Heart Failure

What heart failure is

The heart is two pumps side by side. The right side sends blood through the lungs to collect oxygen. The left side pumps that blood out to the body. In heart failure, one or both sides cannot keep up. The heart may be too weak to squeeze (a problem of pumping) or too stiff to relax and fill (a problem of filling).

When the heart falls behind, the body tries to compensate. The kidneys hold on to salt and water, hormones tighten blood vessels and the heart rate speeds up. In the short term these help, but over time they overload the heart further and cause fluid to collect in the lungs, legs and belly. When fluid buildup is prominent, the condition is often called congestive heart failure. Today doctors usually just say heart failure.

Heart failure vs heart attack

A heart attack is a sudden blockage of a coronary artery that kills part of the heart muscle. Heart failure is a long-term problem with the heart's pumping or filling. A heart attack is one of the most common causes of heart failure, because the damaged muscle no longer pumps well.

Types of heart failure

By ejection fraction

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

The distinction matters because the medicines proven to lengthen life work best in HFrEF. HFpEF now makes up about half of all cases.

Left-sided vs right-sided heart failure

Many people have both, because left-sided failure eventually strains the right side.

Acute vs chronic

Chronic heart failure develops over months and years. Acute heart failure comes on suddenly or is a sudden worsening (decompensation) of chronic disease, often from fluid in the lungs (pulmonary edema). It usually needs hospital treatment.

Heart failure symptoms

• Breathlessness: first with exertion, later with less activity or at rest
• Breathlessness lying flat (orthopnea), needing extra pillows, or waking at night gasping (paroxysmal nocturnal dyspnea)
• Swelling of the ankles, legs, thighs or belly
• Fatigue and weakness, because muscles get less blood
• Rapid weight gain from fluid, often before swelling is visible
• dry cough or wheeze, especially at night
• a fast or irregular heartbeat
• poor appetite, feeling full quickly, nausea
• getting up at night to urinate
• confusion or poor concentration in older people

NYHA classes

Doctors grade symptoms with the New York Heart Association classes: Class I, no symptoms with ordinary activity; Class II, symptoms with ordinary activity such as brisk walking; Class III, symptoms with less than ordinary activity, such as dressing; Class IV, symptoms at rest. A person can move between classes as treatment works or the disease progresses.

Causes and risk factors

• coronary artery disease and previous heart attacks, the most common cause in the US
• long-standing high blood pressure
• cardiomyopathy: heart muscle disease from genes, alcohol, viral infection, some chemotherapy drugs or pregnancy
• heart valve disease, especially aortic stenosis and mitral regurgitation
• atrial fibrillation and other arrhythmias
• diabetes, obesity, sleep apnea and chronic kidney disease
• less common: thyroid disease, severe anemia, amyloidosis, congenital heart disease

Common triggers of a sudden worsening include missed medicines, too much salt or fluid, NSAIDs such as ibuprofen, infections, uncontrolled blood pressure and a new arrhythmia.

How heart failure is diagnosed

• History and examination: listening for crackles in the lungs and extra heart sounds, and checking neck veins and leg swelling.
• BNP or NT-proBNP blood test: these hormones rise when the heart is under strain. A normal level makes heart failure unlikely.
• ECG: looks for past heart attacks, arrhythmias and thickened muscle.
• Echocardiogram: an ultrasound that measures ejection fraction, valve function and wall stiffness. It is the key test.
• Chest X-ray: shows an enlarged heart and fluid in the lungs.
• Other tests: blood counts, kidney and thyroid function, iron studies, and sometimes a coronary angiogram, cardiac MRI or exercise test.

Treatment

Medicines for HFrEF (weak pumping)

Four medicine groups, often called the "four pillars", each reduce hospital stays and deaths. Most people are started on all four and the doses are increased gradually:

1. ARNI (sacubitril-valsartan), or an ACE inhibitor or ARB if an ARNI is not suitable
2. Beta blockers (carvedilol, metoprolol succinate or bisoprolol)
3. Mineralocorticoid receptor antagonists (spironolactone or eplerenone)
4. SGLT2 inhibitors (dapagliflozin or empagliflozin)

Other options include ivabradine, hydralazine with isosorbide dinitrate, digoxin, vericiguat and IV iron for iron deficiency.

Medicines for HFpEF (stiff heart)

SGLT2 inhibitors reduce hospital admissions in HFpEF. Treatment also focuses on controlling blood pressure, AFib, diabetes, sleep apnea and weight. Some people with obesity benefit from GLP-1 medicines.

Diuretics (water pills)

Furosemide, bumetanide or torsemide remove excess fluid and relieve breathlessness and swelling in every type. They ease symptoms but do not change the course of the disease on their own.

Devices and procedures

• ICD: an implanted defibrillator for people at high risk of dangerous heart rhythms.
• CRT (biventricular pacemaker): coordinates the heart's pumping in some people with a wide QRS on ECG.
• Repair or replacement of faulty valves, and stents or bypass surgery for blocked arteries.
• LVAD (mechanical pump) or heart transplant for advanced heart failure.

Living with heart failure

Self-care has a big effect on how you feel and how often you need hospital care:

• Weigh yourself every morning after urinating, before breakfast, on the same scale. Report a gain of more than 1 to 1.5 kg (2 to 3 lb) in a day or 2.5 kg (5 lb) in a week.
• Limit salt. Many guidelines suggest under about 2,000 mg of sodium a day. Processed and restaurant foods are the main sources.
• Follow your fluid advice, which some people are given if they have low sodium or severe congestion.
• Take every medicine every day, even when you feel well. Many lower blood pressure, so stand up slowly.
• Stay active. Cardiac rehabilitation programs are safe and improve energy and quality of life.
• Avoid NSAIDs such as ibuprofen and naproxen, and check decongestants and supplements with your pharmacist.
• Limit alcohol and stop smoking.
• Get vaccinated against flu, COVID-19 and pneumococcus.
• Use a symptom zone plan from your care team: green (stable), yellow (call the clinic), red (call 911).

Heart failure life expectancy and outlook

The outlook varies more than many people expect. It depends on the cause, the type, how severe symptoms are, kidney function, age and especially how well treatment works. Some people, particularly those whose heart failure came from a treatable cause such as a fast heart rhythm, alcohol or pregnancy, see their EF improve substantially. Large studies have historically reported that around half of people diagnosed are alive 5 years later, but these figures predate today's combination therapy and include many older adults with other illnesses. Ask your cardiologist what your own numbers suggest. Palliative care can be added at any stage to help with symptoms and planning.

Frequently asked questions

What are the first signs of heart failure?

The earliest signs are usually breathlessness with activities that used to be easy, tiredness, and ankle swelling by evening. Some people notice they need more pillows at night or have gained weight quickly without eating more. These deserve a check-up and a BNP test.

What is the difference between HFrEF and HFpEF?

In HFrEF the heart muscle is weak and the ejection fraction is 40% or less. In HFpEF the ejection fraction is normal but the muscle is stiff and does not fill properly. Both cause similar symptoms. HFrEF has more proven life-extending medicines.

What is the life expectancy with heart failure?

It varies widely, from many decades in people whose heart recovers to months in advanced disease. Older studies suggested about half of people lived 5 years after diagnosis, but modern medicines and devices have improved this. Your cardiologist can give an estimate based on your test results.

Can heart failure be reversed?

Sometimes. When the cause is treatable, such as a fast heart rhythm, alcohol, thyroid disease, a valve problem or pregnancy, the heart can recover. Many people with HFrEF see their EF improve on the four core medicines. Treatment should usually continue even after improvement.

Is heart failure the same as congestive heart failure?

Mostly, yes. Congestive heart failure describes heart failure with fluid congestion in the lungs or body. Doctors now usually use "heart failure" because not everyone has congestion, and then specify the type by ejection fraction.

Can you exercise with heart failure?

Yes, and it helps. Regular moderate activity, ideally starting in a supervised cardiac rehabilitation program, improves energy, breathlessness and quality of life. Avoid heavy straining and stop if you get chest pain, severe breathlessness or dizziness.