Heart failure

Symptoms

If you have congestive 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, when lying down, when bending over or even at rest. Shortness of breath also is called dyspnea.
• Fatigue and weakness.
• Swelling in the legs, ankles and feet.
• Fast or irregular heartbeat.
• Reduced ability to exercise.
• Wheezing.

Other symptoms may include:

• 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, causing nausea, bloating or a sensation of fullness.
• Very fast weight gain from fluid buildup.
• Nausea and lack of appetite.
• Trouble concentrating or decreased alertness.
• Chest pain if heart failure is caused by a heart attack.

These symptoms can be caused by many different health conditions. A complete checkup by a healthcare professional is needed to make a diagnosis.

Symptoms of end-stage or advanced heart failure

Symptoms that heart failure may be at an advanced stage include:

• Shortness of breath with very little activity or at rest.
• Swelling that is hard to control and requires higher doses or additional medicines called diuretics.
• Low blood pressure or worsening kidney or liver function.
• Repeated hospital stays or ER visits, dangerous heartbeats, or repeated shocks from an implantable cardioverter-defibrillator (ICD).
• Difficulty tolerating heart failure medicines, which may require lowering the dose or stopping some medicines because of problems such as low blood pressure or worsening kidney function.

These symptoms cannot tell exactly how long someone will live. If you have advanced heart failure, your care team can talk with you about treatment choices and what matters to you.

When to seek care

See your healthcare professional if you think you might have symptoms of heart failure.

Call your healthcare professional right away if you have heart failure and:

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

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

Follow the action plan from your healthcare professional. It may give a different weight-change limit or other instructions based on your condition.

When to seek emergency care

Call 911 or your local emergency number if you have any of the following:

• Chest pain.
• Fainting or severe weakness.
• Fast or irregular heartbeat with shortness of breath, chest pain or fainting.
• Repeated shocks from a defibrillator if you have one.
• 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.

In the emergency room (ER), healthcare professionals do tests to learn whether your symptoms are due to heart failure or something else.

Risk factors

Heart and blood vessel conditions that increase the risk of heart failure or make existing heart failure worse 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 changes in the structure or function of their heart.

Other health conditions that may increase the risk of heart failure or make it worse include:

• Diabetes. Having diabetes increases the risk of high blood pressure and coronary artery disease.
• Sleep apnea. This condition causes breathing to repeatedly stop and start during sleep. It can lower blood oxygen levels and raise the risk of irregular heartbeats. Obstructive and central sleep apnea can worsen heart failure, including right-sided heart failure.
• Obesity. People who have obesity have a higher risk of developing heart failure.
• Viral infections, including COVID-19. Some viral infections can injure the heart and cause myocarditis, irregular heartbeats or heart failure. They also may worsen existing heart failure.
• Stroke. A stroke can affect signals between the brain and heart. Some people have irregular heartbeats or changes in how the heart squeezes or relaxes after a stroke. Heart failure can sometimes occur, but it does not happen to everyone who has a stroke.
• Pneumonia and other respiratory infections. These infections can trigger or worsen heart failure. They also can cause shortness of breath, so tests may be needed to find the cause.
• Anorexia nervosa. This eating disorder is linked with a higher risk of heart failure and other heart conditions.

Medicines that may increase the risk of heart failure or make it worse include:

• Some diabetes medicines. The diabetes medicines rosiglitazone 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 healthcare professional.
• Some other medicines. Other medicines that may lead to heart failure or heart conditions 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 conditions, 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.
• Drugs, including amphetamines and alcohol.
• Smoking or using tobacco. If you smoke, quit. Using tobacco increases the risk of heart disease and heart failure.

Prevention

One way to prevent heart failure is to treat and manage the conditions that can cause heart failure or increase the risk. 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.

Treatment

Treatment of congestive heart failure may depend on the cause. Treatment often includes lifestyle changes and medicines. Heart failure is not always curable. But 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.

Even when symptoms and ejection fraction improve, heart failure may return or worsen. Continue your medicines and follow-up care unless your healthcare professional changes your treatment plan.

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 medicines 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 2 receptor blockers (ARBs). These medicines 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 medicines 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) and bumetanide (Bumex), also decrease fluid in the lungs, so it's easier to breathe.

Some diuretics make the body lose potassium and magnesium. Your healthcare professional 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 medicines include spironolactone (Aldactone, CaroSpir) and eplerenone (Inspra). They may help people who have 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 with your healthcare professional 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).

More medicines that may be used to treat heart failure include:

• Digoxin (Lanoxin). This medicine, 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. Someone with a heart rhythm disorder, such as atrial fibrillation, may be more likely to receive it.
• Hydralazine and isosorbide dinitrate (BiDil). This combination of medicines 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 medicine 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 than those who got a pill with no medicine.
• Positive inotropes. These medicines may be given by IV to people with severe advanced 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 with your healthcare professional about the benefits and risks of these medicines.
• Other medicines. Your healthcare professional 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 healthcare professional 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.

Heart failure medicines can cause side effects. Depending on the medicine, these may include dizziness, low blood pressure, changes in kidney function or changes in potassium levels. Your healthcare team may check your blood pressure and do blood tests after you start a medicine or the dose changes. Tell your healthcare team if you have any side effects. Do not stop a medicine without talking with your healthcare professional.

Treatment during a flare-up

You may need to stay in 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 procedures may be recommended to treat heart failure or the condition that led to it.

Surgery or other procedures for heart failure may include:

• Coronary artery bypass graft surgery. You may need coronary artery bypass graft 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 health professional may recommend repairing or replacing the valve. There are many different types of heart valve surgery. The type needed depends on the cause of the heart valve disease.

  Heart valve repair or replacement may be done as open-heart, minimally invasive surgery or through a small puncture in a blood vessel.

• 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 checks 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 also can 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 chamber.

  Your healthcare professional may recommend a ventricular assist device 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 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 a heart transplant.

  A heart transplant isn't the right treatment for everyone. A team of healthcare professionals at a transplant center helps determine whether the procedure may be safe and beneficial for you. The team looks at your overall health and how well your heart and other organs work. Not everyone with advanced heart failure can have a heart transplant.

  A ventricular assist device may be used while you wait for a transplant.

Possible complications depend on the procedure and your health. They may include:

• Bleeding.
• Infection.
• Blood clots.
• Stroke.
• An irregular heartbeat.
• Kidney issues.

Implanted devices can cause infection or have issues that require another procedure. A heart transplant also can lead to rejection of the donor heart. Your care team can talk with you about the benefits and risks of each option.

End-of-life care

Heart failure may get better for a time and then get worse again. No single symptom or test can predict exactly how long someone will live. The healthcare team looks at the overall pattern. This includes repeated severe episodes, how symptoms respond to treatment, how well other organs are working and how much strength the person has.

Your healthcare professional 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 you. 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 those who care for them:

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

Although it can be hard, discussing end-of-life issues with your family and healthcare 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 if you can't speak for yourself.

If you have an ICD, also discuss whether and when to turn off the device so that it can't give shocks near the end of life.

Prognosis

Prognosis means what may happen over time. It also is called outlook. It is an estimate of what will happen. But it doesn't say what exactly will happen. The outlook for people with heart failure is different for everyone.

Your outlook depends on many things, including your age and whether you have other conditions, such as kidney disease or diabetes. The outlook also depends on details about your heart failure, including:

• The cause of heart failure and whether it can be treated.
• The type and stage of heart failure.
• How your symptoms limit your activity.
• How well treatment is working.

Other things that play a role in your outlook include:

• How well your heart and kidneys work.
• Test results.
• Recent emergency visits or hospital stays.

Life expectancy

It is understandable to wonder about life expectancy with congestive heart failure. Survival rates can offer a general picture, but they are based on large groups of people. They cannot tell exactly how long you will live.

Healthcare professionals use survival rates along with information about your health and treatment to discuss life expectancy and plan care. The rates are only one part of that discussion.

In general, life expectancy tends to be shorter at older ages. But age alone cannot predict how long a person with heart failure will live. Your overall health, heart function and response to treatment also matter.

On average, people with heart failure with preserved ejection fraction (HFpEF) may have a lower risk of death than people with HFrEF. Both types can be serious, and ejection fraction alone cannot predict life expectancy.

Across large groups of people with chronic or stable heart failure, about 57% live five years after diagnosis. About 35% live 10 years after diagnosis. These numbers do not mean that a person will live for only five or 10 years. Some people live longer than these estimates suggest. Others live for less time.

These estimates are based partly on people who received heart failure care years ago. Because care changes over time, the numbers may not fully reflect the outlook for people receiving treatment today.

Heart failure often is a long-term condition and is not always curable. When a treatable condition causes it, treatment may improve or sometimes reverse the heart failure. Many people still need ongoing care.

Coping and support

Managing heart failure requires open communication between you and your healthcare professional. Be honest about any challenges concerning your diet, lifestyle and medicine use. Pay attention to your body and how you feel. Tell your healthcare professional when you're feeling better or worse. This helps guide your treatment.

These steps may help you manage heart failure:

• Take medicines as directed. If side effects or costs are a concern, ask your health professional about options. Don't stop taking your medicines without talking to your health professional. Also, go to all scheduled health appointments. Reschedule any that you miss.
• 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 not be safe if you take medicines for heart failure. Always tell your healthcare professional about all the medicines you take, including those you take without a prescription.
• Weigh yourself daily. If your healthcare professional asks you to weigh yourself every day, do it after you wake up and urinate, before you eat or drink, and at about the same time each day. 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 to your health checkups. This helps your health professional know if treatment is working or your condition is getting worse. Home blood pressure monitors are available at stores and pharmacies.
• Know how to contact your healthcare professional. Keep your health professional'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.

Talk with your healthcare team if you need help managing stress, anxiety or depression. Counseling and support groups may help.

Stages

During or after testing for heart failure, your healthcare professional may tell you the stage of disease. Staging helps determine the most appropriate treatment. There are two main ways to determine the stage of heart failure:

New York Heart Association (NYHA) classification

This system groups heart failure into four categories by number. You may see Roman numerals used for these category names.

• Class 1 heart failure. There are no heart failure symptoms.
• Class 2 heart failure. Everyday activities can be done without difficulty. But exertion causes shortness of breath or fatigue.
• Class 3 heart failure. It's difficult to complete everyday activities.
• Class 4 heart failure. Shortness of breath occurs even at rest. This category includes the most severe heart failure. It may be called end-stage or advanced congestive heart failure.

American College of Cardiology/American Heart Association classification

This stage-based classification system uses letters A to D. It includes a category for people who are at risk of developing heart failure.

• Stage A. There are several risk factors for heart failure but no signs or symptoms.
• Stage B. There is heart disease but no signs or symptoms of heart failure.
• Stage C. There is heart disease and signs or symptoms of heart failure.
• Stage D. There is heart disease and the symptoms disrupt daily life or lead to hospitalization. This stage is usually called end-stage or advanced congestive heart failure. Advanced heart failure requires specialized treatments.

Healthcare professionals often use the staging systems together to help decide the right treatment for you. Your health professional can help you interpret your stage.