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Shortness of breath in congestive heart failure: Heart Failure Symptoms | Johns Hopkins Medicine

Heart Failure Symptoms | Johns Hopkins Medicine

A normal, healthy heart is a very strong muscle that pumps blood throughout the body. The blood delivers necessary oxygen and important nutrients to tissues and organs.

With heart failure, the organ becomes progressively weaker. Over time, it loses its ability to pump enough blood to meet the body’s needs. In early heart failure, the heart tries to keep up with the body’s demands by:

  • Getting larger
  • Pumping faster
  • Narrowing the blood vessels to increase blood pressure to try to get blood where it needs to go
  • Diverting blood away from other organs so other parts of the body can have it

There are several kinds of heart failure. Some types have overlapping symptoms, some types can happen at the same time, and some types can lead to other types. This article covers the different kinds of heart failure:

  • Left-sided heart failure
  • Right-sided heart failure
  • Congestive heart failure
  • Congenital heart failure

As heart failure progresses, you may have more — and more severe — symptoms. The exact signs and symptoms of heart failure depend on the type of heart failure and how advanced it is.

Early Symptoms of Heart Failure

A person with early heart failure might not have any noticeable signs. When early symptoms occur, they can be subtle and easy to miss or ignore. Early signs of heart failure include:

  • Shortness of breath, at first when you’re active and later even when you’re sitting or lying down
  • Lowered ability to exercise or be active
  • Confusion or forgetfulness
  • Frequent fatigue, sleepiness or weakness
  • Palpitations, or a fluttering feeling in your chest, as the heart pumps harder and faster

Without treatment, heart failure can worsen over time. Symptoms that were once mild can become increasingly more severe, and may prevent you from doing everyday tasks.

Left-Sided Heart Failure Symptoms

Most heart failure occurs in the left ventricle (the bottom left chamber of the heart). Left-sided heart failure can be systolic heart failure, when the ventricle can’t contract (squeeze) normally. Or it can be diastolic (heart failure with preserved ejection fraction), when the chamber is stiffer and can’t relax normally.

If the chamber can’t pump well, blood backs up in the blood vessels that carry oxygenated blood from the lungs to the heart. This backup leads to fluid accumulation in the lungs, which causes shortness of breath. Most people with left-sided heart failure first notice mild breathing difficulty only during exercise. Over time, people may experience shortness of breath when they are being less active and even when resting.

Other symptoms of left-sided heart failure include:

  • Bluish color in the fingertips and lips
  • Cough, which may bring up phlegm or mucus tinged with blood 
  • Fatigue and weakness, even after resting 
  • Rapid or irregular heartbeat (arrhythmia)
  • Sudden, unexpected weight gain
  • Swelling in the ankles, legs, feet and/or abdomen
  • Trouble concentrating 

People with severe left-sided heart failure may experience orthopnea, shortness of breath when lying down. This troubled breathing is caused by fluid accumulating in the lungs when you lie down. You may wake up wheezing or gasping for air, called paroxysmal nocturnal dyspnea. Sitting up causes some of the fluid to drain to the bottom of the lungs, and makes breathing easier.

Right-Sided Heart Failure Symptoms

Right-sided heart failure happens when the right ventricle is too weak to pump enough blood to the lungs. Blood backs up in vessels that carry it from the body to the heart. This backup can push fluid out of the veins and into other tissues, causing swelling in these areas of the body:

  • Ankles
  • Belly
  • Feet
  • Genital area (groin)
  • Internal organs
  • Legs
  • Lower back

This fluid buildup and swelling can cause additional symptoms, such as:

  • Discomfort in the chest
  • Frequent urges to urinate
  • Loss of appetite
  • Nausea
  • Palpitations
  • Shortness of breath
  • Unexpected weight gain

Congenital Heart Failure Symptoms

Heart failure mostly affects older adults. But babies, children and young adults can develop heart failure due to a congenital heart condition (a heart condition present since birth).

Symptoms of heart failure in children and young adults may include:

  • Coughing, wheezing or difficulty breathing
  • Dizziness or fainting
  • Excessive sleepiness
  • Excessive sweating
  • Failure to thrive (gain weight)
  • Irritability due to pain or fatigue
  • Rapid or irregular heartbeat or breathing rate
  • Swelling in the belly, legs, ankles or feet
  • Trouble keeping up with peers during physical activities
  • Unexplained weight gain

What to Do If You Notice Worsening Heart Failure Symptoms

Heart failure can lead to serious complications, such as kidney or liver damage, other heart conditions, pulmonary hypertension and stroke. If you’re experiencing worsening symptoms of heart failure, keep track of them and talk to your doctor.

Seek immediate medical attention or call 911 if you experience:

  • Cough that brings up a white or pink foamy substance
  • Fainting, dizziness or confusion
  • Nausea or loss of appetite
  • New, sudden chest pain
  • Rapid weight gain (2 pounds or more in a day, or 5 pounds or more in a week)
  • Sudden, severe shortness of breath
  • Sudden, severe weakness
  • Swelling that has gotten significantly worse
  • Very fast or irregular heartbeat

Shortness of Breath and Heart Failure


ESC Guidelines for Heart Failure – what patients need to know

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Shortness of breath is a common symptom for many people with heart failure. You should monitor your breathing and be aware of any changes. For example, you may find that in a matter of days or weeks the distance you can walk before shortness of breath appears has diminished. You may also notice increasing shortness of breath at night and while lying flat. You may need more pillows to prop up your upper body, in this case to allow for easier breathing.

Shortness of breath occurs because blood in the body backs up in the blood vessels, which return blood from the lungs to the heart, due to the heart not pumping blood out of the heart effectively. This causes fluid to leak into the lungs, also known as congestion.

If you experience SEVERE and persistent shortness of breath, you should call for emergency treatment immediately. If you are experiencing increasing shortness of breath and tolerating less and less activity, you should contact your doctor or nurse for advice.

ESC Guidelines for Heart Failure

What patients need to know

This guide for patients from the European Society of Cardiology aims to provide an overview of the latest evidence-based recommendations for the diagnosis and treatment of heart failure.

In particular, it should help patients to understand the:

  • main types of heart failure
  • medicines used to treat heart failure
  • devices that may be appropriate
  • importance of rehabilitation
  • management by a multidisciplinary team
  • importance of self-care in managing your own condition

Learn more

Download the Guidelines


A series of 9 simple, captivating animations explaining heart failure and its treatment.

These narrated animations explain how a healthy heart works, what happens to it in heart failure and how various treatments work to improve your health.

How the normal heart works

What goes wrong in heart failure

How the heart and body compensate in heart failure

How heart failure causes fluid accumulation

How a heart attack can cause heart failure

How abnormal heart valves can cause heart failure

How vasodilators work in heart failure

How diuretics work in heart failure

How medical devices work in heart failure


In this section you can watch, listen or read interviews with other people with heart failure and their caregivers.

Patient in exercise training

Patient with an ICD

An LVAD as a bridge to transplantation

Adjusting lifestyle and staying optimistic

Living with heart failure devices

Challenges in making the diagnosis

Living with an LVAD


and share your own views and experiences with other patients, families and caregivers.


heartfailurematters.org is a European Society of Cardiology website

The heartfailurematters.org website was developed under the direction of the Heart Failure Association of the European Society of Cardiology (ESC). The ESC is a world leader in the discovery and dissemination of best practices in cardiovascular medicine. Our members and decision-makers are healthcare professionals who volunteer their time and expertise to represent professionals in the field of cardiology in Europe and beyond.

Heart failure: symptoms, diagnosis, treatment of heart failure

The main function of the heart is pumping – the heart muscle pumps blood through the body. The task of blood is to carry oxygen to all organs and tissues.

Heart failure is the inability of the heart to deliver the required amount of blood and oxygen to organs and tissues.
A lot of heart diseases (hypertension, myocardial infarction, heart defects, myocarditis, etc.) can lead to heart failure. Sometimes heart failure is a complication of diseases of other organs.

Symptoms of heart failure are varied, from very mild shortness of breath, which a person hardly notices, to the most severe degrees of the disease, when a person is practically unable to move (severe shortness of breath, massive swelling, etc.) Shortness of breath and swelling are the most specific symptoms of heart failure . Also, symptoms of the disease can be weakness and fatigue, hypotension, palpitations, blue lips and earlobes during physical exertion.
The most common symptom.

Shortness of breath is rapid breathing caused by oxygen starvation of the tissues. Normally, a person makes 14-16 respiratory movements per minute. With heart failure, this figure can double. With shortness of breath caused by heart failure, it is difficult to breathe.
Initially, physical activity becomes a “provocateur” of shortness of breath. There is a classification of heart failure into 4 functional classes, depending on exercise tolerance.

  • functional class – shortness of breath occurs during very large physical exertion.
  • functional class – shortness of breath appears with moderate physical exertion.
  • functional class – small household loads already cause shortness of breath.
  • functional class – shortness of breath occurs at rest – the person does not move, but breathes very quickly.

The extreme manifestation of shortness of breath is the inability to sleep lying down (in the supine position, shortness of breath increases). As soon as a person tries to lie down, he begins to suffocate. This is due to the fact that when a person lies down, the flow of blood from the veins to the heart increases, and it is unable to pump it. Blood stagnates in the vessels of the lungs, so shortness of breath occurs. Sometimes patients with heart failure sleep half-sitting or even sitting, lowering their legs down – in this position, part of the blood goes into the veins and it is easier for the heart to work. The maximum relief from such symptoms is achieved in the sitting position on a chair – this is the easiest way for a person to breathe.
Shortness of breath in heart failure may lead to pulmonary edema. This is an acute condition, accompanied by weakness and panic attacks, cold sweat, blue lips. Shortness of breath is getting stronger, not stopped by the usual methods. If you experience these symptoms, you should immediately call an ambulance. Before the arrival of the brigade, take a semi-sitting position with legs down, remove all items of clothing that tighten the throat and chest, and provide fresh air.

Edema usually occurs on the legs. Most often, swelling begins to appear on the ankles and legs. In the first stages, swelling occurs after a long walk, in the evening – and disappears after rest, in the morning. Each person can check his body for the presence of edema. To do this, just press on the shin in front, hold for a few seconds and release. If a trace (fossa) remains, there is edema.
The location of the edema depends on how mobile the person is. If a person is mainly in bed rest, lying, swelling can be localized on the face, on the sacrum, on the legs. The degree of edema depends on the degree of heart failure – only the ankles or lower legs can swell, the ankles, lower legs and thighs can swell at the same time. There may be swelling throughout the body (including an edematous abdomen – accumulation of fluid in the abdominal cavity) – the highest degree of heart failure. In advanced cases of the disease, the kidneys suffer, which cannot cope with the excretion of fluid and it lingers in the body; liver and other internal organs.

Systolic and diastolic, left ventricular and right ventricular, heart failure
Heart failure is primarily subdivided into systolic and diastolic. Systole is a period of contraction of the heart muscle (the heart pushes blood out), diastole is a period of relaxation (the heart draws blood). In systolic heart failure, the heart is unable to contract strongly enough. The heart muscle is weak and does not push all the blood into the body. As a result, a certain amount of blood constantly remains in the heart, it begins to stretch, and all organs and tissues suffer from a lack of oxygen. Systolic heart failure occurs when diseases of the heart muscle itself, such as myocarditis, coronary heart disease (CHD), scarring of the heart, myocardial infarction.
In diastolic heart failure the heart muscle can contract and eject all the blood, but it is unable to relax sufficiently. The heart takes in less blood than the body needs. Diastolic heart failure can occur with arterial hypertension, amyloidosis (deposition of a certain protein on the inner wall of the heart, due to which it loses elasticity), valvular heart disease, diabetes mellitus and other diseases.
To understand the mechanism of right ventricular and left ventricular failure, you need to understand how blood moves through the body.
The heart consists of two sections – right and left. The right heart is venous. Blood in the heart flows from the veins into the right atrium, then into the right ventricle, and from there into the lungs. This is a small circle of blood circulation. The blood in it is venous, “dirty”, blue. In the lungs, the blood is enriched with oxygen, it becomes not venous, but arterial. From the lungs, it flows into the left atrium, from there into the left ventricle, and the left ventricle sends blood to the aorta, from where the blood will disperse through all the vessels to nourish the organs and tissues. In the smallest vessels (capillaries) gas exchange occurs – the blood gives off oxygen, takes carbon dioxide. From the capillaries, blood enters small veins, and then the “dirty” blood moves through the veins back to the heart.

Right ventricular heart failure – reduced ability of the right side of the heart to draw blood from the veins. Because of this, the veins begin to expand, there is a leakage of part of the blood fluid into the intervascular bed of the subcutaneous fatty tissue. Edema occurs. Therefore, the main manifestation of right ventricular failure is edema. Right ventricular heart failure may develop in diseases of the lungs. For example, the primary disease is bronchial asthma. Due to the fact that the vessels of the lungs are very much changed, the right parts of the heart, in order to push the blood into these changed vessels, are forced to work with a very large overload. The right parts of the heart are weak, not adapted to heavy loads. They do not have time to take blood from the veins.
Left ventricular failure is reduced function of the left side of the heart. The left side of the heart must take blood from the lungs and pump it into the body. If the left ones do not work well, blood from the lungs flows through the arteries, and the heart cannot pump it. Then part of the blood stagnates in the lungs. There is shortness of breath. From the left ventricle, blood is also ejected weakly – an insufficient amount of blood – a person has low pressure, a person may faint. Edema in left ventricular failure can also occur, but the right side of the heart is involved.

Diagnosis of heart failure
It is very important to diagnose the disease in time, to establish its causes. Sometimes when the causes of heart failure are eliminated, the heart returns to normal . Only a doctor can determine the scope of diagnosis in case of suspected heart failure based on the patient’s story – what exactly worries you, how the first signs of discomfort appeared, etc.
As a rule, an ECG, ECHO KG (ultrasound examination of the heart) is performed. ECHO KG allows you to see how much the heart contracts and relaxes (systole and diastole), to clarify the ejection of blood (amount of blood), to evaluate the functioning of the heart valves. A biochemical blood test is mandatory, and sometimes the function of the thyroid gland is examined. In each case, the scope of the necessary diagnostics is specified depending on the symptoms.

Treatment of heart failure
In the treatment of heart failure , drug treatment is primarily used. But in some situations, surgical methods have better results. For example, for many heart defects, the most effective surgical treatment is valve replacement.
It is very important that in case of heart failure the patient is observed by one doctor, because the treatment regimen, the selection of drugs is strictly individual. The doctor selects the dosage of the drug for each specific case, and carefully monitors the dynamics of the patient’s condition.

Outpatient dyspnoea | Vertkin A.L., Topolyansky A.V., Knorring G.Yu., Abdullaeva A.U.

It is known that shortness of breath is a fairly common reason for visiting a doctor; it accompanies many diseases of both the respiratory and cardiovascular systems (CVS), disturbing patients in different ways and, unfortunately, far from always having a favorable outcome.
The great Russian clinician D.D. Pletnev wrote: “It is difficult to give an exact definition of the concept of “shortness of breath”. It is difficult because two kinds of phenomena are simultaneously mixed here: objective and subjective. In some cases, the patient complains of shortness of breath, while the doctor does not find any symptoms of it, with the exception of the patient’s complaints, and vice versa. There may be objective symptoms of shortness of breath (increased or slower and deeper breathing, cyanosis), while the patient does not complain of shortness of breath” [1].
“Complaints of patients with cardiovascular disorders are reduced primarily to shortness of breath. Shortness of breath in heart patients usually occurs during physical exertion (walking, climbing stairs, muscle work). In people accustomed to physical exertion, shortness of breath in violation of the cardiovascular system occurs later, while in untrained people, shortness of breath occurs earlier and from less significant exertion. At rest, shortness of breath of cardiac origin appears only in seriously ill patients. Shortness of breath is distinguished from asthma attacks, which most often develop suddenly, at rest or some time after physical (or mental) stress; often these attacks appear at night, during sleep” [2].
In modern clinical medicine, shortness of breath is understood as the subjective perception of respiratory discomfort, which includes sensations of a variety of nature and intensity and may or may not be accompanied by objective respiratory disorders (American Thoracic Society, 1999). It can be accompanied by hyper- and hypopnea, tachy- and bradypnea, hyper- and hypoventilation, it can be subjective, objective or subjective and objective at the same time. Choking is an extreme degree of dyspnea, usually characterized by a painful feeling of lack of air.
A typical reason for a patient to seek medical help is the desire to relieve symptoms and exclude the presence of a serious pathology. Shortness of breath can also occur in a healthy person with significant physical exertion, however, it should be regarded as a sign of a pathological condition only in those cases when it occurs at rest or with a slight exertion that was previously easily tolerated by the patient. The doctor’s task is to exclude life-threatening pathology, including a severe attack of bronchial asthma (BA), pulmonary embolism (PE), myocardial infarction, etc. (Table 1).

In the differential diagnosis of dyspnea, it is necessary to evaluate the factors contributing to it or accompanying this condition (Table 2).

Alarming symptoms when a patient complains are: tachypnea, tachycardia, stridor, cyanosis, hypotension, participation of the auxiliary muscles of the chest in breathing (the so-called “red flags”), which indicates the severity of the condition and requires immediate assistance.
It is necessary to pay attention to the subjective manifestations of shortness of breath: patients may complain of rapid breathing, lack of air, inability to breathe deeply, and sometimes they mean pain that limits respiratory movements by shortness of breath. It is also important that it is harder for the patient – to inhale or exhale? Expiratory dyspnea is more often observed with violations of bronchial patency (additional respiratory muscles work mainly on inhalation), inspiratory – with heart failure (insufficient blood flow causes stimulation of the respiratory center, which makes you breathe more often and deeper).
However, severe bronchial obstruction may be accompanied by a feeling of inability to take a full breath, with cardiac asthma, swelling of the bronchi can cause bronchial obstruction, and patients with anxiety conditions often complain of the inability to take a deep breath. In BA, after coughing with viscous sputum, breathing is facilitated; in heart failure, sputum, usually liquid and foamy, does not bring relief.
One of the key issues is the relationship of dyspnea with exercise. In diseases of the cardiovascular system and respiratory organs, shortness of breath occurs or increases with physical exertion. An episodic, unrelated feeling of lack of air (incomplete inspiration), a periodic need to take a deep breath, are observed in patients with anxiety, autonomic dystonia and hyperventilation. The patient’s exercise tolerance (shortness of breath occurs at rest, when talking, when going uphill or stairs, when walking on a flat surface) allows you to assess the severity of respiratory or heart failure. Choking at night can occur with asthma, and in patients with cardiovascular diseases (CVD) – indicate the development of cardiac asthma. With heart and respiratory failure, breathing always becomes easier in a sitting position, with PE, shortness of breath does not depend on body position, a decrease in shortness of breath when walking can be a sign of autonomic dystonia.
When examining a patient, it is necessary to focus on dry rales audible at a distance, which are described by patients with asthma. However, bubbling breathing occurs with acute left ventricular failure. Shortness of breath in some cases is combined with chest pain (with myocardial infarction, PE, spontaneous pneumothorax), productive or unproductive cough (with COPD, cardiac asthma, pneumonia), hemoptysis (with bronchiectasis, lung cancer, pulmonary tuberculosis, PE), with palpitations (with atrial fibrillation), symmetrical edema (with heart, renal failure), fainting (with pulmonary embolism). Swelling in one leg may indicate deep vein thrombosis (a risk factor for PE).
Pay attention to general symptoms: fever (usually a sign of exacerbation of COPD or pneumonia), lack of appetite and progressive weight loss (suspicious in terms of oncopathology). Patients with panic attacks describe paroxysmal conditions with a host of unpleasant symptoms, including, in addition to anxiety and shortness of breath, pain or discomfort in the left side of the chest, palpitations, muscle tremors, dizziness, paresthesia, etc.
A special place in the questioning of a patient with shortness of breath is the collection of anamnesis (Table 3). The age at which shortness of breath appeared plays a role: CVD often debut in the elderly and senile age, broncho-obstructive – in the young, anxiety disorders – in puberty or menopause.

During the physical examination, it is important to look for the following symptoms.
1. Fever may indicate an infection, and a slight increase in temperature occurs with PE, oncological diseases.
2. Cyanosis indicates the presence of a serious pathology of the heart or lungs. In some cases, it is not expressed in anemia, which is characterized by a pale color of the skin and visible mucous membranes. With carbon monoxide poisoning, the skin turns cherry in color.
3. Hyperhidrosis can be a sign of infection or myocardial infarction.
4. “Hour glasses” and “drumsticks” indicate the presence of a chronic pulmonary disease, more often observed in the formation of bronchiectasis.
5. Patients with COPD are often obese, with a barrel-shaped chest and cyanosis, or, conversely, thin people.
6. Swelling of the legs usually indicate heart failure; unilateral swelling of the leg may be a manifestation of deep vein thrombosis of the legs (a possible source of PE).
7. Exhalation through closed lips is a characteristic sign of emphysema. Harsh breathing and dry scattered rales are detected with bronchial obstruction, unvoiced fine bubbling rales below the shoulder blades – with congestive heart failure. Physical changes in pneumonia include localized shortening of lung sounds, crepitating or ringing fine bubbling rales, and hard or bronchial breathing. Bronchial breathing can also be heard in lung cancer. With pneumothorax, tympanitis is detected on the side of the lesion, breathing is sharply weakened or not carried out. A dull percussion sound is observed with effusion into the pleural cavity.
8. The shift of the apex beat down and to the left indicates cardiomegaly (and, accordingly, speaks in favor of the cardiac nature of shortness of breath). Analysis of heart sounds and the presence of heart murmurs can detect aortic and mitral heart defects. Characteristic signs of heart failure are the appearance of the III tone and the gallop rhythm. The presence of an arrhythmia indicates heart failure, while atrial fibrillation is a risk factor for PE. Blood pressure is most often normal, rises with anxiety, its fall is a possible sign of the development of shock.
Analysis of laboratory data can also guide the doctor – for example, the identification of anemia, which can provoke an increase in heart failure or cause shortness of breath by itself. Erythrocytosis often accompanies the course of COPD, and leukocytosis indicates infections of the lower respiratory tract (purulent bronchitis, pneumonia). Eosinophilia is observed in asthma, allergies. An increase in ESR may indicate an infection or tumor process.
EchoCG in patients with left ventricular heart failure sometimes reveals signs of left ventricular overload, cicatricial changes in the myocardium, cardiac arrhythmias, in patients with COPD, pulmonary embolism, primary pulmonary hypertension – signs of overload of the right heart. An x-ray examination of the chest organs with left ventricular failure reveals cardiomegaly, signs of stagnation in the pulmonary circulation, effusion in the pleural cavity; with COPD – signs of pneumosclerosis, emphysema.
With spirography, a decrease in FEV1 (PSV) less than 80% of the proper value indicates the presence of bronchial obstruction, an increase in this indicator by 20% or more from the initial value in a sample with short-acting bronchodilators indicates reversible bronchial obstruction (BA), less than 12% indicates irreversible (COPD).
Shortness of breath is one of the most common reasons for seeking medical help and the main manifestation of CHF, which remains one of the world’s leading medical problems [3, 4]. In a significant number of cardiac patients, acute decompensated heart failure (ADHF) becomes the cause of death. According to the 2014 data presented in the latest revision of the European guidelines for the treatment and diagnosis of CHF and ADHF, 10 million patients suffer from CHF. According to experts of the European Society of Cardiology, the percentage of patients with CHF in the coming years will reach 3% of the entire population [3]. It is the decompensation of CHF that is the cause of 5% of all emergency hospitalizations in Europe and occurs in 10% of all patients in hospitals.
The course of decompensation can be different: from the rapid onset and progression of typical symptoms within a few hours to the gradual development of the clinical picture over several weeks (Fig. 1).
At a certain stage, progressive CHF begins to pose a threat to life and requires immediate hospitalization; with such a development of events, the term ADHF has been proposed, which includes: rapid progression of CHF itself; the development of the same acute conditions leading to new acute heart failure (AHF) (acute infarction, PE, acute valvular lesions, etc. , see Fig. 1).

Both CHF and OHF lead to ODSN. However, it is necessary to clearly understand the differences in their clinical picture (Table 4).

At the same time, the polyclinic doctor must, using well-known diagnostic techniques (Table 5), correctly assess the patient’s condition, correct therapy, and determine indications for inpatient observation.

The number of patients hospitalized in the cardio intensive care unit (CRO) with decompensated CHF is increasing every year. In 2014, out of 3325 patients hospitalized in the KRO, 2250 (67.7%) were with ADHF: AHF developed against the background of CHF in 80% of cases, and in 20% of patients it occurred for the first time (Fig. 2) [5].

Due to the fact that a large number of patients experience episodes of acute CHF decompensation over and over again, all the efforts of doctors are aimed at reducing the risk of CHF decompensation and sudden death, as well as keeping the patient within the existing FC. However, in modern patients, recurrent episodes of CHF decompensation, comorbid pathology, kidney dysfunction, diuretic resistance, susceptibility to hypertension, predisposition to arrhythmia are increasingly noted [7, 8].
Decompensation of heart failure is primarily an excess of fluid in the body, which naturally requires increased diuretic therapy. However, there are more and more patients with resistance to diuretics. According to the ADHERE registry, the number of such patients exceeds 20% of all those suffering from CHF. It is obvious that decompensated patients require not only increased therapy (by increasing doses or changing routes of administration, for example, infusion of loop diuretics), but also the appointment of new drugs [6].
Torasemide is the first diuretic capable of influencing not only the symptoms of CHF patients, but also the progression of the disease and the course of pathological processes in the heart muscle (Table 6).

According to the diuretic effect, torasemide at a dose of 5 mg corresponds to 25 mg of hydrochlorothiazide, and at a dose of 10 mg – 40 mg of furosemide. However, unlike furosemide, the absorption of torasemide does not depend on the severity of heart failure. The TORIC Study, which included 1377 patients, showed that torasemide had a significantly better effect on the main endpoints, including both total and cardiac mortality, than furosemide [9] (Fig. 3).

Another randomized open 6-month study [10] compared the efficacy of torasemide and furosemide in 50 patients with HF II-III FC who did not respond to treatment with low-dose furosemide and ACE inhibitors. Patients of the main group were transferred to torasemide at a dose of 4–8 mg/day, while patients in the comparison group continued to take furosemide at the same dose (20–40 mg/day). Therapy with torasemide for 6 months. contributed to a statistically significant decrease in end-diastolic size, myocardial mass index, LV diastolic dysfunction and natriuretic peptide concentration. There were no similar changes in the furosemide group. According to the authors, they could be explained by the blockade of aldosterone receptors under the action of torasemide.
The accumulated experience of using this drug made it possible to determine its place in the algorithm for the use of diuretics in CHF (Table 7).

In Russia, the generic torasemide drug Trigrim is successfully used. Due to its clinical and pharmacoeconomic efficiency, it deserves wider use in outpatient practice in the management of patients with CHF. Although all loop diuretics increase diuresis at equivalent doses, their effectiveness may be impaired by impaired renal function or absorption in the gastrointestinal tract (as a result of mucosal edema). Therefore, when choosing a drug, it is necessary to take into account the features of its pharmacokinetics and pharmacodynamics. Compared to furosemide, torasemide has a higher and more predictable bioavailability, a longer half-life, and a stable diuretic effect. These properties determine its increased efficacy in patients with heart failure, which has been demonstrated in a number of controlled clinical trials.
An important advantage of torasemide is the reduced risk of hypokalemia.