Skip to main content
Black Health logo Black Health
Cardiovascular Last reviewed:

Heart Failure

Also known as: CHF, Congestive Heart Failure, HFrEF, HFpEF

Reviewed by the Black Health editorial team Last reviewed

~14 years

earlier average age at first heart failure hospitalization for Black patients vs. white patients (JAMA Network Open, 2025)

Overview

Heart failure is not an equal-opportunity disease. Black adults develop it earlier, are hospitalized for it at 2.5 times the rate of White adults, and die from it at nearly three times the rate in middle age.[1][2] The disparity is not a fixed biological fact -- it is driven by undertreated hypertension, earlier-onset risk factor accumulation, and consistent underuse of proven medications. This page explains the condition, the disparity, and what guideline-directed care actually looks like for Black patients.

How Heart Failure affects Black patients

Heart failure shows up in Black patients differently, earlier, and harder. In the CARDIA cohort followed over 20 years (Bibbins-Domingo et al., NEJM 2009), 26 of 27 incident heart failure cases in adults under 50 were Black. Mean age at onset was 39. The single biggest driver was hypertension that was present at baseline and stayed poorly controlled through early adulthood. This is not a story about genes. It is a story about a disease that took root in people's twenties and was never adequately treated.

The age gap at first hospitalization is wide. A 2025 JAMA Network Open analysis of first heart failure admissions found Black patients averaged about 60 years old, compared with roughly 74 for white patients, a difference of nearly 14 years (Mwansa et al., 2025). Roughly half of that gap was explained by differences in insurance access. Black patients are also more likely to present with HFrEF specifically, the reduced-pump phenotype, where guideline-directed medical therapy has the strongest mortality benefit.

The most important Black-specific evidence is the A-HeFT trial (Taylor et al., NEJM 2004). 1,050 self-identified Black patients with NYHA class III-IV HFrEF were randomized to fixed-dose isosorbide dinitrate plus hydralazine (H-ISDN) on top of standard therapy, versus placebo. The trial was stopped early because the drug arm had a 43 percent reduction in all-cause mortality and a 33 percent reduction in first heart failure hospitalization. The 2022 AHA/ACC/HFSA guideline gives H-ISDN a Class I, Level of Evidence A recommendation for self-identified Black patients with NYHA III-IV HFrEF already on optimal therapy. If you are Black, have HFrEF, and have moderate-to-severe symptoms, you should be on this combination, or your cardiologist should be able to tell you why not.

Hypertension drug response also differs. ALLHAT (JAMA 2002) showed that in Black participants, lisinopril (an ACE inhibitor) was less effective than chlorthalidone (a thiazide diuretic) at lowering blood pressure and preventing stroke and heart failure. AASK (Wright et al., JAMA 2002) found that in Black patients with hypertensive kidney disease, ramipril slowed kidney decline better than amlodipine despite similar BP control. SGLT2 inhibitors are now part of standard HFrEF therapy regardless of diabetes status; a prespecified DAPA-HF subgroup analysis (Docherty et al., JACC Heart Failure 2021) found dapagliflozin reduced events to the same relative degree in Black and white patients, and because Black patients had higher baseline event rates, the absolute benefit was greater (NNT 12 in Black patients vs 17 in white patients). The Southern diet pattern, high in sodium and processed meat, is independently associated with worse hypertension control.

Symptoms

  • Shortness of breath with activity, or when lying flat
  • Waking up at night gasping or having to sit up to breathe
  • Swelling in the ankles, feet, legs, or belly
  • Weight gain of 2-3 pounds in a day or 5 pounds in a week from fluid
  • Persistent dry cough or wheezing, sometimes with pink-tinged sputum
  • Fatigue that is new or out of proportion to what you did
  • Reduced exercise tolerance: stairs that used to be nothing now wind you
  • Racing or irregular heartbeat
  • Loss of appetite, nausea, or feeling full quickly
  • Trouble concentrating, confusion (from reduced blood flow to the brain)

When to see a doctor

Call 911 or go to the ER now for: severe shortness of breath at rest, chest pain or pressure, coughing up pink frothy sputum, fainting, a heart rate that will not slow down, or sudden severe leg swelling with pain (could be a clot).

Call your cardiologist or primary care this week if: you are gaining more than 2-3 pounds overnight or 5 pounds over a week, your shortness of breath is getting worse with normal activity, your ankles are swelling more than usual, or you need more pillows than before to sleep flat. These are signs of fluid building up and often mean a diuretic adjustment, not a hospital stay, if caught early.

Schedule a regular visit if you have risk factors (long-standing hypertension, diabetes, prior MI, family history of cardiomyopathy under 60, history of cocaine or methamphetamine use, prior chemotherapy with anthracyclines or trastuzumab) and have not had a heart check in over a year. Asking for an echocardiogram and a BNP or NT-proBNP blood test is reasonable.

Screening

There is no population-wide heart failure screening program, but in patients at high risk, two tests do most of the work. BNP or NT-proBNP is a blood test that rises when the heart wall is stretched; useful both for diagnosis when you have symptoms and for monitoring once you are being treated. An echocardiogram (a heart ultrasound) is the definitive test: it measures the ejection fraction, looks at the valves, the wall thickness, and the chamber sizes. The 2022 AHA/ACC/HFSA guideline endorses echocardiography for anyone with symptoms suggesting heart failure or with high pre-test risk.

If your blood pressure has been running 130/80 or higher for years and has not been treated to goal, you are already in Stage A heart failure by guideline definition (at-risk stage). That is the moment to get serious about BP control, not after the symptoms start.

Treatment overview

For HFrEF the modern standard is what cardiologists call the four pillars of guideline-directed medical therapy (GDMT), all started and titrated together: a beta-blocker proven in HFrEF (carvedilol, metoprolol succinate, or bisoprolol); an ACE inhibitor, ARB, or, preferably, an ARNI (sacubitril/valsartan); a mineralocorticoid receptor antagonist (spironolactone or eplerenone); and an SGLT2 inhibitor (dapagliflozin or empagliflozin), with or without diabetes. Each of these independently reduces mortality. The benefit compounds when they are all on board.

For self-identified Black patients with NYHA III-IV HFrEF already on the four pillars, the 2022 guideline adds fixed-dose isosorbide dinitrate plus hydralazine (Class I, Level A) based on A-HeFT. This is not an alternative to ACE/ARB/ARNI, it is on top. The combination pill is BiDil; the components can also be prescribed separately, which is usually cheaper.

Loop diuretics (furosemide, torsemide, bumetanide) treat the fluid overload but do not change the disease trajectory. Many patients learn to adjust their diuretic dose based on daily weights at home.

For advanced disease that does not respond to medication, options include cardiac resynchronization therapy, implantable defibrillators, left ventricular assist devices (LVADs), and heart transplant. Black patients have historically been referred to advanced therapies later and less often; ask your cardiologist directly whether you meet criteria.

For HFpEF the evidence is thinner but evolving. SGLT2 inhibitors now have the strongest data and a guideline recommendation. Strict blood pressure control and treatment of comorbidities (sleep apnea, obesity, atrial fibrillation) carry most of the benefit.

Questions to ask your doctor

Bring this list to your next appointment.

  1. What type of heart failure do I have -- reduced or preserved ejection fraction -- and what is my ejection fraction number?
  2. Am I on all four components of guideline-directed therapy: an ARNI (or ACE/ARB), a beta-blocker, an MRA, and an SGLT2 inhibitor?
  3. As a Black patient, should I also be on hydralazine plus isosorbide dinitrate?
  4. Is my ejection fraction low enough that I should be evaluated for an ICD or CRT device?
  5. What is my target weight, and at what weight should I call you before it becomes an emergency?
  6. Am I on a beta-blocker that has evidence in heart failure (carvedilol, metoprolol succinate, or bisoprolol) rather than one that does not?

Find care for heart failure

Not sure where to start? Describe what you're experiencing and we'll help you find the right kind of care, including a cardiology.

Find care

The numbers

  • Black adults have the highest incidence of heart failure of any racial or ethnic group in the United States: 4.6 per 1,000 person-years in the MESA study, compared to 2.4 for White adults.[2]
  • Heart failure hospitalizations for Black patients run approximately 2.5 times higher than for White patients -- a gap that has not narrowed over the past decade.[1]
  • The CARDIA study found that Black women and men under age 50 developed heart failure at roughly 20 times the rate of White counterparts (cumulative incidence 1.1% and 0.9% in Black adults vs. 0.08% and 0% in White adults).[2]
  • Age-adjusted heart failure cardiovascular death rates for Black men ages 35 to 64 are 2.6 times higher than for White men; for Black women, 2.97 times higher.[1]
  • Average age of incident heart failure in Black participants in the CARDIA study: 39 years.[1]
  • Black patients who survive to hospitalization show lower in-hospital mortality than White patients (1.83% vs. 3.09%), but receive advanced interventions at far lower rates: cardiac resynchronization therapy (aOR 0.71), ventricular assist devices (aOR 0.45), and heart transplants (aOR 0.57).[3]
  • Only 11 percent of eligible Black patients receive hydralazine/isosorbide dinitrate (H-ISDN), a Class I guideline recommendation specifically for Black adults with heart failure.[1]
  • 55 percent of Black heart failure patients fall in the lowest income quartile, contributing to access barriers that affect both medication adherence and device therapy.[3]

What it is

Heart failure does not mean the heart has stopped. It means the heart cannot pump enough blood to meet the body's needs, or cannot fill with enough blood, or both. The most common form is heart failure with reduced ejection fraction (HFrEF), where the left ventricle pumps out less than 40 percent of the blood it holds with each beat (normal is above 55 percent). There is also heart failure with preserved ejection fraction (HFpEF), where the pumping fraction looks normal but the heart muscle is too stiff to fill properly.

Symptoms include shortness of breath (especially lying flat or with activity), ankle and leg swelling, rapid weight gain from fluid retention, fatigue, and a persistent cough or wheeze. Symptoms are caused by fluid backing up into the lungs or body because the heart is not moving blood forward efficiently.

In Black adults, hypertension is the leading driver. Three-quarters of Black adults who developed heart failure in the CARDIA study had diagnosed hypertension by age 40.[1] Uncontrolled blood pressure over years causes the heart muscle to thicken and stiffen, setting up the structural changes that lead to failure.

Why it is different for Black patients

The timeline is the central clinical fact: heart failure in Black adults is a disease of the 30s and 40s, not the 60s. A 45-year-old Black man with shortness of breath and ankle swelling is more likely to have heart failure than a clinician trained on White population norms might expect. Under-index on suspicion, and the diagnosis is delayed.

The pathophysiology also has a specific racial dimension. Research shows reduced nitric oxide bioavailability in Black adults with hypertension, which is the mechanistic basis for the Class I guideline recommendation for hydralazine-isosorbide dinitrate (H-ISDN) in Black patients with heart failure with reduced ejection fraction. Organic nitrates restore nitric oxide signaling; hydralazine reduces the oxidative stress that degrades it. The A-HeFT trial, which was conducted exclusively in Black patients, showed a 43 percent relative reduction in mortality with H-ISDN added to standard therapy.[1] Despite this evidence, the drug remains widely underused.

Structural factors compound the biology. Low neighborhood income, higher uninsurance rates, and reduced access to advanced cardiac care (transplant centers, mechanical circulatory support programs) all track with race and reduce access to the full spectrum of treatment.

Treatment, plainly

Guideline-Directed Medical Therapy (GDMT) is the term for the specific combination of drugs the AHA/ACC/HFSA guidelines have shown reduce death, hospitalization, and symptoms in heart failure with reduced ejection fraction. The full four-drug regimen is:

  1. ACE inhibitor or ARB, or preferably ARNI (angiotensin receptor-neprilysin inhibitor, brand name Entresto): Reduces pressure the heart pumps against and slows disease progression. ARNI is the preferred agent in current guidelines; it showed superiority over ACE inhibition in the PARADIGM-HF trial.
  1. Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol): Slows heart rate and reduces harmful neurohormonal activation. Only these three specific agents have mortality evidence in HFrEF.
  1. Mineralocorticoid receptor antagonist (MRA): Spironolactone or eplerenone. Blocks aldosterone, reducing fluid retention and fibrosis. Requires monitoring of potassium and kidney function.
  1. SGLT2 inhibitor (dapagliflozin or empagliflozin): Originally a diabetes drug, now a proven HF therapy regardless of diabetes status. Reduces hospitalizations and cardiovascular death.

For Black adults with HFrEF who remain symptomatic despite the above, current ACC/AHA guidelines include a Class I recommendation for hydralazine plus isosorbide dinitrate (H-ISDN). This combination is specifically supported by trial evidence in Black patients (A-HeFT). The dosing requires three-times-daily administration, which is a real adherence burden -- if it is prescribed, ask your care team about strategies to keep up with it.

Beyond medications, device therapy matters. Patients with an ejection fraction below 35 percent despite three to six months of GDMT are candidates for an implantable cardioverter-defibrillator (ICD) to prevent sudden cardiac death. Those with both low ejection fraction and certain ECG patterns may benefit from cardiac resynchronization therapy (CRT), which coordinates the two ventricles. Black patients receive these devices at lower rates despite similar eligibility -- this is a conversation worth having with your cardiologist if it has not happened.

Heart failure with preserved ejection fraction (HFpEF) is more common in Black women and in older adults. SGLT2 inhibitors have shown benefit in HFpEF as well. Aggressive blood pressure control and weight management are the primary levers for HFpEF.

How to find care

Sources

  1. Lewis GA, et al. "Understanding the Complexity of Heart Failure Risk and Treatment in African Americans." PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC7644144/
  2. Racial and Ethnic Disparities in the Outcomes and Treatment of Patients Admitted with Heart Failure: A Nationwide Analysis. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC11722288/
  3. Racial and Ethnic Disparities in Heart Failure: Current State and Future Directions. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC8130651/
  4. Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the ARIC Surveillance Study. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC9271140/
  5. AHA/ACC/HFSA 2022 Heart Failure Guidelines. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10457686/
  6. HF STATS 2024: Heart Failure Epidemiology and Outcomes Statistics. Journal of Cardiac Failure. https://onlinejcf.com/article/S1071-9164(24)00232-X/abstract
  7. Racial Differences in Incident Heart Failure among Young Adults. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa0807265
  8. 2024 Update to the ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure. ScienceDirect. https://www.sciencedirect.com/science/article/pii/S0735109724072887

Was this helpful?

Your feedback shapes what we cover next.

Thanks for letting us know.

If you found this useful, sign up for our newsletter to get more like this.

Thanks. What was missing?

Optional. We read every response.

Thanks.

We use this to prioritize the next round of edits.

Medical disclaimer

This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition. If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

Share:
Find a Black doctor near you