Heart Failure
Also known as: CHF, Congestive Heart Failure, HFrEF, HFpEF
~14 years
earlier average age at first heart failure hospitalization for Black patients vs. white patients (JAMA Network Open, 2025)
Overview
Heart failure is what happens when the heart muscle can no longer pump enough blood to keep up with the body's demand. It is not the heart "stopping." It is the heart working harder than it should for years, usually because of untreated high blood pressure, a prior heart attack, diabetes, or damaged valves, until the pump weakens or stiffens. Fluid backs up into the lungs, the legs, the belly. Walking up a flight of stairs starts to feel like a hill.
There are two main types. Heart failure with reduced ejection fraction (HFrEF) means the left ventricle is weak and squeezes out less than about 40 percent of its blood with each beat. Heart failure with preserved ejection fraction (HFpEF) means the squeeze looks normal, but the muscle is stiff and cannot fill properly between beats. The treatments overlap but are not identical, and the diagnosis only gets made for sure with an echocardiogram. The 2022 AHA/ACC/HFSA Guideline (Heidenreich et al.) is the clinical standard of care.
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.
- What is my ejection fraction, and is this HFrEF or HFpEF?
- Am I on all four pillars of GDMT, and if not, why not?
- If I am Black with HFrEF and class III-IV symptoms, am I on isosorbide dinitrate plus hydralazine? If not, what's the reason?
- Am I on an SGLT2 inhibitor? The 2022 guideline recommends one regardless of whether I have diabetes.
- Should I see a heart failure cardiologist, not just a general cardiologist, given my age and severity?
- Can you write me a prescription for a home blood pressure cuff and a digital scale, and tell me the weight gain threshold that should make me call you?
- Am I a candidate for cardiac rehab? It is covered by Medicare and most insurance for heart failure.
- What is my target sodium intake per day, and can I get a referral to a registered dietitian who works with Black patients and Southern food?
- If my disease is advanced, am I a candidate for an LVAD, transplant evaluation, or palliative care?
- What is my prognosis with current therapy, and what should make me consider hospice?
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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.