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Heart failure

Heart failure

Also known as Congestive heart failure and CHF


The first thought that comes to your mind when you hear about “heart failure” is that the heart is no longer working and you can’t do anything about it. But this is not true. In reality, heart failure is a condition in which the heart fails to pump blood to the body as efficiently as it should.

To put it technically, heart failure is a complex condition that impairs the ability of the lower chambers of the heart (called ventricles) to eject blood due to an underlying structural or functional heart problem. The condition develops over time as the heart muscles become weaker or stiffer, which ultimately affects the pumping capacity of the heart. 

While the risk of suffering from heart failure increases with age, there are certain factors that can put you at risk even at a young age. These include having a high BMI (body mass index), unhealthy choices such as smoking, sedentary lifestyle, consuming a diet high in saturated and trans fats as well as diseases that damage your heart.

There are various treatment options that can help in heart failure and many people with heart failure live active lives. Medications for heart failure aim to manage the symptoms, improve the quality of life as well as increase the lifespan. In some cases, medical devices, surgery or heart transplant are recommended to help the heart function better.

Key Facts

Usually seen in
  • Individuals above 65 years of age
Gender affected
  • Both men and women but common in men
Body part(s) involved
  • Heart
Mimicking Conditions
  • Acute kidney injury
  • Acute respiratory distress syndrome (ARDS)
  • Bacterial pneumonia
  • Cirrhosis
  • Community-acquired pneumonia (CAP)
  • Emphysema
  • Interstitial (nonidiopathic) pulmonary fibrosis
  • Myocardial infarction
  • Nephrotic syndrome
  • Pneumothorax imaging
  • Pulmonary embolism (PE)
  • Respiratory failure
  • Venous insufficiency
  • Viral pneumonia
Necessary health tests/imaging
Specialists to consult
  • Cardiologist
  • Cardiac surgeon

Symptoms Of Heart Failure

Before knowing about the symptoms of heart failure, it is important to know what happens in heart failure. 


What happens in heart failure?

The heart, which is just the size of your fist, serves the action of continuously pumping blood over the body. The heart has four chamber -- two upper chambers called atria and two lower chambers called ventricles. For the heart to function properly, the four chambers must beat in an organized way.

But in some cases, the heart cannot pump blood with enough force to reach the rest of the organs, or the heart may not get filled with enough blood to meet the demands of other organs. Since the heart ‘fails’ to meet the body's needs for blood and oxygen, the condition is termed as heart failure.

Heart failure can affect the right or the left side of the heart, or even both sides. However, it usually affects the left side first. 

Right-side heart failure: It occurs if the heart is not able to pump adequate blood to the lungs for oxygenation.

Left-side heart failure: It occurs if adequate oxygen-rich blood cannot be pumped by heart to the rest of the organs.

Signs and symptoms to watch out for!

The symptoms of heart failure may start suddenly or progress gradually over weeks or months. The most common symptoms of heart failure and their reasons are listed below: 

Breathlessness: In left-sided heart failure, inefficient pumping of blood causes extra fluid to collect in your lungs, causing rapid and shallow breathing. 

Persistent cough and wheezing: The fluid build-up in lungs can also make you cough and wake up at night. The persistent cough may be accompanied by white or blood-tinged mucus.

Tiredness or fatigue: Since the heart is incapacitated to pump enough blood, the body diverts blood away from less vital organs, particularly muscles in the limbs leading to tiredness.

Swelling of feet, ankles and legs: In right-sided heart failure, fluid may back up into the abdomen, legs and feet, causing swelling.

In addition to the above-listed symptoms, other symptoms that can occur in patients with heart failure are:

  • Loss of appetite
  • Increased heart rate
  • Dizziness
  • Confusion 

In systolic heart failure (also called heart failure with reduced ejection fraction), the left ventricle can't contract vigorously, indicating a pumping problem. In heart failure with preserved ejection fraction, the left ventricle can't relax or fill fully, indicating a filling defect.

Types Of Heart Failure

There are four stages of heart failure based on severity: 

  • Symptom-free (asymptomatic) heart failure: There are no symptoms, but certain tests can detect that the heart isn't performing as well as it should.

  • Mild heart failure: Strenuous exercises like walking up the stairs causes symptoms like extreme tiredness or shortness of breath. However, mild activity doesn't cause any symptoms.

  • Moderate heart failure: Even everyday activities and light physical exercise like walking on a level surface can cause symptoms.

  • Severe heart failure: Symptoms occur at rest or during even the minor physical activity. You can only lie down if your upper body is elevated. Some people with severe heart failure are bedridden.


Your heart along with the blood vessels that feed it is one big muscular structure. So, when this structure starts to fail, you can get signs and symptoms anywhere in the body. Here are seven surprising clues that your heart needs a check.

Causes Of Heart Failure

Most people who develop heart failure have (or had) another heart condition first. The most common conditions that can lead to heart failure are:

  • Coronary artery disease: It causes build-up of plaque (fatty deposits) in the arteries that supply blood to your heart muscle leading to narrowing of the blood vessels. 

  • Heart attack (myocardial infarction): It reduces/blocks blood flow to the heart muscle and impacts the heart’s ability to pump blood.

  • Cardiomyopathy (heart muscle disease): These diseases of the heart muscle may lead to left ventricle dysfunction and damage the heart muscles and change the structure of your heart making it harder for your heart to pump blood.

  • Valvular heart disease (disease of heart valves): Rheumatic fever may permanently damage the heart valves leading to heart failure.

  • Hypertension (high blood pressure): When the blood pressure is high, your heart has to pump harder than normal to maintain blood circulation. 

  • Atrial fibrillation (AF): It refers to the irregular and rapid beating of the heart. It is both a cause and consequence of heart failure. 

  • Untreated congenital heart defects: Although rare, it is a condition in which the heart and its chambers may not be formed correctly at birth.

  • Anemia: Anemia can worsen cardiac function and add further stress to the heart, which may lead to heart failure.

  • Infections: Infections activates the body’s immune response, generating inflammation that causes rupture and blockages that lead to heart failure.

Heart failure should not be confused with a heart attack
Heart attack comes on suddenly and may happen without any warning. However, heart failure occurs more gradually. You might even have it for years before you notice any symptoms.
Heart failure should not be confused with a heart attack

Risk Factors For Heart Failure

You can know your risk of having heart failure by taking a look at the following modifiable and non-modifiable risk factors.

Non-modifiable factors

Age: By the time you get older, diseases you may have been suffering from for many years like coronary artery disease, diabetes & hypertension might have damaged your heart, increasing the risk of heart failure.

Gender: Women are at a higher risk of heart failure if they have hypertension, while men are greatly impacted if they have coronary artery disease.

Race/ethnicity: Race/ethnicity can be a risk factor for heart failure. Heart failure strikes young in black-skinned people, particularly men, and people of Hispanic (Spanish) origin. 

Genetic predisposition: Growing numbers of Indians are being afflicted and genetic predisposition is one of the reasons. Indians have high levels of lipoprotein (a), a type of cholesterol, which is reported to accentuate the risk associated with other risk factors of heart failure.

Modifiable factors
Some of the conditions that can up your risk of heart failure (but can be managed) include:

  • Heart disease
  • Diabetes mellitus
  • Sleep apnea
  • Obesity
  • Lifestyle factors such as smoking

Diagnosis Of Heart Failure

To diagnose heart failure, your doctor will take a careful medical history, review your symptoms and perform a physical examination. Your doctor will also check for the presence of risk factors such as high blood pressure, coronary artery disease or diabetes. You may have to undergo the following tests to diagnose heart failure:


Blood tests: Some of the common blood tests that can help determine heart failure and its impact on other organs include: 

Chest X-ray: It shows accumulation of fluid in the lungs & and enlargement of heart in patients with heart failure. 

Electrocardiography (ECG or EKG): This test records the electrical activity in the heart by using sensors that are connected with wires to an electrocardiograph monitor. It is an important diagnostic method for determining heart failure associated with conditions like myocardial infarction, atrial fibrillation, abnormalities in heart rhythm, or acute ischemia. 

Echocardiography (Echo): An echocardiogram is an ultrasound, which is used to determine volume of the blood in the heart, mass, and valve functioning of the heart. 

Multigated acquisition scan (MUGA scan): This is a non-invasive diagnostic test that shows how well the lower chambers of your heart (ventricles) are pumping blood. During this test a small amount of a radioactive tracer or dye is injected into a vein. A special gamma camera detects the radiation released by the tracer to create video of the beating heart. 

Ejection fraction (EF): It is a measurement of the blood pumped out of the heart each time it contracts. EF can be measured using an echocardiogram, multigated acquisition scan, nuclear medicine scan, magnetic resonance imaging (MRI) or during a cardiac catheterization. According to the American Heart Association, the normal ejection fraction is about 50% to 75%.

Treadmill test (TMT) or exercise stress test:
This test shows how the heart works during physical activity. The test involves walking on a treadmill or stationary bike at different levels of difficulty while your heart rate, breathing and blood pressure are recorded. If someone cannot exercise, a drug may be used to mimic the effect of exercise on the heart.

Celebs affected

Elizabeth Taylor
The legendary American actress was diagnosed with congestive heart failure. She was able to manage her condition for years with treatment options.

Prevention Of Heart Failure

Prevention of diseases that damage the heart is the best way to keep heart failure at bay. If you suffer from any of the conditions that cause heart failure, then prompt, optimal management of the condition is important. Recognizing and avoiding all the factors that may lead to or contribute to heart failure can help prevent the development of the condition. The following pointers can help you understand the preventive measures to avoid or delay heart failure.

1. Consume diet that promotes heart health

  • Prefer eating fruits and vegetables, low-fat dairy products, lean protein such as chicken without the skin, and healthy fats like olive oil, walnuts, avocados and fish like tuna and salmon. 

  • Limit saturated fats, trans fats, and cholesterol in your diet.

  • Limit salt (sodium) in your diet as excess salt can cause fluid retention and put strain on your heart. It also elevates your blood pressure.

  • Limiting sugar in your diet can lower your blood sugar level which can prevent or control diabetes.

  • Modern day diets are sometimes not sufficient to fulfill the needs of the body. To augment the health of your heart, take dietary supplements containing conenzyme Q10 (CoQ10), L-carnitine, crataegus (hawthorne), magnesium, and fish oil.

2. Exercise and stay active

Exercising can help to improve your general wellbeing and heart function by maintaining a healthy weight, blood pressure, blood cholesterol, and blood sugar levels. Adults should aim at 2 hours and 30 minutes of moderate-intensity exercise like brisk walking or bicycling every week. Children and adolescents should have 1 hour of physical activity every day. One should also avoid sitting for more than 2 hours at a stretch in a day.

3. Lose weight if you’re overweight or obese

Lose weight to attain body mass index (BMI) between 18.5 and 24.9. Pay more attention to losing abdominal or belly fat as it can increase the risk of heart disease more than fat on other parts of the body.

4. Do not smoke and if you do, quit smoking at the earliest

Consult your doctor for advice on ways to stop smoking. Smoking can damage your arteries that can cause heart failure. Also try to stay away from secondhand smoke. 

5. Limit alcohol intake

Do not drink too much alcohol, which can raise your blood pressure. Men should consume no more than 2 drinks per day, and women no more than 1 drink per day. And in case you already have heart failure, alcohol can make it worse.

6. Treat another type of heart disease or related condition

Other heart problems, like heart attacks, increase the risk of heart failure. Hence, treatment and adherence to prescribed medications for high blood pressure can make a big difference. 

7. Manage your stress as it can elevate your blood pressure

Mind-body practices such as Tai Chi, yoga, Qi Gong, and meditation can help in managing stress and thereby preventing heart diseases that lead to heart failure.

8. Have good quality sleep

Make lifestyle changes to get sound sleep, like going to bed and getting up at the same time every night, and keeping electronics out of the bedroom. Sleep problems like sleep apnea can increase the risk of heart failure. If you suffer from it, get treatment at the earliest.

9. Get your annual flu vaccination

The flu shot helps to prevent lung infections which can worsen the symptoms of heart failure.

For patients at risk of developing heart failure, screening for natriuretic peptide biomarkers and early intervention may prevent the condition.

To help you prevent heart disease and lead a healthy life, here are a few tips that every cardiologist wants you to know.

Specialist To Visit 

If you experience any symptoms of heart failure, do not take them lightly. It is best to consult a doctor who will evaluate the underlying cause of these problems and also assess the functioning of your heart. In addition to a general physician, specialists who can help to diagnose and treat heart failure include:

  • Cardiologist
  • Cardiac surgeon

We all know that a heart specialist is an expert who specializes in diagnosing, treating and preventing heart-related illness and complications. However, not all cardiologists or heart specialists are the same. Here’s more on the types of heart specialists and who you should consult for various heart problems.

Treatment Of Heart Failure

The risk of heart failure can definitely be lowered by home-based lifestyle modifications like diet and exercise, but once you have been diagnosed with heart failure, it may become necessary to take certain medications or go for surgery.

A. Medications
People suffering from heart failure may need multiple medications for their condition. These medications are beneficial in treating and preventing heart failure. Whereas some of the medications help in improving sodium excretion, exercise tolerance, and cardiac function. The medicines that are commonly used in congestive heart failure are:

1. Diuretics: Also known as water pills, these drugs work by removing extra water and certain electrolytes from the body. This increases the amount of urine produced and aids in controlling hypertension and treating heart failure. Examples of drugs that belong to this class include:
2. Angiotensin-converting enzyme (ACE) inhibitors: They work by dilating or widening blood vessels. This makes the blood flow more freely and the heart is able to pump blood more efficiently. Examples include: 
3. Beta-blockers: Beta-blockers slow down the heart rate and make it easier for the heart to pump blood around the body. This lowers blood pressure and prevents a heart attack. They also widen the blood vessels in the body for better blood flow. Some of the common drugs include:
4. Aldosterone antagonists: Aldosterone antagonists work by inhibiting the effects of aldosterone, a hormone that causes retention of sodium and water, leading to increased blood volume, and a subsequent increase in blood pressure. These drugs lower blood pressure and reduce fluid around the heart by removing the extra water and electrolytes from the body without loss of potassium. Some of the common examples include:
5. Angiotensin II receptor blockers (ARBs): This class of drugs relaxes blood vessels by blocking the action of Angiotensin, a chemical that narrows the blood vessels. These drugs lower the blood pressure, allowing the blood to flow more freely to different organs and the heart to pump more efficiently. Examples of the common medicines in this category are:

6. Other drugs: Additionally, other drugs that can be used to treat heart failure include: 

  • Sacubitril + valsartan belongs to a class of angiotensin receptor neprilysin inhibitors (ARNI). This combination treats heart failure by relaxing the blood vessels and making it easier for your heart to pump blood throughout your body. In addition, it also helps the body retain less water.
  • Ivabradine reduces the heart rate and lowers the workload on the heart and hence the oxygen requirement. As a result, the pumping action of the heart remains fully efficient.
  • Isosorbide dinitrate + hydralazine is a combination drug. Isosorbide dinitrate relaxes the blood vessels and decreases the oxygen demand of the heart. Hydralazine acts as an antioxidant and lessens tolerance to isosorbide dinitrate, thereby preserving its capacity to relax blood vessels. Together, they improve symptoms of heart failure.
  • Dapagliflozin is a drug commonly used to treat diabetes mellitus but recently this medicine has been found to be effective in patients with heart failure as well. It works by removing excess sugar from the body through urine. It is also known to reduce cardiovascular events and deaths due to heart failure.

B. Surgery
Some of the commonly recommended surgical treatment options for people with heart failure are: 

  • Angioplasty: Angioplasty is the procedure for opening up the blocked blood vessels that can restrict the blood supply to the heart muscle (a major cause of heart failure).
  • Coronary artery bypass: The procedure of coronary bypass redirects a blood supply around a blocked artery.
  • Valve replacement: A defective or diseased valve can be a major cause of heart failure. In valve replacement, a faulty heart valve is replaced by an artificial mechanical valve.
  • Heart transplantation: A heart transplant is needed if the heart muscle function continues to deteriorate despite treatment. People with end-stage heart failure and those with congenital heart disease require heart transplantation.

C. Devices
Based on the cause & severity of your condition your doctor can recommend certain surgical devices to improve your heart condition. 
  • Implantable cardiac defibrillator (ICDs): It is a small battery-powered device placed in your chest to detect and stop abnormal heartbeats. This device delivers electrical signals inside the heart to restore a normal heart rhythm. 
  • Cardiac resynchronization therapy (Biventricular Pacing): It is a treatment for heart failure in people whose ventricles don't contract at the same time.
  • Ventricular assist devices (VADs): This is also known as a mechanical circulatory support device, which is an implantable mechanical pump that helps pump blood from the lower chambers of your heart (the ventricles) to the rest of your body.  A VAD is used in people who have heart failure or temporarily by patients waiting for a heart transplant or heart recovery from injury.

Home-care For Heart Failure

The following simple changes in your lifestyle can be a major contributing factor in alleviating the symptoms of heart failure:

Stay physically active: Supervised moderate exercise is an integral part of a healthy heart regimen. It also helps in maintaining a healthy weight as obesity is a known factor that worsens heart failure. You can consult your doctor on which exercise to do in case you are at risk of heart failure.

Eat a heart-friendly diet: Foods that are good for your heart include green leafy vegetables, fruits, nuts, whole grains & low-fat dairy products. Try to limit the consumption of trans fat, saturated fats, cholesterol, red meat, and sugary foods.

Keep stress at bay: Stress can increase your blood pressure, hence it is important to manage it effectively. For stress-relieving, you can try yoga and meditation or deep breathing exercises.

Find out how yoga can keep your heart healthy.

Limit the amount of fluid you drink:
Do not drink more than 1.5 litres or 6 cups of fluid every day. Fluids include water, juice, soup, tea, coffee, and even some fruits like watermelons. You can also maintain a fluid balance chart to record how much fluids you are drinking.

Weigh yourself daily: Weigh yourself every day to monitor any signs of fluid retention in the body. Note your weight at the same time every day in the morning after using the washroom. Make sure not to eat anything before weighing yourself. Also, try to use the same weighing scale every day. Consult your doctor in case of any sudden increase of 2 kgs in 2 days.

Monitor yourself daily for symptoms of fluid retention: Keep a check on symptoms like increased shortness of breath or swelling in ankles which indicate fluid retention.

Limit your alcohol intake: Drinking excessive alcohol can increase the levels of certain fats known as triglycerides in your blood. These tend to clog the arteries and increase the risk of heart failure. Thus, it is important to keep your alcohol intake moderate.

Quit smoking: Smoking is known to increase heart rate and blood pressure, so it is important to quit smoking in order to improve the symptoms of heart failure. 

Explore our smoking cessation range to help you quit smoking.

Did you know?
After a year you quit smoking, your risk of coronary heart disease reduces by 50% as compared to that of a smoker. Moreover, your circulation improves within 2-12 weeks. Here's more on how quitting smoking can improve your heart health.
Did you know?

Complications Of Heart Failure

Some of the common health complications of heart failure include:

1. Arrhythmia or abnormal heart rhythm
Abnormal heart rhythm conditions such as atrial fibrillation, ventricular arrhythmias (ventricular tachycardia, ventricular fibrillation), and bradyarrhythmias are quite common in people suffering from heart failure. Atrial fibrillation is present in about one-third (range 10-50%) of patients with chronic heart failure and may represent either a cause or a consequence of heart failure.

2. Heart valve complications
The four valves of the heart open and close to keep blood flowing in the right direction. As the heart damage gets worse, the heart has to work harder to pump out blood. This can cause the heart to get enlarged, causing the valves to get damaged.

3. Thromboembolism
An irregular heartbeat can cause blood to pool which might lead to the formation of blood clots. These clots can cause a stroke, peripheral embolism, deep venous thrombosis, or pulmonary embolism.

4. Respiratory complications 
Pulmonary congestion, respiratory muscle weakness, and pulmonary hypertension (rare) are also seen with heart failure.

5. Kidney damage or failure
Heart failure can reduce the blood flow to the kidneys. If left untreated, kidneys are not able to remove enough waste from the blood, eventually leading to kidney damage. Kidney damage can further worsen heart failure. As damaged kidneys are not able to remove water from the blood, it leads to an elevation in blood pressure, straining the heart even more.

6. Anemia
Kidneys make a protein called erythropoietin, which helps in the synthesis of new red blood cells. Kidney damage from heart failure prevents the body from making enough erythropoietin thereby causing anemia.

7. Liver damage
Heart failure reduces blood supply to the liver. Fluid buildup puts too much pressure on the portal vein that brings blood to the liver. This can lead to scarring and liver damage.

8. Weight and muscle loss
Heart failure can lead to extreme loss of weight and muscle mass.

Living With Heart Failure

Here are a few ways how people suffering from heart failure can improve their quality of life and lead a healthy life.

Be physically active: There are special heart exercise programs for people with heart failure, with a focus on individually adjusted training to build up their stamina and muscles. These programs can improve physical fitness and overall health.

Keep a watch on your fluid intake and weight: Limit your fluid intake to 1.5 litres or 6 cups of fluid everyday. You can also record or chart the amount of fluid consumption. Also keep a check on your weight everyday to monitor any signs of fluid retention in the body. Note your weight in the morning after using the washroom. Make sure not to eat anything before weighing yourself. Also, try to use the same weighing scale every day. Consult your doctor in case of any sudden increase of 2 kgs in 2 days.

Learn about factors affecting the heart health: Patients need to be educated on the importance of maintaining a healthy body weight, discontinuation of smoking, controlling blood pressure and ensuring normoglycemia. Get in touch with experts as heart failure is a serious disorder that is best managed by an interprofessional team. For example, dietitians can help educate the patient on the importance of a low salt diet and limiting fluid intake. Healthcare professionals can advise the patient on the importance of exercise, avoiding stress, and ensuring follow-up with the cardiologist.

Track and manage your symptoms: Patients with heart failure present with a variety of symptoms, most of which are non-specific. The common symptoms of congestive heart failure include fatigue, dyspnoea, swollen ankles, and exercise intolerance, or symptoms that relate to the underlying cause. So if you experience any symptoms of heart failure or worsening of the symptoms, then do report to your doctor. Also, keep a tab of your symptoms to understand how your condition is faring with time.

Coordinate with your doctor: The way in which heart failure continues to develop over time varies from person to person, depending on things like what is causing it and whether they have other medical conditions. In some people, the symptoms can be kept under control for many years. But sometimes the heart becomes weaker after a short amount of time. Keep in regular touch with your doctor.

Follow a proper medication regimen: It is a good idea to develop a medication regimen together with your doctor, to avoid interactions between different drugs. Non-prescription medications should be included too. For instance, non-prescription painkillers like diclofenac and ibuprofen aren’t suitable for people who have heart failure because they add to the burden on the kidneys.

Get vaccinated: Flu and pneumonia pose a greater danger to people who have heart failure (or any heart condition) than to healthy people. Ask your doctor about getting a yearly influenza (flu) vaccine and a one-time pneumococcal vaccine. Pneumonia is a lung infection that keeps your body from using oxygen as efficiently as it should. Your heart has to work harder to pump oxygenated blood through the body. If you have heart failure, you should avoid putting this extra stress on your heart.

Frequently Asked Questions


  1. Malik A, Brito D, Chhabra L. Congestive Heart Failure. [Updated 2021 Feb 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.External Link
  2. What is Heart Failure? The American Heart Association (AHA). External Link
  3. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Heart failure: Overview. 2006 Feb 14 [Updated 2018 Jan 25].External Link
  4. Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation. 2009 May 12;119(18):2516-25. External Link
  5. Devices and Surgical Procedures to Treat Heart Failure. The American Heart Association (AHA). Last Reviewed: May 31, 2017. External Link
  6. Gomberg-Maitland M, Baran DA, Fuster V. Treatment of Congestive Heart Failure: Guidelines for the Primary Care Physician and the Heart Failure Specialist. Arch Intern Med. 2001;161(3):342–352. External Link
  7. Medications Used to Treat Heart Failure. The American Heart Association (AHA). Last Reviewed: May 31, 2017. External Link
  8. Ural D, Çavuşoğlu Y, Eren M, et al. Diagnosis and management of acute heart failure. Anatol J Cardiol. 2015;15(11):860-889. External Link
  9. Lifestyle Changes for Heart Failure. The American Heart Association (AHA). Last Reviewed: May 31, 2017. External Link
  10. Is drinking alcohol part of a healthy lifestyle? The American Heart Association (AHA). Last Reviewed: May 31, 2017. External Link
  11. McMurray JJV, Solomon SD, Inzucchi SE, et al; DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008.External Link
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