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What is heart failure?

Heart failure (HF) is defined by the American Heart Association as a clinical condition in which the heart's ability to pump oxygen-rich blood to the body’s cells isn’t as well as it should.1 It is characterized by symptoms such as shortness of breath, ankle swelling, and fatigue that may be accompanied by signs such as increased jugular venous pressure, pulmonary crepitations, and peripheral edema according to European Society of Cardiology.2
Heart failure is caused by a structural and/or functional heart defect and results in inadequate cardiac output and/or increased intracardiac pressures at rest or during exercise.2 HF can be divided into three types based on measurement of the ejection fraction of the left ventricle, also known as left ventricle (LV). Left ventricular ejection fraction is a measure used to categorize the types of HF. 3 It is the percentage (%) of blood that is pumped out from the left ventricle to the rest of the body after each squeeze of the heart.4 Based on this ejection fraction, heart failure is divided into:

  • Heart failure with reduced ejection fraction (≤40% HFrEF) 2
  • Heart failure with mildly reduced ejection fraction (41-49% HFmrEF) 2 and
  • Heart failure with preserved ejection fraction (≥50% HFpEF) 2
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Heart failure Burden

Heart failure (HF) is a major challenge for global public health, affecting individual health and well-being while also carrying a substantial economic burden on healthcare systems and societies.5 The condition is associated with mortality, high rates of hospitalization, frequent readmissions, and substantial healthcare costs.6 In Egypt, the burden is amplified by younger age of onset and limited access to specialized care.7 Therefore, HF management in Egypt certainly requires optimization, as all these limitations result in some patients not being diagnosed in a timely manner, not receiving optimal pharmacological and non-pharmacological recommendations, or not being adequately followed up after discharge.7

  • Mortality
  • Hospitalization
  • Quality Of Life
  • Economic

    1. Mortality

    It is known that patients with HF, irrespective of ejection fraction and symptomatology, all have increased mortality rates. 34% Of NYHA class I and II patients, and 42% of NYHA class III and IV patients die8*

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    * A Propensity Matched Study of NYHA and Natural History End Points in Heart Failure, Kaplan-Meier plots for death due to all causes showed 641 deaths from all causes in patients in NYHA classes I and II during 5,455 person-years of follow-up (rate 1,175 in 10,000 person-years), compared to 777 deaths in patients in NYHA classes III and IV during 5,162 person-years (rate 1,505 in 10,000 person-years).9

     

    Severity of Heart Failure

     

    Sudden cardiac death accounts for approximately half of death in patients with heart failure10, with proportion of sudden cardiac deaths varies according to NYHA class and is greater in patients with mild-to-moderate symptoms (NYHA classes II-III)11,12

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    Heart Failure is deadlier than many cancers

     

    Heart failure (HF) is often underestimated in terms of its severity, yet it carries a mortality risk that surpasses many common cancers—including breast, colorectal and ovarian cancer in women, and bladder, colorectal, and prostate cancer in men. Only lung cancer has a higher mortality rate than heart failure13. Despite advances in treatment, there is still a lack of understanding of what HF is, and of its associated risks and healthcare burden 14

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    Relationship between heart failure, hospitalization and mortality

     

    Viewing the relationship between heart failure, hospitalization and mortality is associated with high rates of readmission and mortality.6 Acute heart failure (AHF), in particular, often requires urgent medical attention and is the primary reason for hospital admissions in individuals over 65 years of age.2 Studies show that 24.4% of patients are readmitted within 30 days of discharge15, and 43.9% within 1 year for any cause, reflecting the chronic and progressive nature of the disease.16 Moreover, HF hospitalization rates for HF remain significant, especially in patients with comorbidities such as diabetes, renal dysfunction, and chronic obstructive pulmonary disease.17 These outcomes underscore the importance of ensuring the best care in hospital involves a multidisciplinary team, supported and often led by an expert in heart failure, developing and implementing guidelines and protocols for treatment and a smooth and swift transition to follow-up care.18

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    2- Hospitalization

    Patients with heart failure are at high risk of repeated hospitalization

     

    HF is associated with high rates of hospitalization. Health service data for a number of European countries show hospitalizations with a primary diagnosis of HF generally account for 1–2 % of all hospital admissions.18 In the USA, HF accounts for approximately 3% of hospitalizations.18 In developed countries HF is now the most common cause of hospitalization in patients aged over 65 years.18 Moreover, after a period of hospitalization for AHF, patients are at increased risk of frequent, repeated hospitalizations.18

    The risk of hospitalization for HF is high regardless of the severity of HF. In a study examining the association between NYHA functional class and outcomes in HF, patients with mild HF (NYHA class I/II) and moderate/severe HF (NYHA class III/IV) had hospitalization rates of 66% and 71%, respectively.9

    There is a wealth of evidence for an increased risk of rehospitalization following an initial HF admission. For example, a large US study of Medicare/Medicaid data (>1 million admissions for acute HF) found that 24.4% of patients initially hospitalized for HF are readmitted to hospital within 30 days,15 and a large European study (ESC-HF Pilot study) showed that 43.9% of patients are readmitted within 1 year.16

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    3- Quality Of Life

    HF has a detrimental effect on quality of life

     

    HF can severely affect patients’ social capacity and emotional health:

    • 76% of patients struggle to perform their daily activities19
    • 63% of patients reported symptoms that are consistent with depression20
    • At least 50% of patients reported difficulty with recreational pastimes, sports or hobbies19

    Patients with HF often suffer from fear, anxiety or depression, and have difficulty performing different activities.18

    4- Economic

    HF imposes a significant economic burden on the healthcare system

     

    The overall cost of HF in the year 2012 was analyzed in a study, which included 197 countries, corresponding to 98.7% of the world’s population.21 The economic burden of HF was determined in both direct and indirect costs.21 Direct costs included expenditure on hospital services, medications, physician costs, primary healthcare costs and follow-up, while indirect costs included expenditure in terms of lost productivity resulting from morbidity and mortality, sickness benefit and welfare support. 21

    Hospitalization for HF has been reported to account for up to 70% of the costs associated with this condition.22 When global HF spending in 2012 was stratified according to country, the mean direct cost burden of HF per year, as a percentage of the total healthcare expenditure, was 1.42% in high-income countries, and 0.11% in middle- and low-income countries (countries were classified as high-, middle- or low-income as per the World Bank Development Indicators).21

    Factors including an aging, and the development of life-extending therapies suggest that the economic burden of HF will rise.23 Studies indicate that the prevalence of HF in the USA will increase by 46% from 2012 to 2030, to result in >8 million individuals with HF in this country.23 Correspondingly, the cost of HF in the USA is expected to increase by ~127%, from $30.7 billion to $69.8 billion, (the equivalent of ~$244 per adult in the USA) between 2012 and 2030.23

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Types of heart failure:

 

Congestive Heart Failure (CHF)

 

CHF is a long-term life-timing condition; symptoms follow a relapsing and remitting course.
Patients can be stable, have a worsening in their symptoms or decompensate, suffering an acute episode of that requires hospitalization,25 fall into two categories:

A) Systolic Dysfunction: 26

 

Systolic dysfunction is defined as a reduction in the ability of the left ventricle (LV) to contract and eject blood, Usually quantified by a reduced left ventricular ejection fraction (LVEF ≤40%).

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B) Diastolic Dysfunction:26

 

Diastolic dysfunction is an abnormality of the left ventricle characterized by impaired relaxation, increased stiffness, leading to elevated left ventricular filling pressure despite a preserved or only mild reduced ejection fraction.

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Causes of Heart Failure

 

Heart failure occurs when the heart cannot pump blood effectively to meet the body's needs. It can develop gradually (chronic) or suddenly (acute) and is often the result of other underlying health conditions. Key causes include:27

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HFrEF: Heart failure with reduced ejection fraction, HFmrEF: Heart failure with mildly reduced ejection fraction, HFpEF: Heart failure with preserved ejection fraction, NYHA: New York Heart Association Functional Classification, AHF: acute heart failure, ESC: European Society of Cardiology, CHF: congestive Heart Failure, LV: left ventricle.

References

  1. American Heart Association. What is Heart Failure? available at: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure. last accessed at: 22/09/2025.

  2. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JG. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal. 2021 Sep 21;42(36):3599-726.

  3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JG. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal. 2023 Oct 1;44(37):3627-39.

  4. Mayo clinic. Ejection fraction: What does it measure? available at: https://www.mayoclinic.org/tests-procedures/ekg/expert-answers/ejection-fraction/faq-20058286. last accessed at: 22/09/2025.

  5. Darvish M, Shakoor A, Feyz L, Schaap J, van Mieghem NM, de Boer RA, Brugts JJ, van der Boon RM. Heart failure: assessment of the global economic burden. European Heart Journal. 2025 May 30:ehaf323.

  6. Raya Ortega L, Martínez Tapias J, Ferreras Fernández MJ, Jiménez-Navarro M, Ortega-Gómez A, Romero-Cuevas M, Gómez-Doblas JJ. In-Hospital Mortality and Costs of Added Morbidity in Heart Failure Patients at a University Hospital: A Retrospective Cross-Sectional Study. Journal of Cardiovascular Development and Disease. 2025 May 15;12(5):185.

  7. Hassanein M, Tageldien A, Badran H, Samir H, Elshafey WE, Hassan M, Magdy M, Louis O, Abdel‐Hameed T, Abdelhamid M. Current status of outpatient heart failure management in Egypt and recommendations for the future. ESC Heart Failure. 2023 Oct;10(5):2788-96.

  8. Papadimitriou L, Moore CK, Butler J, Long RC. The limitations of symptom-based heart failure management. Cardiac failure review. 2019 May 24;5(2):74.

  9. Ahmed A. A propensity matched study of New York Heart Association class and natural history end points in heart failure. The American journal of cardiology. 2007 Feb 15;99(4):549-53.

  10. Authors/Task Force Members, McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European heart journal. 2012 Jul 1;33(14):1787-847.

  11. CR M. Effect of metoprolol CR/XL in chronic heart failure. Lancet. 1999;353:2001-7.

  12. Desai AS, McMurray JJ, Packer M, Swedberg K, Rouleau JL, Chen F, Gong J, Rizkala AR, Brahimi A, Claggett B, Finn PV. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. European heart journal. 2015 Aug 7;36(30):1990-7.

  13. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More ‘malignant’than cancer? Five‐year survival following a first admission for heart failure. European journal of heart failure. 2001 Jun;3(3):315-22.

  14. Lam CS, Harding E, Bains M, Chin A, Kanumilli N, Petrie MC, Pohja-Hutchison P, Yang J, Butler J. Identification of urgent gaps in public and policymaker knowledge of heart failure: Results of a global survey. BMC Public Health. 2023 May 30;23(1):1023.

  15. Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, Wang Y, Wang Y, Lin Z, Straube BM, Rapp MT. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation: Cardiovascular Quality and Outcomes. 2009 Sep;2(5):407-13.

  16. Maggioni AP, Dahlström U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, Fruhwald F, Gullestad L, Logeart D, Fabbri G, Urso R. EURObservational Research Programme: regional differences and 1‐year follow‐up results of the Heart Failure Pilot Survey (ESC‐HF Pilot). European journal of heart failure. 2013 Jul;15(7):808-17.

  17. Bhatt AS, Ambrosy AP, Dunning A, DeVore AD, Butler J, Reed S, Voors A, Starling R, Armstrong PW, Ezekowitz JA, Metra M. The burden of non‐cardiac comorbidities and association with clinical outcomes in an acute heart failure trial–insights from ASCEND‐HF. European journal of heart failure. 2020 Jun;22(6):1022-31.

  18. Cowie MR, Anker SD, Cleland JG, Felker GM, Filippatos G, Jaarsma T, Jourdain P, Knight E, Massie B, Ponikowski P, López‐Sendón J. Improving care for patients with acute heart failure: before, during and after hospitalization. ESC heart failure. 2014 Dec;1(2):110-45.

  19. Calvert MJ, Freemantle N, Cleland JG. The impact of chronic heart failure on health‐related quality of life data acquired in the baseline phase of the CARE‐HF study. European journal of heart failure. 2005 Mar;7(2):243-51.

  20. Moser DK, Dracup K, Evangelista LS, Zambroski CH, Lennie TA, Chung ML, Doering LV, Westlake C, Heo S. Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft. Heart & Lung. 2010 Sep 1;39(5):378-85.

  21. Cook C, Cole G, Asaria P, Jabbour R, Francis DP. The annual global economic burden of heart failure. International journal of cardiology. 2014 Feb 15;171(3):368-76.

  22. Ku H, Chung WJ, Lee HY, Yoo BS, Choi JO, Han SW, Jang J, Lee EK, Kang SM. Healthcare costs for acute hospitalized and chronic heart failure in South Korea: a multi-center retrospective cohort study. Yonsei medical journal. 2017 Jul 31;58(5):944.

  23. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, Ikonomidis JS, Khavjou O, Konstam MA, Maddox TM, Nichol G. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circulation: Heart Failure. 2013 May;6(3):606-19.

  24. Hessel FP. Overview of the socio-economic consequences of heart failure. Cardiovascular Diagnosis and Therapy. 2021 Feb;11(1):254.

  25. Cleveland Clinic. Congestive Heart Failure. Available at: https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure. Last accessed at: 22/09/2025.

  26. American Heart Association. Types of Heart Failure. available at: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure. last accessed at: 22/09/2025.

  27. Johns Hopkins Medicine. Heart Failure. available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/heart-failure. last accessed at: 22/09/2025.

  28. National Heart, Lung and Blood Institute. Heart Failure Causes and Risk Factors. available at: https://www.nhlbi.nih.gov/health/heart-failure/causes. last accessed at: 22/09/2025.

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