Congestive Heart Failure

What happens in congestive heart failure

The heart is a pump with two sides. When it weakens or stiffens:

• Left-sided failure: blood backs up into the lungs, causing breathlessness and cough.
• Right-sided failure: blood backs up into the body's veins, causing swollen legs, a swollen abdomen, and an enlarged liver. The most common cause of right-sided failure is left-sided failure.
• The kidneys sense low blood flow and hold on to salt and water, adding to congestion.

"Congestive" refers to this fluid build-up. Today, doctors often simply say heart failure.

Types by ejection fraction

Ejection fraction (EF) is the percentage of blood pumped out of the left ventricle with each beat. Normal is about 50 to 70%.

Symptoms

• shortness of breath on exertion, and later at rest
• breathlessness when lying flat (orthopnea) and waking up gasping at night
• swelling of the feet, ankles, legs or abdomen (leg swelling)
• rapid weight gain from fluid
• fatigue and weakness
• persistent cough or wheeze, sometimes with pink, frothy mucus
• reduced appetite, nausea, feeling full quickly
• fast or irregular heartbeat
• needing to pass urine at night
• confusion or poor concentration in older adults

Stages and classes

The ACC/AHA stages describe progression:

The NYHA class describes symptoms: class I (no limitation), II (symptoms with ordinary activity), III (symptoms with less than ordinary activity), IV (symptoms at rest). Classes can improve with treatment; stages do not go backward.

Causes and risk factors

• coronary artery disease and previous heart attack
• high blood pressure
• heart valve disease
• cardiomyopathy: genetic, alcohol-related, viral, pregnancy-related or from chemotherapy
• atrial fibrillation and other arrhythmias
• diabetes, obesity, sleep apnea
• thyroid disease, severe anemia
• kidney disease

Common triggers of a flare-up

Too much salt or fluid, missed medicines, NSAIDs (ibuprofen, naproxen), infections, uncontrolled blood pressure, new atrial fibrillation, heavy alcohol, and some diabetes medicines.

Diagnosis

• Echocardiogram: ultrasound of the heart; measures EF, valves and wall motion.
• BNP or NT-proBNP blood test: raised when the heart is under strain.
• ECG: rhythm problems, past heart attack.
• Chest X-ray: fluid in the lungs, enlarged heart.
• Blood tests: kidney function, electrolytes, blood count, thyroid, iron.
• Further tests: coronary angiography, cardiac MRI, stress tests.

Treatment

Core medicines for HFrEF

Four medicine groups reduce hospital admissions and help people live longer:

1. ARNI (sacubitril-valsartan), or an ACE inhibitor or ARB
2. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
3. Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
4. SGLT2 inhibitors (dapagliflozin, empagliflozin), which also benefit HFpEF

Doses are increased gradually to target levels as tolerated, with checks of blood pressure, kidney function and potassium.

Diuretics

"Water pills" such as furosemide relieve congestion and swelling. Doses are adjusted by weight and symptoms.

Devices and procedures

• Implantable cardioverter-defibrillator (ICD): prevents sudden death from dangerous rhythms in people with a low EF.
• Cardiac resynchronization therapy (CRT): a special pacemaker that coordinates the heart's pumping.
• Valve repair or replacement, coronary stents or bypass surgery for underlying causes.
• Advanced therapies: left ventricular assist devices (LVAD) and heart transplant for stage D.

Self-care

• Weigh yourself every morning after using the bathroom, before eating, in the same clothes. Report rapid gain.
• Limit salt, usually to less than about 2,000 to 3,000 mg of sodium a day as advised.
• Follow your fluid limit if one has been set.
• Take medicines every day and do not stop them without advice.
• Avoid NSAIDs such as ibuprofen and naproxen, which cause fluid retention.
• Stay active: cardiac rehabilitation improves exercise capacity and quality of life.
• Get vaccinated against flu, COVID-19 and pneumococcus.
• Stop smoking and limit alcohol.

Outlook

Heart failure is a serious long-term condition, but outlook has improved greatly with modern treatment. Many people with HFrEF see their ejection fraction improve on full medical therapy. Recognizing early warning signs and acting on them prevents many hospital stays. Palliative care can support quality of life alongside active treatment in advanced disease.

Frequently asked questions

What are the first signs of congestive heart failure?

Early signs often include breathlessness on exertion, tiredness, swollen ankles or feet, needing extra pillows to breathe at night, and rapid weight gain from fluid. Report these to a doctor, especially if you have heart disease or high blood pressure.

What is the difference between heart failure and congestive heart failure?

They mean essentially the same thing. "Congestive" describes the fluid build-up in the lungs, legs and abdomen that often occurs. Doctors increasingly use "heart failure" and describe the type by ejection fraction.

What is a normal ejection fraction?

A normal left ventricular ejection fraction is about 50 to 70%. An EF of 40% or less indicates heart failure with reduced ejection fraction. People can still have heart failure with a normal EF if the heart is stiff.

Can congestive heart failure be reversed?

Sometimes. When the cause is treatable, such as a fast heart rhythm, alcohol, a valve problem or blocked arteries, heart function can improve significantly. Many people with reduced EF improve on modern medicines, though ongoing treatment is usually needed.

How much salt can I have with heart failure?

Many heart failure programs recommend limiting sodium to roughly 2,000 to 3,000 mg a day, though advice varies. Ask your heart team for a specific target and read food labels, since most salt comes from processed and restaurant foods.