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Breathless lying flat, waking gasping at night — left heart failure; diuretics + four pillars. Heart failure (pump failure — left: pulmonary congestion — orthopnea, PND, crackles; right: systemic — edema, JVP, hepatomegaly): BNP confirms, echo classifies (HFrEF <40% — four pillars: ARNI/ACE-I + evidence beta-blocker + MRA + SGLT2i; HFpEF — SGLT2i + diuretics + comorbidities). Acute decompensation — IV diuretics, oxygen, nitrates; shock — inotropes/IABP. Cardiomyopathies — dilated (commonest — alcohol, viral, peripartum), hypertrophic/HOCM (athlete sudden death — septal, avoid strenuous), restrictive (amyloid). The pillow count is the measure — orthopnea counts pillows, failure counts them too.