In this condition, feeling better is evidence that the medicine is working, not evidence that you no longer need it. So do not stop a prescribed medicine, do not change a dose, and do not add any medicine, supplement or herb, except on your doctor’s decision.
• Not keeping up with follow-up: when follow-up lapses, deterioration goes unnoticed until it arrives as a crisis. Weighing yourself daily and writing the number down, and measuring your blood pressure at home, are among the simplest ways of catching that deterioration early.

Risk factors you cannot change — but knowing them changes your follow-up plan

• Getting older: it becomes commoner with age, because of natural changes in the elasticity of the heart and the arteries.
• Family history: a parent or a sibling with a weak heart muscle, or an early sudden cardiac death in the family.
• A previous heart attack, catheter procedure or heart surgery: a muscle that has been damaged once needs regular follow-up even after a successful procedure.
• Your sex (male or female): men are more prone to a loss of pumping strength at younger ages, while women are more prone to the pattern in which the muscle stiffens and struggles to relax and fill, particularly after the menopause and alongside high blood pressure or diabetes.
• A previous pregnancy complicated by a heart problem, by pregnancy-related high blood pressure, by pre-eclampsia or by gestational diabetes: this raises the chance of heart problems later on, and it is worth telling your cardiologist about even years afterwards.
• Chronic kidney disease: the heart and the kidneys each affect the other, and weakness in one adds load to the other.
• Chemotherapy in the past, or radiotherapy to the chest: both call for regular heart check-ups even years after the treatment has ended.
• Autoimmune and chronic inflammatory disease: some of these come with continuous inflammation in the blood vessels and in the heart muscle.

Having one risk factor or two does not mean the illness is inevitably on its way, just as having none of them does not rule it out completely. But several together — high blood pressure, diabetes and smoking in particular — make a regular cardiac check a necessity rather than a luxury, even before any symptom appears.

How is a weak heart muscle diagnosed?

A weak heart muscle cannot be confirmed or ruled out on symptoms alone, because breathlessness, swelling and exhaustion are shared by many conditions that have nothing to do with the heart: lung disease, kidney disease, thyroid disorders and anaemia. Nor is an ECG on its own enough, and nor is a blood test on its own. So the diagnosis moves in steps: the doctor starts by asking and examining, then requests tests that each fill in what the others cannot, and ends by answering two questions — is the muscle weak, and what made it weak? Most of these tests are simple, quick and painless, and what follows is what you will actually go through in each one. If your breathlessness is severe, though, or came on suddenly while you were resting, that is an emergency: it needs to be assessed straight away and it does not wait for tests to be booked.

The clinical examination: always the starting point

The doctor asks about the nature of your breathlessness and when it comes on, how many pillows you sleep on, whether an attack of breathlessness wakes you at night, about swelling of the feet and changes in your weight, and about your long-term conditions, your current medicines and your family history. Then the doctor measures your blood pressure and pulse, listens to your heart and lungs, looks at the veins in your neck, presses gently on your legs to see the mark that swelling leaves, and may feel your abdomen. All of this takes only minutes and causes no pain, but it is what decides which tests are requested and how urgently.

At this stage the doctor also grades how severe your symptoms are by how much effort brings the breathlessness on — from strenuous effort, to ordinary effort such as climbing stairs, to light effort such as walking around the house, to breathlessness while resting. You may find this grade written in your report as a Roman numeral from I to IV. It describes how you are today rather than passing a fixed judgement, and patients often move to a milder grade with treatment and by sticking to it.

The echocardiogram: the central test, and the one that measures the ejection fraction

The echocardiogram — an ultrasound scan of the heart — is at the centre of the diagnosis in this condition, and the treatment plan is built on it. It is central because it is the test that measures the ejection fraction, the heart’s pumping percentage, the number most people have in mind when they talk about the efficiency of the heart muscle. It is the percentage of the blood sitting in the left ventricle that the heart pushes out with each beat, compared with what was inside it just before, and it appears on your echo report as Ejection Fraction, usually shortened to EF. This is the number the doctor uses to describe your condition and to choose your treatment, and its normal range is usually between 50% and 70%.

Because so many people leave the echo room holding a number they do not know how to read, these are the categories doctors use: an ejection fraction is reduced at 40% or below, mildly reduced between 41% and 49% (you may also see this called mid-range), and preserved at 50% or above. These categories define the type of the condition and steer the choice of treatment, and certain treatment decisions rest on them.

But four things stop that number from becoming a verdict.

• The number is not a forecast of how long you will live. A great many people live settled, working lives for years with a low ejection fraction, because what shapes the course is the cause, the symptoms, and sticking to treatment and follow-up — not the number by itself.
• The number improves. With many causes — uncontrolled atrial fibrillation, thyroid disorders, viral inflammation of the muscle, the weakness that follows childbirth, and weakness caused by alcohol — the ejection fraction rises appreciably once the cause is treated and the medicines are taken regularly.
• The measurement itself has a margin. The number varies by a few points with the machine, with the person doing the scan, and with how you are on the day. So do not read a difference of three or five points between two reports as deterioration or improvement in itself; the doctor is the one who reads that difference alongside the rest of the picture.
• Most important of all: a normal ejection fraction does not rule out heart failure. There are patients whose ejection fraction is 55% or 60% and who nevertheless have genuine breathlessness and genuine swelling, because their problem is in filling rather than in emptying. So do not reassure yourself with a normal number while the symptoms carry on.

The echo gives more than that number. It also shows the size of the heart’s chambers and the thickness of their walls, the movement of each part of the muscle (a part damaged by an old heart attack moves differently), the state of all four valves, an estimate of the pressure in the arteries of the lungs, and whether there is fluid around the heart.

More importantly, it tells apart two conditions that are treated and followed up differently: a heart whose pumping force has weakened — which is what people mean by a weak heart muscle — and a heart that has kept its pumping force but whose muscle has stiffened, so that it struggles to relax and fill with blood between beats. That second condition is called diastolic dysfunction, or heart failure with a preserved ejection fraction. Telling the two apart is not a matter of wording: the stiff, poorly filling muscle is not a milder grade of weakness and not an earlier stage of it, but a different problem with causes of its own — chiefly long-standing high blood pressure, older age, diabetes and excess weight — and it is commoner in women after the menopause. Its symptoms can be just as severe, and its treatment and follow-up differ. So ask your doctor plainly: is my problem weak pumping, or stiff filling?

Here is what you will actually go through during an echo. You lie on a bed on your back or on your left side with the upper chest uncovered, small sticky pads are put on to trace your heartbeat, and the doctor puts a cool gel on your chest and moves a small probe over it, under the ribs and sometimes at the base of the neck; you may be asked to take a breath and hold it for a moment. You will hear whooshing sounds during the scan, which are the sound of blood flowing inside the heart. It usually takes between 15 and 30 minutes, needs no fasting and no injection, uses no radiation at all, and should cause no pain beyond the light pressure of the probe on the chest. Always keep a copy of the report, because comparing today’s number with the number on your last echo tells the doctor far more than the number on its own.

The ECG (electrocardiogram)

This is a quick test in which sticky pads are placed on the chest, the arms and the legs, and the machine records the electrical activity of the heart in under five minutes. No electrical current passes into your body, the test causes no pain, and all that is asked of you is to lie still and breathe normally. The ECG shows the type of heartbeat and whether it is regular, picks up atrial fibrillation, shows the traces of an old or a recent heart attack, shows signs of an enlarged ventricle, and shows conduction problems that can change the treatment plan itself. What it cannot do is measure pumping efficiency, and a normal ECG does not rule out a weak muscle — which is why it completes the echo rather than replacing it.

The chest X-ray

You stand in front of the imaging plate, take a deep breath and hold it for a few seconds, and it is over in a minute; the radiation dose is small. The X-ray shows an enlarged heart, congestion in the lungs and fluid collecting around them, and it helps rule out lung causes of breathlessness such as pneumonia or chronic airway disease. It does not measure pumping efficiency either. A woman who may be pregnant should tell the radiography staff before the test.

Blood tests — including the natriuretic peptide

One blood sample is usually enough for the whole set. The most important of them in this condition specifically is the natriuretic peptide (BNP, or NT-proBNP), a substance the heart releases when its wall is stretched under pressure or extra load. A raised level makes it likely that the breathlessness is coming from the heart, and a low level makes heart failure largely unlikely — which is particularly useful when it is not clear whether the cause is the heart or the chest.

Reading the result correctly means knowing two things. This substance can rise for reasons other than a weak muscle, among them older age, atrial fibrillation, reduced kidney function and a clot in the lung artery; and it can come back lower than expected in people carrying excess weight even when heart failure is genuinely present. It is therefore a test that helps steer the doctor, and it does not take the place of the echo or make it unnecessary. It should also not be confused with the troponin test, which is requested when a heart attack is suspected, not to measure the efficiency of the muscle.

The tests usually requested alongside it are a full blood count, because anaemia on its own can cause breathlessness and tire the heart; kidney function and the salts (sodium and potassium), because these bear directly on the choice of medicines and on monitoring them; thyroid function; the long-term blood sugar (HbA1c) and the blood fats; iron stores, because iron deficiency is common in this condition and adds to the exhaustion and the breathlessness; and liver function. Some of these may require fasting beforehand, so ask about that when the tests are requested.

Further tests when they are needed

These are not requested for every patient, but only when the cause remains unidentified, or when the test would change the treatment plan.

• A Holter monitor (continuous ECG recording): a small device fixed to the chest with sticky pads, which you carry for 24 to 48 hours while going about your usual day, noting the times when palpitations or dizziness appear. It picks up intermittent rhythm disturbances that a momentary ECG cannot catch. When the episodes are further apart, recorders that run for longer periods are used instead.
• An exercise test or a stress echo: walking on a treadmill with the ECG and blood pressure monitored, or an echo performed before and after exertion, to judge how well the heart copes with effort and to investigate a suspected shortage of blood supply to the muscle. It is not done during an episode of deterioration, nor when there is breathlessness at rest, nor with increasing swelling — only once the condition is stable, and on the doctor’s decision.
• A CT scan of the coronary arteries: a non-invasive alternative in selected cases for assessing the arteries, done by injecting a dye into a vein in the arm without passing a catheter. The doctor decides when it is sufficient and when it cannot replace catheterisation.
• Cardiac MRI: the most accurate way of measuring the size and efficiency of the ventricles, and the best at detecting fibrosis inside the muscle and at identifying the cause when it is unclear. You lie inside a tube-shaped machine, usually for 30 to 60 minutes; it is loud, so you are given earplugs or headphones; you are asked to hold your breath several times; and a dye may be injected into a vein in the arm once kidney function has been checked. Tell the team in advance about any implanted device or metal in your body, any pacemaker, any possibility of pregnancy, or severe claustrophobia — and note that having a pacemaker or a modern device does not necessarily rule the scan out, since many of them are designed to be scanned under special arrangements the team will set up.
• Diagnostic coronary catheterisation: done when narrowed arteries are suspected as the cause of the weakness, because that is a treatable cause and finding it changes the course. It is performed through an artery in the wrist or the upper thigh under local anaesthetic; you stay awake throughout; a dye is injected that shows the arteries on the screen; and kidney function is checked beforehand. You feel the sting of the anaesthetic at the start, and perhaps a brief wave of warmth when the dye goes in, and then you are asked to rest for some hours afterwards.
• A sleep study: requested when sleep apnoea is suspected alongside loud snoring and daytime sleepiness, because treating it lifts a load the heart is carrying repeatedly every night.
• A biopsy of the heart muscle: rarely used, and performed only in specific situations where inflammation or deposits within the muscle are suspected and need a tissue diagnosis.
• Genetic testing and screening of relatives: considered when the family history points to an inherited cardiomyopathy.

What is worth taking with you on the day

• Your previous echo, ECG and catheterisation reports — the originals if you can, not only a photograph on your phone.
• A complete list of your current medicines exactly as written on the boxes, including anything you buy without a prescription, painkillers, supplements and herbal remedies.
• Your home readings for blood pressure and blood sugar if you record them, together with your current weight and how much it has changed over recent weeks.
• The names of your long-term conditions and the dates of any previous heart operations or procedures, and the date of any chemotherapy or radiotherapy to the chest.

And before you leave, ask the doctor for your own ejection fraction number and write it down, and ask plainly: is my problem weak pumping, or stiff filling? Then ask which cause the doctor thinks is most likely, and when the next test is due.

Treating a weak heart muscle (heart failure)

Treating a weak heart muscle – what doctors call heart failure – is no longer simply a tablet that eases symptoms. It is a long-term plan with three clear aims: to relieve the symptoms that disrupt your daily life, to protect the heart muscle from weakening further, and in many cases to raise the pumping efficiency itself over time. With regular treatment, the ejection fraction (the heart’s pumping efficiency) may improve in many patients over a period of months, and admissions to hospital because of fluid retention become less likely. How much it improves differs from one patient to another, depending on the cause, how long the condition has been present and how early treatment began. It cannot be guaranteed in advance for anyone, and none of it happens unless you take the medicines regularly, in the way your doctor has set out.

The first step: treating the cause itself

Before anything else, the doctor looks for the cause that weakened the muscle, because treating the cause can restore a large part of the heart’s efficiency. Narrowed coronary arteries may need a catheter procedure or surgery to restore blood flow. Valve problems may need repair or replacement. A persistent rhythm disturbance such as atrial fibrillation, or a chronically fast pulse, may itself be the cause of the weakness, so the heart improves once it is brought under control. With atrial fibrillation, the doctor will usually add a blood-thinning medicine to protect against clots, and that is a decision for the doctor alone after assessing your case. The same goes for controlling blood pressure and diabetes, treating an underactive or overactive thyroid, correcting anaemia, treating sleep apnoea, complete abstinence from alcohol, stimulants and energy drinks, and reviewing any medicine that may itself be the cause of the weakness – some kinds of chemotherapy, for example, which are reviewed with the treating doctor and never stopped on your own. None of this is a side issue; it is a core part of the treatment.

One thing that is often overlooked is iron deficiency. It is common in heart failure even when there is no obvious anaemia on the blood count, and replacing it – once a test of your iron stores has confirmed it – improves symptoms and the ability to exert yourself. In some cases the doctor gives it directly into a vein. Do not buy iron supplements on your own: the blood test is what decides whether you need them and how they should be given. You are also advised to have the seasonal vaccinations your doctor recommends, because a chest infection is one of the commonest reasons a person with heart failure deteriorates suddenly and ends up in hospital.

The four core medicines

Modern drug treatment for a weak heart muscle with reduced pumping efficiency rests on four classes of medicine that work together. Each class protects the heart from a different angle, which is why most patients are prescribed medicines from all four classes rather than a single drug. These are the names of the classes as you will hear them from your doctor:

• Angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers: they widen the blood vessels and reduce the load on the heart, and they slow the way the muscle changes shape and stretches over time. There is also a newer class that combines an angiotensin receptor blocker and a neprilysin inhibitor in a single medicine; studies have shown greater benefit from it in many patients with reduced pumping efficiency, and many doctors now turn to it for those it suits. It is very important never to take this newer class and an angiotensin-converting enzyme inhibitor at the same time, and to leave the gap your doctor sets when switching from one to the other – so do not finish off an old strip lying at home after your doctor has changed your medicine. An angiotensin-converting enzyme inhibitor can cause a troublesome dry cough in some patients; that is a reason to tell your doctor so that you can be moved to a suitable alternative, not a reason to stop the medicine on your own. If, however, you develop sudden swelling of the lips, the tongue or the face, or difficulty swallowing or breathing, stop the medicine and go to the nearest emergency department immediately.
• Beta blockers: they slow the heartbeat and protect the muscle from the exhausting effect of stress hormones, giving the heart longer to fill with blood and pump more efficiently, and they reduce the risk of dangerous rhythm disturbances. You may also see them written as “beta receptor blockers” or “beta-adrenergic blocking agents”, which is the same class. It is normal for the pulse to be slower than usual once you start them; that is part of how they work, and not a reason to stop them on your own. Tell your doctor the reading, and go back sooner than your next appointment if a slow pulse comes with severe dizziness, fainting, or unusual exhaustion.
• Mineralocorticoid receptor antagonists: they block the effect of the hormone aldosterone, which causes salt and water retention and scarring of the heart muscle tissue, so they protect the muscle from gradual stiffening and help keep fluid under control. This class does not lower potassium the way some other diuretics do; it holds potassium in the body and can raise it. A high potassium level very often causes no obvious symptoms, despite its dangerous effect on the heart rhythm, and that is why potassium and kidney function are checked regularly with blood tests, and why you must not take potassium supplements or use “healthy table salt” or salt substitutes (most of them are potassium chloride) without your doctor’s knowledge.
• SGLT2 inhibitors (sodium-glucose co-transporter inhibitors): they were used at first to treat diabetes, and were then found to protect the heart and the kidneys, to reduce fluid retention and to reduce hospital admissions. They are now prescribed for patients with a weak heart muscle whether they have diabetes or not. They are generally well tolerated. They may make you pass urine more often in the first few days, and increase the chance of a fungal infection in the genital area, so careful hygiene helps, along with drinking the amount of water your doctor has set for you. If you develop a sudden illness with vomiting or diarrhoea, or you stop eating and drinking, or you are about to have an operation, tell your doctor, because this class may be stopped temporarily in circumstances like these – on the doctor’s instructions, not on your own decision.

Some of these medicines need to be started at a small dose that the doctor raises gradually over a series of visits, until it reaches the most beneficial dose your body can tolerate, with blood pressure, kidney function and potassium checked by regular blood tests. You may feel mild dizziness or tiredness at first, until your body adjusts. Tell your doctor about it, and do not stop the medicine on your own.

Three numbers in particular frighten patients into stopping their treatment themselves when there is no need to: a blood pressure reading lower than usual with no symptoms at all, a pulse slower than usual on a beta blocker, and a slight rise in creatinine after starting an angiotensin medicine. All three are often expected and acceptable at the start of treatment, and the number on its own is not enough to judge by. Write the reading down, tell your doctor, and let the doctor decide. Go back sooner if it comes with dizziness on standing, fainting, a very slow pulse, or a clear drop in the amount of urine you pass.

Which medicine you take, how much each dose is, and when it is raised or lowered – all of that is the decision of your treating doctor alone, after looking at your echo, your ECG, your blood tests, your blood pressure and your kidney function. It is never right to take a medicine because a relative of yours takes it and says it helped them: the same class may suit one patient and be completely forbidden for another.

If you are a woman of childbearing age, tell your cardiologist before you plan a pregnancy, or as soon as you find out you are pregnant, because several classes of heart failure medicine – including the angiotensin medicines in all their forms, and the mineralocorticoid receptor antagonists – are not safe during pregnancy, and your doctor will need to draw up an alternative plan. What is needed here is a prompt review with your doctor, not stopping the medicine on your own.

Diuretics: they relieve your symptoms, they do not stop the disease

Diuretics draw the excess fluid out of the body, so breathlessness eases and the swelling of the feet and the abdomen goes down within days. That is why many patients feel the diuretic is “the most important medicine”. The truth is exactly the opposite: diuretics treat the symptom. They do not change the course of the disease and they do not raise the efficiency of the heart muscle. The medicines that protect the muscle and improve its efficiency are the four classes above, and the diuretic remains a tool for controlling fluid alongside them.

This means there are two common mistakes to avoid: sticking to the diuretic and neglecting the rest of your medicines because you “cannot feel them working”, or increasing the amount of the diuretic yourself whenever the swelling increases. Too much diuretic does harm of its own: dehydration, a drop in blood pressure, dizziness, worsening kidney function, and a loss of potassium and magnesium that can disturb the heart rhythm. That pulls in the opposite direction to the mineralocorticoid receptor antagonists, which can raise potassium, and this is why the doctor balances the two classes with regular blood tests. Some doctors give the patient a written plan for adjusting the diuretic according to the daily weight – weighed in the morning, after going to the toilet, before eating, in roughly the same clothes – and that plan is followed only if your own doctor wrote it for you, and only within the limits your doctor has set.

What about a stiff heart muscle that does not fill properly?

In the stiff-muscle form – where the pumping efficiency is preserved but the muscle is stiff and does not fill well – the treatment is different. SGLT2 inhibitors have become a mainstay in these cases too, along with diuretics to relieve the congestion, but the greater weight falls on controlling blood pressure and diabetes, losing weight, and treating atrial fibrillation and sleep apnoea, because these are the factors that stiffen the muscle in the first place. The doctor may add other classes depending on the case. This is why one patient’s treatment plan is never passed on to another simply because the complaint sounds similar: the echo is what decides which of the two roads the treatment takes, and a medicine that works for one form may not be what is needed for the other.

Never stop or change your medicine on your own

This is one of the most important points in this whole guide. Medicines for a weak heart muscle do not work like a painkiller that you take when you are in pain and stop when the pain goes. They are continuous protection for the muscle for as long as you keep taking them. The most dangerous of all is stopping beta blockers suddenly: that can lead to a sudden racing of the pulse, a rise in blood pressure, more load on the heart, and rhythm disturbances within a few days.

The commonest mistake of all is for a patient to improve, then think they have been cured and no longer need the medicine. The improvement is itself proof that the medicine is working, and stopping it takes the condition back to where it started; the heart’s efficiency may fall again after it had improved. The same applies to:

• Stopping a medicine because its price has risen or it is not available – tell your doctor, who can suggest a suitable alternative from the same class, rather than leaving yourself with no treatment at all.
• Reducing the dose yourself when you feel dizzy or tired – the answer may be a small change in the timing, or in the diuretic, not stopping the medicine that is protecting your heart.
• Advice from a relative, or a post on the internet, to change your medicine – any change goes through your doctor first.
• Adding herbs, food supplements or “natural remedies for the heart” – some of them interact with heart medicines, or raise blood pressure, or affect the potassium level. The best known is liquorice, which raises blood pressure and lowers potassium.
• Fasting, travelling, or changing the hours of your day – discuss it with your doctor beforehand so that the timing of your doses can be arranged. In most cases that can be arranged; skipping a dose on your own is never the answer.

An important warning: anti-inflammatory painkillers

Non-steroidal anti-inflammatory drugs – the common painkillers bought in Egypt from the pharmacy without a prescription for joint, back, neck and period pain – make the body retain salt and water, raise blood pressure, blunt the effect of diuretics and blood pressure medicines, and affect kidney function. The result is that a completely stable patient can, within a few days, develop swelling, breathlessness and congestion that need urgent treatment; and many cases of sudden deterioration are caused by a strip of painkillers bought for a pain that has nothing to do with the heart at all.

The rule is practical and simple: do not take any new painkiller – even for a knee, a back or a tooth – before asking your doctor which painkiller is right for your condition. And always tell any doctor or dentist you see that you have a weak heart muscle and that you take medicines for your heart. Watch out too for painkilling injections and creams, for cold remedies that contain decongestants, and for steroid medicines such as cortisone, because all of these can cause fluid retention or raise blood pressure, and must not be taken without your doctor’s knowledge. Be careful of effervescent tablets in general as well: many of them contain a large amount of sodium, which is extra salt in your day without your noticing it.

Implanted devices: the defibrillator and cardiac resynchronisation

Devices are not put forward as an early option. They are considered after the patient has had the full drug treatment, at the appropriate doses, for at least three months, and the pumping efficiency has then remained substantially low (in the region of 35% or less) on the follow-up echo. That number is a condition for considering a device, not a verdict in itself: the decision is also weighed against the symptoms, the cause of the weakness and the general condition, and many patients at that number do not need a device. There are two completely different types, and people often confuse them with each other and with an ordinary “pacemaker”:

• The implantable defibrillator: a small device implanted under the skin below the collarbone, which monitors the heart rhythm continuously. If a fast and dangerous rhythm disturbance occurs, it stops it at once with rapid beats or an internal electric shock. It is therefore protection against sudden death caused by a rhythm disturbance, and not a treatment that raises the pumping efficiency or eases breathlessness.
• The resynchronisation device: used when the ECG shows a delay in the electrical signal – the best known form being what is called left bundle branch block – that makes the two ventricles contract at two different moments, so part of the pumping force is lost. Through additional leads, the device brings them back into step so that they contract together, and in suitable patients breathlessness may improve and the pumping efficiency may rise, although the response differs from one patient to another. It is sometimes combined with the defibrillator function in a single device.

The decision to fit either of them is entirely individual, and it is taken by the cardiologist after the echo, the ECG and a full assessment of the case. It does not suit every patient with a weak heart muscle. The device does not replace the medicines and does not guarantee any particular result; it is added to a continuing treatment plan, with regular follow-up to check the device and its battery. Anyone who has one should keep its card with them, and should tell any doctor, dentist or radiographer about it before any procedure.

Advanced options

In a small number of patients, symptoms continue despite full drug treatment and devices. These patients need assessment at a centre specialising in advanced heart failure, which is the medical name for the severe stages of a weak heart muscle. The options may include medicines given into a vein in hospital to support the pumping and clear the fluid; mechanical circulatory support devices that help the left ventricle to pump, used sometimes as a temporary bridge until a heart transplant and sometimes as a long-term solution; or a heart transplant itself, for those who meet its conditions. A heart transplant is a very limited option, with strict conditions and a long assessment, and it is not right to wait for it as a solution available to every patient. Alongside all of this, care directed at relieving symptoms and improving day-to-day quality of life remains a core part of the plan in the advanced stages, and not an alternative to be turned to only at the very end.

Cardiac rehabilitation and supervised exercise: treatment, not a luxury

For years it was believed that a patient with a weak heart muscle should rest and move as little as possible. That is not true. Complete rest weakens the muscles, increases breathlessness and reduces stamina. Cardiac rehabilitation – a programme of graded exercise under medical supervision – is today regarded as part of the treatment itself, and studies have shown that it improves the ability to exert yourself, reduces symptoms and hospital admissions, and improves quality of life.

• The programme begins with an assessment of your condition and your capacity for exertion. A plan is then drawn up to fit you, starting with very light effort and increasing gradually, and the medical supervision matters most in the first few weeks.
• The basis is usually regular walking or a stationary bicycle on most days of the week, with light resistance exercise to strengthen the muscles, and a warm-up and a cool-down at the beginning and the end.
• The practical measure is that you should be able to talk while exercising. If you are too breathless to speak, the effort is more than it should be.
• Avoid lifting heavy weights and straining while holding your breath, and avoid exertion in severe heat, in high humidity, or in the hottest hours of the day. Choose a cooler time and a shaded place.
• The programme also includes teaching you to monitor your weight and your symptoms, to control the salt in your food, and to stop smoking – and these in themselves are treatment.
• Stop exercising and see your doctor if you develop chest pain, severe dizziness, unusual palpitations, breathlessness worse than usual, or a rapid gain in weight and swelling, and do not start again until your condition has been assessed.

During periods of deterioration and fluid retention, the exercise is reduced or stopped temporarily until the condition settles, and the programme is then resumed gradually. If no organised rehabilitation programme is available to you, ask your doctor for a simple written walking plan that suits your condition, because regular, considered movement is far better than sitting still out of fear for your heart.

Living with a weak heart muscle day to day

Heart failure — what most people call a weak heart muscle — is a condition managed at home far more than it is managed in the clinic. Your doctor adjusts the medicines and orders the tests, but what actually decides whether the condition stays stable is what you do in the days between one appointment and the next: salt, fluids, the daily weight, movement, sleep, and keeping to your treatment and your follow-up appointments. What follows is not general advice about "heart health". It is the day-to-day management of a condition you already have.

Salt: the problem is not the salt shaker alone

When people are told to cut down on salt, most of them picture taking the salt shaker off the table. But most of the sodium in an Egyptian diet comes from foods nobody ever added salt to at the table. Excess sodium holds water in the body, which raises the volume of fluid an already strained heart has to move, and the result shows up within a few days as swollen legs and breathlessness.

The commonest hidden sources in an Egyptian home:

• Bread of every kind — baladi bread and fino rolls above all, because they are eaten in large amounts every day even when they do not taste salty.
• Processed cheese, salted white cheese, roumi cheese and mish — among the highest-sodium items on the breakfast table.
• Pickles, olives and salted lemons.
• Stock cubes, instant soup powders, tinned sauces and ready-made spice mixes.
• Luncheon meat, basterma, sausage and frozen burgers.
• Salted, smoked and tinned fish: fesikh, herring, sardines and tuna.
• Crisps, salted nuts and savoury snacks.

The usual guidance for someone with heart failure — unless your own doctor has told you otherwise — is to keep your total salt for the day to about five grams, roughly one teaspoon, and that has to include the salt hidden inside food, not only the salt you add at the table. The aim is moderation, not deprivation: cutting salt to an extreme has not been shown to be better, and it can make food so unpalatable that people end up eating less than they need. In practice it helps to cook at home, to let lemon, garlic, onion, cumin, dill, coriander and vinegar take the place of part of the salt, and to read the label on packaged products looking for the word "sodium".

As for the salt substitutes sold as "healthy salt", most of them are based on potassium chloride, and a high potassium level in the blood is a real danger for anyone taking several of the drug classes used in heart failure. Do not use these substitutes without asking your doctor first.

Fluids: an individual limit your doctor sets, never a blanket rule

Restricting fluids is not a general rule for every patient. Many stable patients need no restriction at all. It is usually prescribed for people with repeated fluid retention, a low sodium level in the blood, or advanced disease, and in that case the doctor sets a daily amount in millilitres for that individual. What matters is that you know your own figure from your own doctor, rather than taking a number you heard from another patient.

Where a limit genuinely applies, everything liquid counts towards it: tea, coffee, juice, soup, milk and jelly, and even very juicy fruit such as watermelon. Restricting fluids on your own initiative, on the other hand — especially in the summer heat, or while you are taking a diuretic — can cause dehydration, a drop in blood pressure and strain on the kidneys. If thirst is troublesome, sucking a small piece of ice or a slice of lemon, or chewing sugar-free gum, eases the feeling without adding to your daily total.

Movement and everyday exertion

Complete rest is not a treatment for heart failure. It weakens your fitness and makes breathlessness worse over time. Regular moderate activity — walking on level ground most days of the week, building the time up gradually — improves what you are able to do and how you feel through the day. The practical test is that you should still be able to talk while you are walking; if you cannot finish a sentence, the effort is more than your heart can take today.

Avoid sudden heavy exertion, lifting heavy weights, and holding your breath while you strain, and ask your doctor what limit is right for your case specifically. If chest pain, severe dizziness, unusual palpitations, or breathlessness out of proportion to what you are doing come on while you are exerting yourself, stop, and speak to your doctor before you try again.

Smoking and alcohol

Stopping smoking is one of the cheapest decisions open to you and one of the most powerful in changing the course of the disease. It covers cigarettes, shisha, flavoured shisha tobacco and electronic cigarettes alike: every one of them raises blood pressure, narrows the arteries and reduces the oxygen reaching a muscle that is already struggling. Smoking indoors harms you even when you are not the one smoking, which is why stopping works far better as a family decision than an individual one.

Alcohol has a direct toxic effect on heart muscle and is capable of weakening it on its own. For someone whose condition was caused by alcohol, stopping completely can improve the pumping function markedly; for someone whose condition has another cause, complete abstinence is still the medical advice.

Sleep, and the question of the pillow

Raising your head on two or three pillows eases breathlessness when you lie down, because it reduces the pooling of fluid in the lungs, and there is no reason not to do it. But more important than a comfortable night is noticing the change: if you used to sleep on one pillow and now need two, or if you have started waking an hour or two after falling asleep, gasping, and having to sit up or stand at the window, this is not a question of pillows. It is a sign that fluid is accumulating and that the condition is deteriorating, and it calls for a prompt review with your doctor rather than waiting for the next appointment. And if the breathlessness reaches the point where you cannot lie flat at all, or it comes on while you are sitting at rest, that is an emergency: go to the nearest emergency department straight away. Do not put it off, and do not wait until morning.

It is also worth telling your doctor about heavy snoring or pauses in breathing during sleep. Sleep apnoea is common alongside a weak heart muscle and adds to the load on it, and treating it shows in the symptoms and in the quality of sleep.

The daily weight: a scale at home and a reading every morning

The bathroom scale is the cheapest piece of monitoring equipment you own and the most useful, because it picks up accumulating fluid days before any swelling appears or the breathlessness gets worse. A rapid gain in weight here is not fat, and it is not a sign that your nutrition is improving. It is retained water.

• Weigh yourself every day at the same time: in the morning, after you have been to the toilet and before breakfast, in light clothing, on the same scale and in the same place.
• Write the number down in a small notebook or on your phone, and take the record with you to every visit; how the number moves across the days matters more than any single day's reading.
• A rapid gain — in the region of two kilograms over about three days, or whatever limit your doctor has set for you — means seeing your doctor without delay, and particularly so if it comes with shoes feeling tight, swelling in the legs, a bloated abdomen, or increasing breathlessness.
• Do not change the dose of your diuretic yourself because of what you see on the scale, unless your doctor has given you a specific written plan for dealing with weight gain — and in that case follow it, and tell your doctor what you did. Otherwise the number is information you report, and the decision on it is your doctor's.
• Rapid unintended weight loss, or dizziness on standing, is worth reporting too; it can mean that you are losing more fluid than your condition needs.

Vaccination: a chest infection is one of the commonest triggers of sudden deterioration

Sudden deterioration in heart failure very often begins with a chest infection that the patient assumes will simply pass. Fever, a fast pulse and a drop in oxygen all add load to a muscle that is already weak, and a common cold turns into fluid retention and a hospital admission. Patients with heart failure are therefore advised to have the annual influenza vaccine before the winter season starts, and to ask their doctor about the pneumonia vaccine, the COVID-19 vaccine, and any other vaccines appropriate to their age and their condition.

If symptoms of a chest infection do appear — a persistent cough, a fever, or a change in the colour of the sputum — early medical assessment is better than waiting, and better than buying a treatment from the pharmacy on your own judgement; much of what is dispensed without an examination is unsuitable for a heart patient or interacts badly with their medicines.

Painkillers bought without a prescription

The common pain and inflammation painkillers — known medically as the non-steroidal anti-inflammatory drugs — are usually taken for back pain, joint pain, headache and period pain. They make the body hold on to sodium and water, they raise blood pressure, they blunt the effect of diuretics, they strain the kidneys, and they can push potassium up alongside some heart medicines. Their effect on a patient with heart failure is real and can end in swelling and breathlessness within days, and they are just as dangerous taken as tablets, as injections or as suppositories. The same applies to many of the combined cold and flu remedies, which contain either these painkillers or other ingredients that raise blood pressure.

And it is not only painkillers: corticosteroids, some classes of diabetes medication, and some supplements and herbal products can cause fluid retention or interact with heart medicines. The practical rule is simple — tell every doctor you see and every pharmacist you buy from that you have heart failure, carry a list of your medicines with you, ask which painkiller is suitable for you before you buy any of them, and do not rely on what a relative recommends or on what you were used to taking before you were diagnosed.

Follow-up, even on the days when you feel well

Feeling better in heart failure is evidence that the treatment is working, not evidence that you have stopped needing it. Follow-up in this condition rests on numbers rather than on feelings: blood pressure, pulse, weight, kidney function, the potassium level in your blood, and the pumping function on the echo. On top of that, the doses of heart failure medicines are raised gradually over weeks to reach the dose that protects the muscle, and that build-up only happens through regular visits with blood tests in between.

This is why the most dangerous decision a patient takes alone is to stop a heart failure medicine, or cut its dose, without the doctor — because the symptoms improved, because the box ran out, because life got busy, or because money was tight that month. The improvement is itself the work of the medicine, and stopping it very often takes the condition back to where it was, or worse, within weeks. Some of these medicines must never be stopped abruptly — the beta blockers above all, where a sudden stop can send the pulse and the blood pressure up and disturb the heart's rhythm within a few days. If you are having trouble with a medicine — a side effect you find hard to live with, a price that has gone up, or difficulty keeping it up — raise it with your doctor so that the treatment can be adjusted or changed. Do not simply stop it in silence.

It is important to know the difference between the two kinds of medicine on your prescription. Some of them relieve congestion and symptoms, the diuretics above all; their dose is moved up and down according to your fluid state, and they do not treat the weakness of the muscle itself. Others protect the muscle and change the course of the disease, and those are the ones to be taken regularly and continued even after you feel better. Keeping to the diuretic alone because "that is the one that gives me relief" is one of the commonest mistakes, and one of the most costly.

A weak heart muscle in women

Heart failure — the medical name for a weak heart muscle — is not a men's disease, but a woman's road to the diagnosis is longer: the diagnosis comes at a later stage of the illness, and the symptoms are put down to other causes before the heart is ever examined. The result is that many women start treatment after the condition has moved a step further than it needed to.

Why is the diagnosis delayed in women?

The first symptoms — tiredness, breathlessness on exertion, swollen feet and palpitations — overlap with complaints that are extremely common among women, so they are put down to anaemia or a vitamin deficiency, to anxiety and stress, to exhaustion from the house and the children, or to the changes of the menopause. Often the anaemia really is there, so it is treated and that is where the matter stops. The important thing is that one cause does not rule out another alongside it: if the breathlessness or the tiredness continues after the anaemia has been corrected or the thyroid brought under control, the next step is to have the heart examined with an ECG and an echo, not to repeat the supplements. Iron deficiency is common with heart failure itself and correcting it can improve symptoms, but that is decided by blood tests and under a doctor's supervision, not by a supplement bought from the pharmacy.

It also helps to describe the symptom to your doctor precisely: how long it has been there, with exactly what effort it comes on (stairs? a short errand? tidying the house?), whether it is worse lying down or at night, and whether it comes with swelling or a sudden gain in weight. That description alone very often changes the whole direction of the assessment.

The commonest form in women: a stiff muscle with a preserved ejection fraction

Heart failure is not one single condition. In one form the force of contraction weakens, so the ejection fraction falls. In the other, the muscle becomes stiff, so it does not relax properly between beats and does not fill with blood as it should, while the force of contraction and the ejection fraction — the proportion of blood the ventricle pushes out with each beat — look normal on the echo report. This second form is the stiff heart muscle that many people call a "relaxed" or "lax" heart muscle, and it is the more common one in women, particularly after the age of fifty and alongside high blood pressure, diabetes or excess weight. The word "relaxed" is used loosely and means different things to different people, so ask your doctor to explain what your own report actually says.

This is why one situation repeats itself in clinic after clinic: a woman complains of genuine breathlessness and swelling, is told that "the echo is normal" because the ejection fraction is normal, and leaves with no diagnosis. If that happens to you, ask the doctor directly whether there is a problem with the filling of the ventricle or stiffness of the muscle — the report may well state it plainly. The reassuring part is that this form can be brought under control, but its treatment is different: most of the work goes into controlling blood pressure, blood sugar, body weight, salt and fluid, and into treating the other conditions that come with it. There is now also a drug class with proven benefit in it — the SGLT2 inhibitors, used even in people who do not have diabetes — and it is prescribed by the doctor who is following you.

Cardiomyopathy of pregnancy and childbirth

Heart failure can appear for the first time in the last month of pregnancy or during the few months after delivery, in what is known as peripartum cardiomyopathy. It is uncommon, but it is serious, and the reason it is caught late is simple and logical: its symptoms overlap completely with what a woman in late pregnancy and in the weeks after childbirth normally feels — breathlessness, swollen legs and feet, severe tiredness and palpitations. So it is put down to "normal at the end of pregnancy", or to "the exhaustion after delivery and the broken nights with the baby", and time passes.

Several things raise the likelihood of it: pre-eclampsia or raised blood pressure during pregnancy, a twin pregnancy, several previous deliveries, and pregnancy at a later age. The practical difference between ordinary exhaustion and this condition is its severity and its course: ordinary tiredness does not stop you lying down, does not wake you gasping, and does not get worse day after day.

When does a pregnant or newly delivered woman need urgent assessment? Go to the nearest emergency department at once — do not wait for the postnatal check and do not wait for the next clinic appointment — if any of the following appears:

• Breathlessness at rest or while speaking, or being unable to lie flat.
• Waking from sleep gasping for breath and having to sit up.
• A cough bringing up frothy or pink-tinged sputum, fast breathing, or blueness of the lips or fingertips.
• Chest pain, or a heaviness in the chest.
• Fainting or nearly fainting, or severe or continuous palpitations.
• Swelling that is increasing quickly, or a sudden gain in weight over a few days.
• Confusion, or unusual drowsiness.

When you arrive, say clearly that you are pregnant or have recently given birth and that you are breathless, and ask for your heart to be assessed — that one sentence cuts out a great deal of delay. Do not drive yourself, and do not go alone if you can avoid it.

The muscle's function in this condition often improves with treatment and regular follow-up, and sometimes returns to normal, but that takes time, commitment and repeat echo scans to confirm. Three points are missed again and again. First, do not stop any medicine on your own because you are breastfeeding — discuss it with your doctor, who will choose what suits a breastfeeding mother. Second, several classes of heart failure medicine are not safe in pregnancy at all, so if you are of childbearing age, tell your cardiologist if you become pregnant or if you are planning to, so that the treatment can be adjusted in advance; ask them as well which method of contraception is appropriate for you — without stopping anything yourself. Third, any later pregnancy has to be planned with the cardiologist and the obstetrician together, and after the pumping function has been assessed, because the condition can happen again.

Is a weak heart muscle dangerous?

The honest answer is that heart failure — the medical name for a weak heart muscle — is in most cases a long-term condition, and one that deserves to be taken seriously from the first day; and at the same time it is not a final verdict and not the end of a normal life. It is managed over the long term much as high blood pressure or diabetes is managed: with regular follow-up, continuing medication, and control of daily habits. Its real danger does not lie in the name, but in leaving it untreated and in ignoring the signs that it is getting worse.

The important thing is that treatment here is not merely the relief of symptoms. Modern heart failure medicines genuinely change the course of the disease: they reduce the load on the muscle, they limit its enlargement and stretching, they lower the chance of being admitted to hospital with fluid retention, and they improve the prospect of living longer and living better than if the condition is left untreated. This effect does not appear overnight; it usually needs weeks and months of taking the medicines regularly and of building up gradually to the right dose.

The other side of the picture has to be said plainly and without alarm: a weak muscle can be accompanied by an irregular heartbeat, which is why fainting, nearly fainting, or severe continuous palpitations must never be put off or explained away as tiredness — they need to be seen by a doctor straight away. Regular treatment itself reduces that risk, and in particular cases — decided by the doctor after months of optimal drug treatment and on the basis of the echo and the symptoms — a patient may be offered a device that guards against dangerous rhythm disturbances, or one that re-coordinates the contraction of the muscle.

Yes, the ejection fraction can improve

The number that worries patients more than any other is the ejection fraction on the echo report — the proportion of blood the left ventricle pushes out with each beat. The first thing to know about it is that it is not a verdict on its own: the doctor reads it together with the cause of the condition, the severity of the symptoms, the results of the blood tests, and how far you have responded to treatment. The second is that it is not a number fixed for ever: in many patients it rises after months of regular treatment, and sometimes it rises a great deal.

There are causes of a weak muscle where function improves markedly once the cause is treated, among them uncontrolled high blood pressure, an irregular heartbeat and a chronically fast pulse, valve disease, thyroid disorders, viral inflammation of the heart muscle, the cardiomyopathy associated with childbirth, weakness caused by excess alcohol, cardiomyopathy following certain cancer treatments, and a poor blood supply once the blocked arteries behind it are treated.

But an improved number does not mean the disease is "over", and it does not mean the time has come to stop treatment. In most cases the medicine is continued after the pumping function improves precisely because the medicine is the reason for the improvement, and studies have shown that stopping it after recovery takes a considerable proportion of patients backwards within a few months. Any decision to change a medicine belongs to the doctor following you and to nobody else, and it is based on an echo and on blood tests, not on a feeling of being better. If a medicine is troubling you, discuss it with your doctor so that it can be adjusted or replaced — do not stop it in silence.

What makes the condition more dangerous?

• A cause that has never been treated: neglected high blood pressure, uncontrolled diabetes, a blocked artery, a faulty valve, or an irregular heartbeat that was never brought under control.
• Not taking the medicines regularly, or stopping them the moment you feel better — by far the commonest reason of all for relapse.
• Repeated episodes of fluid retention and hospital admission; each episode leaves its mark on the heart and the kidneys and makes the condition harder to control.
• Delay in asking for help when the symptoms worsen, and simply waiting for the next follow-up appointment.
• Too much salt, neglecting the daily weight, and carrying on smoking or drinking alcohol.
• Taking anti-inflammatory painkillers, or other medicines, without your doctor's knowledge.
• Other conditions left uncontrolled: chronic kidney disease, anaemia, sleep apnoea, and marked obesity.

Why this page gives no survival figures

The published figures on survival in heart failure describe large groups of patients. They lump together cases that differ enormously in cause, in age and in the other illnesses the patient has, and many of them come from years that predate the treatments in use today. They do not describe any particular person, and reading them frightens more than it informs. It is far more useful to ask the doctor who is following you about your own case: what caused the weakness in my heart muscle? What is my ejection fraction now? What should we expect to change after some months of treatment? Those are questions with real answers, unlike a general number on the internet.

The conclusion is that a weak heart muscle is a dangerous condition if it is neglected, and one that can be brought a long way under control if it is treated early and consistently. Nobody can promise a cure, but the difference between a patient who keeps to the treatment and the follow-up and a patient who leaves the condition to chance is a large and obvious one — and it is the one difference the patient has the power to change.

Frequently Asked Questions

How do I know if my heart muscle is weak?

Symptoms on their own cannot confirm it, but the signs that most often point to a weak heart muscle — the everyday name for what doctors call heart failure — are breathlessness on effort that used to be easy for you, such as climbing stairs; breathlessness when you lie down, or waking at night gasping and easing once you sit up; swelling of the feet and legs; tiring easily; palpitations or an irregular pulse; a persistent cough or wheeze; and a sudden gain in weight over a few days caused by fluid building up. Confirmation comes from a clinical examination together with an ECG (a tracing of the heart's electrical activity) and an echocardiogram (an ultrasound scan of the heart) — the scan that measures the ejection fraction (EF) — and your doctor may add blood tests, including a blood marker of heart failure, kidney function and thyroid function. A normal ECG on its own does not rule the condition out, and more than one of these signs appearing together is reason enough to see a cardiologist without delay.

Is a weak heart muscle dangerous?

Yes — heart failure is a serious condition that needs treatment and regular follow-up, usually lifelong, but it is not a final verdict and it does not mean the end of a normal life. How serious it is depends on three things: the underlying cause; how far the ejection fraction has fallen; and how early it was found, together with how closely treatment is followed afterwards. Cases picked up early, in people who stay on their medication and adjust their daily habits, often remain stable for many years, and the pumping efficiency of the muscle itself can improve. Neglect, or stopping the medication, leads instead to repeated episodes of fluid retention and hospital admission, dangerous heart rhythm disturbances and strain on the kidneys. The real danger in heart failure is not the moment of diagnosis but a sudden deterioration left without medical assessment, which is why knowing the signs that mean going to the emergency department, and weighing yourself every day, are part of the treatment rather than extras added on top.

What is the difference between a weak heart muscle and a stiff heart muscle?

Both are forms of heart failure, and the difference lies in what the muscle fails to do. In a weak heart muscle the problem is with pumping out: the muscle contracts with less force than normal and pushes out less blood with each beat, which shows on the echocardiogram report as a reduced ejection fraction. In a stiff heart muscle the problem is with filling: the muscle becomes rigid and does not relax properly between one beat and the next, so the ventricle fills with difficulty and pressures inside it rise, while the ejection fraction on the report may look completely normal — echo reports often call this diastolic dysfunction, and when it causes symptoms doctors call it heart failure with preserved ejection fraction. The symptoms are very similar in both — breathlessness, swelling and fatigue — so nothing but an echocardiogram, read alongside a clinical assessment, can tell them apart. Confusing the two is not a matter of wording: the treatment plans overlap in places and differ in others, and in the stiff type, controlling blood pressure, diabetes, weight and any rhythm disturbance is the foundation of treatment. It also means that a report saying the ejection fraction is normal does not by itself mean the heart is healthy.

What does the ejection fraction number mean, and when is it dangerous?

The ejection fraction (EF) is the percentage of the blood in the left ventricle that is pushed out with each beat, and it is written on your echocardiogram (echo) report. The normal range is roughly 50% to 70%. A figure between 41% and 49% means a mild reduction that needs follow-up; 40% or below means the pumping is clearly weak and needs regular drug treatment; and 35% or below means severe weakness, in which case your doctor may discuss — after a period on regular medication, not at the moment of diagnosis — an implanted defibrillator, or a device that resynchronises the contraction of the two ventricles, to protect against dangerous rhythm disturbances. Even so, no single figure is dangerous on its own and the number does not decide your case: your symptoms, the cause and your response to treatment are an essential part of the assessment, the figure itself can vary slightly from one scan to another and from one operator to another, and in many patients it rises after months of regular treatment.

Can a weak heart muscle be cured, or will I have it for life?

It depends on the cause. When the cause is treatable — uncontrolled high blood pressure, a thyroid disorder, viral inflammation of the heart muscle, a valve problem, a long-standing abnormally fast heart rhythm, narrowed coronary arteries treated in time, or the cardiomyopathy linked to pregnancy and childbirth — the pumping efficiency can improve a great deal, and the ejection fraction may return to normal. In other cases heart failure remains a long-term condition, one that is managed successfully with regular medication, changes to daily habits and continued follow-up. What matters is that better numbers do not mean the treatment is finished: the medication usually continues precisely because it is what produced the improvement, and stopping it once things improve sets many patients back. The decision to reduce or stop any medication therefore rests with your cardiologist alone, and only after re-assessment with an examination and an echocardiogram.

When exactly should I go to the emergency department?

Go to the emergency department straight away, without waiting for a clinic appointment, if you develop severe or sudden breathlessness while you are resting, or cannot finish a full sentence without stopping for breath. Go too if you cannot lie flat, or wake at night gasping and it does not settle when you sit up; if you cough up frothy, pink-tinged sputum; if you have chest pain or pressure lasting more than a few minutes, or pain spreading to the arm, neck or jaw, which you should treat as a heart attack until proven otherwise; if you faint or feel close to fainting; if your heartbeat is very fast or irregular and will not settle, or comes with dizziness or chest pain; if your lips or fingertips turn blue; if you become suddenly confused, or unusually drowsy and hard to rouse; or if your skin turns cold and clammy with a racing pulse. A weight gain of more than two kilograms over two to three days, with swelling that keeps increasing and breathlessness that is getting worse, means fluid is building up and needs to be assessed the same day. Do not drive yourself and do not take an extra dose of any medicine on your own hoping the symptoms will settle; call an ambulance or ask someone to drive you, and take your list of medicines and your most recent echo report with you.

Can I stop my medication once I feel better?

No. Feeling better in heart failure is evidence that the medication is doing its job, not that you no longer need it, and stopping treatment on your own is one of the commonest reasons for a sudden deterioration and a hospital admission. Some of these medicines, beta blockers in particular, must never be stopped abruptly, because an abrupt stop can raise the pulse and blood pressure or set off a rhythm disturbance. Be aware too that diuretics — the water tablets — relieve swelling and breathlessness but do not improve the pumping efficiency of the muscle itself; the real improvement comes from the rest of the medicines your doctor has prescribed, and a common mistake is to keep taking the diuretic and stop everything else. If a side effect is troubling you, or the medicine is not available at the pharmacy, or the cost has made staying on it a burden, raise it with your cardiologist so the dose can be adjusted or the medicine changed for another in the same class — adjusting treatment is a medical decision based on examination and tests, not on how well you feel.

Can I take ordinary painkillers for a headache or back pain?

Avoid them, and do not take any painkiller before asking your doctor. Non-steroidal anti-inflammatory drugs (NSAIDs) — the commonest painkillers for headache, joint pain and back pain, sold in pharmacies in Egypt without a prescription — make the body hold on to sodium and water, raise blood pressure, blunt the effect of diuretics and heart medicines, and can strain the kidneys, all of which pushes heart failure towards deterioration and makes swelling and breathlessness worse. The practical rule is to tell any doctor, dentist or pharmacist that you have a heart condition before you take any painkiller, cold remedy or herbal supplement. Take particular care with effervescent tablets, combined cold remedies and fizzy antacid salts, because many of them are high in sodium, and with liquorice products, which raise blood pressure and hold fluid in the body. There are alternatives for pain relief that carry less risk for your heart, and your doctor will tell you which of them suits you.

Is heart failure different in women?

Yes, and in women it is diagnosed later than it should be. Women are more likely to have the form of heart failure in which the muscle becomes stiff, with a normal ejection fraction, so the echo report looks reassuring even though the heart really is unwell. Their symptoms also tend to show up as severe fatigue, breathlessness on exertion and disturbed sleep rather than the classic chest pain, and are wrongly put down to anaemia, stress or the menopause. There are causes specific to women as well: high blood pressure during pregnancy and pre-eclampsia, the cardiomyopathy linked to pregnancy and childbirth, and some breast cancer treatments and radiotherapy to the chest, alongside anaemia and thyroid disorders. Any woman with this history should mention it to her doctor explicitly, and should ask for her heart to be assessed at the first unusual breathlessness, swelling or fatigue instead of waiting.

What should I eat, and how much should I cut down on salt?

The basic rule is to keep salt below about five grams a day, which is less than a teaspoon and includes the salt hidden inside food, and the bigger risk is not the salt cellar on the table but pickles, salty cheese, processed meats such as luncheon meat, tinned food, stock cubes, instant soup, salty snacks and ready meals. Build your meals around vegetables, fruit, wholegrains, pulses, fish and lean protein, and cut down on saturated fat and sugar. Do not use potassium-based salt substitutes unless your doctor allows it, because several heart failure medicines raise potassium in any case. How much fluid you should drink is set by your doctor for your case specifically, and is not something to restrict on your own. The single most useful daily habit is to weigh yourself at the same time every morning, after going to the toilet, before breakfast, in the same clothes, and to write the number down, because a gain of more than two kilograms over two to three days means fluid is collecting and should be reported to your doctor quickly, even before any swelling or breathlessness appears.

Can I exercise, or is that off limits?

Regular moderate exercise is part of the treatment and is not forbidden, provided your condition is stable and your doctor agrees and sets the right level for you; if a medically supervised cardiac rehabilitation programme is available to you, that is the best place to start. For most patients the most suitable forms are walking, a stationary bike or gentle swimming, at a pace that still lets you talk while you exercise, starting with a few minutes a day and building up gradually towards about thirty minutes on most days of the week, with a warm-up at the beginning and a cool-down at the end. Avoid lifting heavy weights, holding your breath while straining, and exercising in extreme heat or while you have a cold or a fever, and do not exercise on a day when your weight, your swelling or your breathlessness has increased. Stop immediately and tell your doctor if you feel unusual breathlessness, chest pain, dizziness or palpitations.

Can heart failure happen after childbirth?

Yes. It is a recognised condition called peripartum cardiomyopathy, heart failure linked to pregnancy and childbirth, and it usually appears in the last month of pregnancy or during the first five months after delivery. The most dangerous thing about it is that its symptoms — severe fatigue, breathlessness, swollen feet and difficulty sleeping flat — are exactly what is normally put down to the exhaustion that follows childbirth, so the mother delays seeking medical advice. Breathlessness that worsens on lying down, swelling that keeps increasing, or palpitations after delivery all deserve an echocardiogram rather than simple reassurance, while severe breathlessness at rest means going to the emergency department there and then. In many cases the pumping efficiency of the heart muscle improves markedly with early treatment, but follow-up continues, and some heart failure medicines are not used during pregnancy or breastfeeding, so decisions about breastfeeding and any future pregnancy are taken jointly by the cardiologist and the obstetrician, because a new pregnancy before the muscle has recovered carries a risk that the condition will return.