Heart failure - overview

Causes

Heart failure is often a long-term (chronic) condition, but it can sometimes develop suddenly. It can be caused by many different heart problems.

The condition may affect only the right side or only the left side of the heart. These are called right-sided heart failure or left-sided heart failure. More often, both sides of the heart are involved.

Heart failure is present when:

• Your heart muscle cannot pump (eject) the blood out of the heart very well. This is called systolic heart failure.
• Your heart muscles are stiff and do not fill up with blood easily. This is called diastolic heart failure.

These problems mean the heart is no longer able to pump enough oxygen-rich blood out to the rest of your body.

As the heart's pumping becomes less effective, blood may back up in other areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive heart failure.

The most common cause of heart failure is coronary artery disease (CAD), a narrowing of the small blood vessels that supply blood and oxygen to the heart. High blood pressure that is not well controlled may also lead to heart failure.

Other heart problems that may cause heart failure are:

• Congenital heart disease
• Heart attack
• Heart valve disease (this can occur from valves that are leaky or narrowed)
• Infection that weakens the heart muscle
• Some types of abnormal heart rhythms (arrhythmias)

Other diseases that can cause or contribute to heart failure:

• Amyloidosis
• Emphysema
• Overactive thyroid
• Sarcoidosis
• Severe anemia
• Too much iron in the body
• Underactive thyroid

Symptoms

Symptoms of heart failure often begin slowly. At first, they may only occur when you are very active. Over time, you may notice breathing problems and other symptoms even when you are resting.

Heart failure symptoms may also begin suddenly; for example, after a heart attack or other heart problem.

Common symptoms are:

• Cough
• Fatigue, weakness, faintness
• Loss of appetite
• Need to urinate at night
• Pulse that feels fast or irregular, or a sensation of feeling the heart beat (palpitations)
• Shortness of breath when you are active or after you lie down
• Swollen (enlarged) liver or abdomen
• Swollen feet and ankles
• Waking up from sleep after a couple of hours due to shortness of breath
• Weight gain

Exams and Tests

Your health care provider will examine you for signs of heart failure:

• Fast or difficult breathing
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Sounds ("crackles") from fluid buildup in your lungs, heard through a stethoscope
• Swelling of the liver or abdomen
• Uneven or fast heartbeat and abnormal heart sounds

Many tests are used to diagnose, find the cause of, and monitor heart failure.

An echocardiogram (echo) is often the best test for heart failure. Your doctor will use it to guide your treatment.

Several other imaging tests can look at how well your heart is able to pump blood, and how much the heart muscle is damaged.

Many blood tests are used to:

• Help diagnose and monitor heart failure
• Identify risks for heart disease
• Look for possible causes of heart failure, or problems that may make your heart failure worse
• Monitor for side effects of medicines you may be taking

Treatment

MONITORING AND SELF CARE

If you have heart failure, your doctor will monitor you closely. You will have follow-up appointments at least every 3 to 6 months, but sometimes much more often. You will also have tests to check your heart function.

Knowing your body and the symptoms that your heart failure is getting worse will help you stay healthier and out of the hospital. At home, watch for changes in your heart rate, pulse, blood pressure, and weight.

Weight gain, especially over a day or two, can be a sign that your body is holding onto extra fluid and your heart failure is getting worse. Talk to your doctor about what you should do if your weight goes up or you develop more symptoms.

Limit how much salt you eat. Your doctor may also ask you to limit how much fluid you drink during the day.

Other important changes to make in your lifestyle:

• Ask your doctor how much alcohol you may drink.
• Do not smoke.
• Stay active. Walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan for you. DO NOT exercise on days when your weight has gone up from fluid or you are not feeling well.
• Lose weight if you are overweight.
• Lower your cholesterol by changing your lifestyle.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest too.

MEDICATIONS, SURGERY, AND DEVICES

Your doctor will ask you to take medicines to treat your heart failure. Medicines treat the symptoms, prevent your heart failure from getting worse, and help you live longer. It is very important that you take your medicine as your health care team directed.

These medicines:

• Help the heart muscle pump better
• Keep your blood from clotting
• Lower your cholesterol levels
• Open up blood vessels or slow your heart rate so your heart doesn't have to work as hard
• Reduce damage to the heart
• Reduce the risk of abnormal heart rhythms
• Replace potassium
• Rid your body of excess fluid and salt (sodium)

It is very important that you take your medicine as your doctor and nurse directed. Do not take any other drugs or herbs without first asking your doctor or nurse about them. Drugs that may make your heart failure worse include:

• Ibuprofen (Advil, Motrin)
• Naproxen (Aleve, Naprosyn)
• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)

The following surgeries and devices for certain patients with heart failure may be recommended:

• Coronary bypass surgery (CABG) or angioplasty with or without stenting may help improve blood flow to the damaged or weakened heart muscle.
• Heart valve surgery may be done if changes in a heart valve are causing your heart failure.
• A pacemaker can help treat slow heart rates or help both sides of your heart contract at the same time.
• A defibrillator sends an electrical pulse to stop life-threatening abnormal heart rhythms.

END-STAGE HEART FAILURE

Severe heart failure occurs when treatments no longer work. Certain treatments may be used when a person is waiting for a heart transplant:

• Intra-aortic balloon pump (IABP)
• Left ventricular assist device (LVAD)

At a certain point, the health care provider will decide whether it is best to keep treating heart failure. The patient, along with his or her family and doctors, may want to discuss the option of palliative or comfort care at this time.

Outlook (Prognosis)

Often, you can control heart failure by taking medicine, changing your lifestyle, and treating the condition that caused it.

Heart failure can suddenly get worse due to:

• Angina
• Eating high-salt foods
• Heart attack
• Infections or other illnesses
• Not taking medicines correctly

Heart failure is usually a chronic illness, which may get worse over time. Some people develop severe heart failure, in which medicines, other treatments, and surgery no longer help.

Many people are at risk for deadly heart rhythms. These people often receive an implanted defibrillator to restore a normal heart rhythm if a deadly abnormal heart rhythm occurs.

When to Contact a Medical Professional

Call your health care provider if you develop:

• Increased cough or phlegm
• Sudden weight gain or swelling
• Weakness
• Other new or unexplained symptoms

Go to the emergency room or call the local emergency number (such as 911) if you experience:

• Fainting
• Fast and irregular heartbeat (especially if you also have other symptoms)
• Severe crushing chest pain

Prevention

Alternative Names

CHF; Congestive heart failure; Left-sided heart failure; Right-sided heart failure - Cor pulmonale; Cardiomyopathy - heart failure

References

Mant J, Al-Mohammad A, Swain S, Laramee P. Guideline Development Group. Management of chronic heart failure in adults: synopsis of the National Institute For Health and Clinical Excellence guideline. Ann Intern Med. 2011;155(4):252-259.

Emanuel LL, Bonow RO. Care of patients with end-stage heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 34.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 28.

Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26.

Update Date: 6/23/2012

Updated by: Michael M. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.