Heart failure

Overview

Heart failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

Certain heart conditions gradually leave the heart too weak or stiff to fill and pump blood properly. These conditions include narrowed arteries in the heart and high blood pressure.

Proper treatment may improve the symptoms of heart failure and may help some people live longer. Lifestyle changes can improve quality of life. Try to lose weight, exercise, use less salt and manage stress.

But heart failure can be life-threatening. People with heart failure may have severe symptoms. Some may need a heart transplant or a device to help the heart pump blood.

Heart failure is sometimes called congestive heart failure.

Symptoms

If you have heart failure, your heart can't supply enough blood to meet your body's needs.

Symptoms may develop slowly. Sometimes, heart failure symptoms start suddenly. Heart failure symptoms may include:

• Shortness of breath with activity or when lying down.
• Fatigue and weakness.
• Swelling in the legs, ankles and feet.
• Rapid or irregular heartbeat.
• Reduced ability to exercise.
• Wheezing.
• A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood.
• Swelling of the belly area.
• Very rapid weight gain from fluid buildup.
• Nausea and lack of appetite.
• Difficulty concentrating or decreased alertness.
• Chest pain if heart failure is caused by a heart attack.

When to see a doctor

See your health care provider if you think you might have symptoms of heart failure. Call 911 or emergency medical help if you have any of the following:

• Chest pain.
• Fainting or severe weakness.
• Rapid or irregular heartbeat with shortness of breath, chest pain or fainting.
• Sudden, severe shortness of breath and coughing up white or pink, foamy mucus.

These symptoms may be due to heart failure. But there are many other possible causes. Don't try to diagnose yourself.

At the emergency room, health care providers do tests to learn if your symptoms are due to heart failure or something else.

Call your health care provider right away if you have heart failure and:

• Your symptoms suddenly become worse.
• You develop a new symptom.
• You gain 5 pounds (2.3 kilograms) or more within a few days.

Such changes could mean that existing heart failure is getting worse or that treatment isn't working.

Causes

Heart failure can be caused by a weakened, damaged or stiff heart.

• If the heart is damaged or weakened, the heart chambers may stretch and get bigger. The heart can't pump out the needed amount of blood.
• If the main pumping chambers of the heart, called the ventricles, are stiff, they can't fill with enough blood between beats.

The heart muscle can be damaged by certain infections, heavy alcohol use, illegal drug use and some chemotherapy medicines. Your genes also can play a role.

Any of the following conditions also can damage or weaken the heart and cause heart failure.

• Coronary artery disease and heart attack. Coronary artery disease is the most common cause of heart failure. The disease results from the buildup of fatty deposits in the arteries. The deposits narrow the arteries. This reduces blood flow and can lead to heart attack.

  A heart attack occurs suddenly when an artery feeding the heart becomes completely blocked. Damage to the heart muscle from a heart attack may mean that the heart can no longer pump as well as it should.

• High blood pressure. Also called hypertension, this condition forces the heart to work harder than it should to pump blood through the body. Over time, the extra work can make the heart muscle too stiff or too weak to properly pump blood.
• Heart valve disease. The valves of the heart keep blood flowing the right way. If a valve isn't working properly, the heart must work harder to pump blood. This can weaken the heart over time. Treating some types of heart valve problems may reverse heart failure.
• Inflammation of the heart muscle, also called myocarditis. Myocarditis is most commonly caused by a virus, including the COVID-19 virus, and can lead to left-sided heart failure.
• A heart problem that you're born with, also called a congenital heart defect. If the heart and its chambers or valves haven't formed correctly, the other parts of the heart have to work harder to pump blood. This may lead to heart failure.
• Irregular heart rhythms, called arrhythmias. Irregular heart rhythms may cause the heart to beat too fast, creating extra work for the heart. A slow heartbeat also may lead to heart failure. Treating an irregular heart rhythm may reverse heart failure in some people.
• Other diseases. Some long-term diseases may contribute to chronic heart failure. Examples are diabetes, HIV infection, an overactive or underactive thyroid, or a buildup of iron or protein.

Causes of sudden heart failure also include:

• Allergic reactions.
• Any illness that affects the whole body.
• Blood clots in the lungs.
• Severe infections.
• Use of certain medicines.
• Viruses that attack the heart muscle.

Heart failure usually begins with the lower left heart chamber, called the left ventricle. This is the heart's main pumping chamber. But heart failure also can affect the right side. The lower right heart chamber is called the right ventricle. Sometimes heart failure affects both sides of the heart.

Risk factors

Diseases and conditions that increase the risk of heart failure include:

• Coronary artery disease. Narrowed arteries may limit the heart's supply of oxygen-rich blood, resulting in weakened heart muscle.
• Heart attack. A heart attack is a form of coronary artery disease that occurs suddenly. Damage to the heart muscle from a heart attack may mean the heart can no longer pump as well as it should.
• Heart valve disease. Having a heart valve that doesn't work properly raises the risk of heart failure.
• High blood pressure. The heart works harder than it has to when blood pressure is high.
• Irregular heartbeats. Irregular heartbeats, especially if they are very frequent and fast, can weaken the heart muscle and cause heart failure.
• Congenital heart disease. Some people who develop heart failure were born with problems that affect the structure or function of their heart.
• Diabetes. Having diabetes increases the risk of high blood pressure and coronary artery disease.
• Sleep apnea. This inability to breathe properly during sleep results in low blood-oxygen levels and an increased risk of irregular heartbeats. Both of these problems can weaken the heart.
• Obesity. People who have obesity have a higher risk of developing heart failure.
• Viral infections. Some viral infections can damage to the heart muscle.

Medicines that may increase the risk of heart failure include:

• Some diabetes medicines. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure in some people. Don't stop taking these medicines without first talking to your health care provider.
• Some other medicines. Other medicines that may lead to heart failure or heart problems include nonsteroidal anti-inflammatory drugs (NSAIDs) and some medicines used to treat high blood pressure, cancer, blood conditions, irregular heartbeats, nervous system diseases, mental health conditions, lung and urinary problems, and infections.

Other risk factors for heart failure include:

• Aging. The heart's ability to work decreases with age, even in healthy people.
• Alcohol use. Drinking too much alcohol may weaken the heart muscle and lead to heart failure.
• Smoking or using tobacco. If you smoke, quit. Using tobacco increases the risk of heart disease and heart failure.

Complications

If you have health failure, it's important to have regular health checkups, even if symptoms improve. Your health care provider can examine you and run tests to check for complications.

Complications of heart failure depend on your age, overall health and the severity of heart disease. They may include:

• Kidney damage or failure. Heart failure can reduce the blood flow to the kidneys. Untreated, this can cause kidney failure. Kidney damage from heart failure can require dialysis for treatment.
• Other heart problems. Heart failure can cause changes in the heart's size and function. These changes may damage heart valves and cause irregular heartbeats.
• Liver damage. Heart failure can cause fluid buildup that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for the liver to work properly.
• Sudden cardiac death. If the heart is weak, there is a risk of dying suddenly due to a dangerous irregular heart rhythm.

Prevention

One way to prevent heart failure is to treat and control the conditions that can cause it. These conditions include coronary artery disease, high blood pressure, diabetes and obesity.

Some of the same lifestyle changes used to manage heart failure also may help prevent it. Try these heart-healthy tips:

• Don't smoke.
• Get plenty of exercise.
• Eat healthy foods.
• Maintain a healthy weight.
• Reduce and manage stress.
• Take medicines as directed.

Diagnosis

To diagnose heart failure, your health care provider examines you and asks questions about your symptoms and medical history. Your provider checks to see if you have risk factors for heart failure, such as high blood pressure, coronary artery disease or diabetes.

Your care provider listens to your lungs and heart with a device called a stethoscope. A whooshing sound called a murmur may be heard when listening to your heart. Your provider may look at the veins in your neck and check for swelling in your legs and belly.

Treatment

Treatment of heart failure may depend on the cause. Treatment often includes lifestyle changes and medicines. If another health condition is causing the heart to fail, treating it may reverse heart failure.

Some people with heart failure need surgery to open blocked arteries or to place a device to help the heart work better.

With treatment, symptoms of heart failure may improve.

Medications

A combination of medicines may be used to treat heart failure. The specific medicines used depend on the cause of heart failure and the symptoms. Medicines to treat heart failure include:

• Angiotensin-converting enzyme (ACE) inhibitors. These drugs relax blood vessels to lower blood pressure, improve blood flow and decrease the strain on the heart. Examples include enalapril (Vasotec, Epaned), lisinopril (Zestril, Qbrelis) and captopril.
• Angiotensin II receptor blockers (ARBs). These drugs have many of the same benefits as ACE inhibitors. They may be an option for people who can't tolerate ACE inhibitors. They include losartan (Cozaar), valsartan (Diovan) and candesartan (Atacand).
• Angiotensin receptor plus neprilysin inhibitors (ARNIs). This medicine uses two blood pressure drugs to treat heart failure. The combination medicine is sacubitril-valsartan (Entresto). It's used to treat some people with heart failure with reduced ejection fraction. It may help prevent the need for a hospital stay in those people.
• Beta blockers. These medicines slow the heart rate and lower blood pressure. They reduce the symptoms of heart failure and help the heart work better. If you have heart failure, beta blockers may help you live longer. Examples include carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL, Kapspargo Sprinkle) and bisoprolol.

• Diuretics. Often called water pills, these medicines make you urinate more frequently. This helps prevent fluid buildup in your body. Diuretics, such as furosemide (Lasix, Furoscix), also decrease fluid in the lungs, so it's easier to breathe.

  Some diuretics make the body lose potassium and magnesium. Your health care provider may recommend supplements to treat this. If you're taking a diuretic, you may have regular blood tests to check your potassium and magnesium levels.

• Potassium-sparing diuretics. Also called aldosterone antagonists, these drugs include spironolactone (Aldactone, Carospir) and eplerenone (Inspra). They may help people with severe heart failure with reduced ejection fraction (HFrEF) live longer.

  Unlike some other diuretics, these medicines can raise the level of potassium in the blood to dangerous levels. Talk to your health care provider about your diet and potassium intake.

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors. These medicines help lower blood sugar. They are often prescribed with diet and exercise to treat type 2 diabetes. But they're also one of the first treatments for heart failure. That's because several studies showed that the medicine lowered the risk of hospital stays and death in people with certain types of heart failure — even if they didn't have diabetes. These medicines include canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance).
• Digoxin (Lanoxin). This drug, also called digitalis, helps the heart squeeze better to pump blood. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in people with HFrEF. It may be more likely to be given to someone with a heart rhythm problem, such as atrial fibrillation.
• Hydralazine and isosorbide dinitrate (BiDil). This drug combination helps relax blood vessels. It may be added to your treatment plan if you have severe heart failure symptoms and ACE inhibitors or beta blockers haven't helped.
• Vericiguat (Verquvo). This medicine for chronic heart failure is taken once a day by mouth. It's a type of drug called an oral soluble guanylate cyclase (sGC) stimulator. In studies, people with high-risk heart failure who took this medicine had fewer hospital stays for heart failure and heart disease-related deaths compared with those who got a dummy pill.
• Positive inotropes. These medicines may be given by IV to people with certain types of severe heart failure who are in the hospital. Positive inotropes can help the heart pump blood better and maintain blood pressure. Long-term use of these medicines has been linked to an increased risk of death in some people. Talk to your health care provider about the benefits and risks of these drugs.
• Other medicines. Your health care provider may prescribe other medicines to treat specific symptoms. For example, some people may receive nitrates for chest pain, statins to lower cholesterol or blood thinners to help prevent blood clots.

Your health care provider may need to change your medicine doses frequently. This is more common when you've just started a new medicine or when your condition is getting worse.

You may be admitted to the hospital if you have a flare-up of heart failure symptoms. While in the hospital, you may receive:

• Medicines to relieve your symptoms.
• More medicines to help your heart pump better.
• Oxygen through a mask or small tubes placed in your nose.

If you have severe heart failure, you may need to use supplemental oxygen for a long time.

Surgery or other procedures

Surgery or other treatment to place a heart device may be recommended to treat the problem that led to heart failure.

Surgery or other procedures for heart failure may include:

• Coronary bypass surgery. You may need this surgery if severely blocked arteries are causing your heart failure. The surgery involves taking a healthy blood vessel from the leg, arm or chest and connecting it below and above the blocked arteries in the heart. The new pathway improves blood flow to the heart muscle.

• Heart valve repair or replacement. If a damaged heart valve causes heart failure, your provider may recommend repairing or replacing the valve. There are many different types of heart valve repair. The type needed depends on the cause of the heart valve problem.

  Heart valve repair or replacement may be done as open-heart or minimally invasive surgery.

• Implantable cardioverter-defibrillator (ICD). An ICD is used to prevent complications of heart failure. It isn't a treatment for heart failure itself. An ICD is a device similar to a pacemaker. It's implanted under the skin in the chest with wires leading through the veins and into the heart.

  The ICD monitors the heartbeat. If the heart starts beating at a dangerous rhythm, the ICD tries to correct the beat. If the heart stops, the device shocks it back into regular rhythm. An ICD can also work as a pacemaker and speed up a slow heartbeat.

• Cardiac resynchronization therapy (CRT). Also called biventricular pacing, CRT is a treatment for heart failure in people whose lower heart chambers aren't pumping in sync with each other. A device sends electrical signals to the lower heart chambers. The signals tell the chambers to squeeze in a more coordinated way. This improves the pumping of blood out of the heart. CRT may be used with an ICD.

• Ventricular assist device (VAD). A VAD helps pump blood from the lower chambers of the heart to the rest of the body. It's also called a mechanical circulatory support device. Although a VAD can be placed in one or both lower chambers of the heart, it's usually placed in the lower left one.

  Your health care provider may recommend a VAD if you're waiting for a heart transplant. Sometimes, a VAD is used as a permanent treatment for people who have heart failure but who aren't good candidates for a heart transplant.

• Heart transplant. Some people have such severe heart failure that surgery or medicines don't help. These people may need to have their hearts replaced with a healthy donor heart.

  A heart transplant isn't the right treatment for everyone. A team of health care providers at a transplant center helps determine whether the procedure may be safe and beneficial for you.

Symptom care and end-of-life care

Your health care provider may recommend special medical care to reduce symptoms and improve quality of life. This is called palliative care. Anyone who has a serious or life-threatening illness can benefit from this type of care. It can be used to treat symptoms of the disease or to ease the side effects of treatment.

In some people with heart failure, medicines no longer work and a heart transplant or device isn't an option. If this occurs, special end-of-life care may be recommended. This is called hospice care.

Hospice care allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one. Hospice care is available in your home or in nursing homes and assisted living centers.

Hospice care provides the following for those who are sick and their loved ones:

• Emotional support.
• Psychological support.
• Spiritual support.

Although it can be difficult, discussing end-of-life issues with your family and medical team is important. Part of this discussion will likely involve an advance care directive. This is a general term for spoken and written instructions you give concerning your medical care, should you become unable to speak for yourself.

If you have an ICD, one important consideration to discuss with your family and health care team is whether the ICD should be turned off so that it can't deliver shocks to make your heart continue beating.

Lifestyle and home remedies

Some people with heart failure may be told to take omega-3 fatty acid supplements. Some research shows that the supplements may help reduce the need for hospital stays.

Making certain lifestyle changes often improve heart failure symptoms. They may even stop the condition from getting worse.

The following changes are recommended to improve heart health:

• Don't smoke. Smoking damages the blood vessels and raises blood pressure. It lowers blood oxygen levels and speeds up the heartbeat. Quitting is the best way to reduce the risk of heart problems. If you need help quitting, talk to your provider. You can't be considered for a heart transplant if you continue to smoke. Also avoid secondhand smoke.
• Check your legs, ankles and feet for swelling. Do this every day. Call your health care provider if the swelling worsens.
• Weigh yourself. Ask your health care provider how often you should do this. Weight gain may mean your body is holding onto fluid. You may need a change in treatment. Call your provider if you gain 5 pounds (2.3 kilograms) or more within a few days.
• Manage weight. Being overweight increases the risk of heart problems. Ask your health care provider what weight is best for you. Even losing a small amount of weight can help improve heart health.
• Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains, fat-free or low-fat dairy products, and lean proteins. Limit saturated or trans fats.

• Limit salt. Too much salt, also called sodium, can make the body hold onto water. This is called water retention. It makes the heart work harder. Symptoms include shortness of breath and swollen legs, ankles and feet.

  Ask your health care provider if you should follow a no-salt or low-salt diet. Remember that salt is already added to prepared foods.

• Limit alcohol. Alcohol can interfere with certain medicines. It also weakens the heart and increases the risk of irregular heartbeats. If you have heart failure, your health care provider may recommend that you don't drink alcohol.
• Ask how much fluids you can drink. If you have severe heart failure, your provider may suggest that you limit the amount of fluids you drink.
• Stay as active as possible. Moderate exercise helps keep the heart and body healthy. But be sure to talk to your health care provider about an exercise program that's right for you. If you have heart failure, your provider may suggest a walking program or a cardiac rehabilitation program at your local hospital.

• Reduce stress. Strong emotions such as anxiety or anger can make the heart beat faster. Breathing becomes heavier and blood pressure goes up. These changes can make heart failure worse.

  Find ways to reduce emotional stress. Practicing mindfulness and connecting with others in support groups are some ways to reduce and manage stress.

• Get better sleep. Heart failure can cause shortness of breath, especially when lying down. Try sleeping with your head propped up using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea.
• Get recommended vaccinations. Ask your health care provider about getting influenza, pneumonia and COVID-19 vaccinations.

Coping and support

Managing heart failure requires open communication between you and your health care provider. Be honest about any challenges concerning your diet, lifestyle and medicine use. Pay attention to your body and how you feel. Tell your provider when you're feeling better or worse. This helps your health care provider know what treatment works best for you.

These steps may help you manage heart failure:

• Take medicines as directed. If side effects or costs cause problems, ask your provider about other options. Don't stop taking your medicines without first talking to a care provider. Also, go to all scheduled health appointments. If you miss one, ask your health care provider how and when to reschedule.
• Use caution with other medicines and supplements. Some medicines available without a prescription to treat pain and swelling can make heart failure worse. They include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some diet pills and supplements also may be unsafe if you take medicines for heart failure. Always tell your health care provider about all the medicines you take, including those bought without a prescription.
• Weigh yourself daily. Do this when you first wake up, after breakfast and after peeing. Write your weight down in a notebook. Bring the notes to your medical checkups. An increase in weight can be a sign of fluid buildup.
• Check your blood pressure at home. Write down your numbers and bring them with you to your health checkups. Doing so helps your care providers know if treatment is working or if your condition is getting worse. Home blood pressure monitors are available at local stores and pharmacies.
• Know how to contact your health care provider. Keep your provider's phone number, the hospital's phone number, and directions to the hospital or clinic on hand. You'll want easy access to this information if you have health questions or if you need to go to the hospital.
• Ask for help. Sticking to treatment and lifestyle changes may be challenging. It may help to ask your friends and family to help you meet your goals.

Preparing for an appointment

If are worried about your heart failure risk, make an appointment with your health care provider. You may be referred to a doctor trained in heart diseases. This type of provider is called a cardiologist. If heart failure is found early, treatment may be easier and more effective.

Appointments can be brief. Because there's often a lot to discuss, it's a good idea to be prepared for your appointment. Here's some information to help you get ready.

What you can do

• Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet. You may need to avoid food and certain drinks before some tests.
• Write down any symptoms you're having, including any that may seem unrelated to heart failure.
• Write down important personal information, including a family history of heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes. Find out if anyone in your family has had heart failure. Some heart conditions that cause heart failure run in families. Knowing as much as you can about your family history can be helpful.
• Make a list of all medicines, vitamins or supplements that you're taking. Include doses. Bring this list with you to all health checkups.
• Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information given to you during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your health care provider. For example, if you have heart failure you might ask if it's safe for you and your partner to have sex. Most people with heart failure can continue having sex once symptoms are under control. If you have questions, talk to your health care provider.

Your time with your provider is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For heart failure, some basic questions to ask your health care provider include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests will I need? Do these tests require any special preparation?
• What treatments are available? Which do you recommend for me?
• What foods should I eat or avoid?
• What's an appropriate level of physical activity?
• Do I have any activity restrictions?
• How often should I be screened for changes in my condition?
• I have other health conditions. How can I best manage these conditions together?
• Is there a generic available for the medicine you're prescribing for me?
• Do my family members need to be screened for conditions that may cause heart failure?
• Are there brochures or other materials that I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your health care provider is likely to ask many questions. Being ready to answer them may save time to go over any details you want to spend more time on. Your provider may ask:

• When did you first notice your symptoms?
• Do your symptoms occur all the time, or do they come and go?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• Does anything make your symptoms worse?

What you can do in the meantime

It's never too early to make healthy lifestyle changes, such as quitting smoking, cutting down on salt and eating healthy foods. These changes can help prevent heart failure from starting or worsening.