Heart Failure

Heart failure is a condition in which the heart can’t pump blood the way it should. In some cases, the heart can’t fill with enough blood. In other cases, the heart can’t send blood to the rest of the body with enough force. Some people have both problems. “Heart failure” doesn’t mean that the heart has stopped or is about to stop working. However, it’s a serious condition that requires medical care.

Heart failure develops over time as the pumping of the heart grows weaker. It can affect the right side of the heart only or both the left and right sides of the heart. Most cases involve both sides of the heart.

Right-side heart failure occurs when the heart can’t pump blood to the lungs, where it picks up oxygen. Left-side heart failure occurs when the heart can’t pump enough oxygen-rich blood to the rest of the body. Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and, rarely, the veins in the neck. Right-side and left-side heart failure also cause shortness of breath and fatigue (tiredness).

The leading causes of heart failure are diseases that damage the heart. These include coronary artery disease (CAD), high blood pressure, and diabetes.

Other Names

• Dropsy
• Left-side, or systolic, heart failure. This is when the heart can't pump enough oxygen-rich blood to the body
• Right-side, or diastolic, heart failure. This is when the heart can't fill with enough blood

Some people have only right-side heart failure. But all people who have left-side heart failure also have right-side heart failure. Treatments for right-side heart failure alone differ from treatments for both right-side and left-side heart failure. A doctor can plan treatment based on the type of heart failure and each person's unique needs.

Causes

Conditions that damage the heart muscle or make it work too hard can cause heart failure. Over time, the heart weakens. It isn't able to fill with and/or pump blood as well as it should. As the heart weakens, certain proteins and other substances may be released into the blood. They have a toxic effect on the heart and blood flow, and they cause heart failure to worsen. The most common causes of heart failure are coronary artery disease (CAD), high blood pressure, and diabetes. Treating these problems can prevent or improve heart failure.

Coronary Artery Disease

CAD occurs when a fatty material called plaque builds up in your coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque narrows the arteries, causing less blood to flow to the heart muscle. This can lead to chest pain, heart attack, and heart damage.

High Blood Pressure

Blood pressure is the force of blood pushing against the walls of the arteries. Blood pressure is “high” if it stays at or above 140/90 mmHg over a period of time. High blood pressure stiffens blood vessels and makes the heart work harder. Without treatment, the heart may be damaged.

Diabetes

This disease occurs when the level of sugar in the blood is high. The body doesn't make enough insulin or doesn't use its insulin properly. Insulin is a hormone that helps convert food to energy. High sugar levels can damage blood vessels around the heart.

Other Causes

Other diseases and conditions that can lead to heart failure are:

• Heart muscle diseases. These diseases may be present at birth or due to injury or infection.
• Heart valve disorders. These problems may be present at birth or due to infections, heart attacks, or damage from heart disease.
• Arrhythmias, or irregular heartbeats. These heart problems may be present at birth or due to heart disease or heart defects.
• Congenital heart defects. These heart problems are present at birth.

Other factors also can injure the heart muscle and lead to heart failure. These include:

• Treatments for cancer, such as radiation and chemotherapy
• Thyroid disorders (having either too much or too little thyroid hormone in the body)
• Alcohol abuse
• HIV/AIDS
• Cocaine and other illegal drug use
• Too much vitamin E

Heart damage from obstructive sleep apnea may cause heart failure to worsen. In obstructive sleep apnea, your breathing stops or gets very shallow while you’re sleeping. This can deprive the heart of oxygen and increase its workload. Treating this sleep problem may improve heart failure.

Chance of Developing

Risk factors

About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. The number of people who have heart failure is growing. Each year, another 550,000 people are diagnosed for the first time. Heart failure is more common in:

• People who are 65 or older. Aging can weaken the heart muscle. Older people also may have had a disease for many years that causes heart failure. Heart failure is the #1 reason for hospital visits in this age group.
• African Americans. African Americans are more likely than people of other races to have heart failure and to suffer from more severe forms of it. They’re also more likely than other groups to have symptoms at a younger age, get worse faster, have more hospital visits due to heart failure, and die from heart failure.
• People who are overweight or obese. Excess weight puts a greater strain on the heart. It also can lead to type II diabetes, which adds to the risk of heart failure.

Men have a higher rate of heart failure than women. But in actual numbers, more women have the condition. This is because many more women than men live into their seventies and eighties when it’s common.

Children with congenital heart defects also can develop heart failure. Children are born with these defects when the heart, heart valves, and/or blood vessels near the heart don’t form correctly. This can weaken the heart muscle and lead to heart failure.

Children don’t have the same symptoms or get the same treatment for heart failure as adults. This article focuses on heart failure in adults.

Signs and Symptoms

The most common signs and symptoms of heart failure are:

• Shortness of breath or trouble breathing
• Fatigue (tiredness)
• Swelling in the ankles, feet, legs, abdomen, and, rarely, the veins in the neck

All of these symptoms are due to the buildup of fluid in the body. When symptoms start, a person may feel tired and short of breath after routine physical effort—like climbing stairs.

As the heart grows weaker, symptoms get worse, people with heart failure begin to feel tired and short of breath after getting dressed or walking across the room. Some people have shortness of breath while lying flat.

Fluid buildup from heart failure also causes weight gain, frequent urination, and a cough that's worse at night and while lying down. This cough may be a sign of a condition called acute pulmonary edema. This is when too much fluid is in the lungs. This severe condition requires emergency treatment.

Heart Failure Signs and Symptoms

Image:Heartfailure.jpg

The illustration shows the major signs and symptoms of heart failure.

Diagnosis

A doctor will diagnose heart failure based on medical and family histories, a physical exam, and tests. Because the symptoms of heart failure also are common in other conditions, the doctor must:

• Find out whether there is a disease or condition present that can cause heart failure, such as coronary artery disease (CAD), high blood pressure, or diabetes
• Rule out other causes of your symptoms
• Find any damage to the heart and measure how well the heart pumps blood

Early diagnosis and treatment can help people with heart failure live longer, more active lives.

Exams and tests

Medical and Family Histories

The doctor will ask about family history as well as past medical history to try and determine if any diseases or conditions are present that can cause heart failure.

The doctor also will ask about symptoms. He or she will want to know which symptoms are present, when they occur, how long they have been occurring, and how severe they are. The answers will help show whether and how much the symptoms limit daily routine.

Physical Exam

During the physical exam, the doctor will:

• Listen to the heart for sounds that aren't normal
• Listen to the lungs for the sounds of extra fluid buildup
• Look for swelling in the ankles, feet, legs, abdomen, and the veins in the neck

Diagnostic Tests

No one test shows heart failure. If the signs and symptoms of heart failure are present, the doctor may order an EKG] (electrocardiogram), a chest x ray, and a BNP blood test as initial tests.

Initial Tests

EKG. This simple test shows how fast the heart is beating and whether its rhythm is steady or irregular. An EKG may show a previous heart attack or whether the walls in the heart's pumping chambers are thicker than normal. Thicker walls can make it harder for the heart to pump blood.

Chest x ray. A chest x ray takes a picture of the heart and lungs. It can show whether the heart is enlarged, whether there is fluid in the lungs, or whether there is lung disease.

BNP blood test. This new test checks the level of a hormone called BNP, which rises during heart failure.

Followup Tests

Patients are often referred to a cardiologist if the initial test results indicate heart failure. A cardiologist is a doctor who specializes in treating people with heart problems.

The cardiologist will likely order one or more other tests to confirm the diagnosis.

Echocardiography. Echocardiography uses sound waves to create a moving picture of the heart. It shows the size and shape of the heart and how well parts of the heart are working. The test also can show where blood flows poorly to the heart, where the heart muscle doesn't contract as it should, and damage to the heart muscle caused by poor blood flow.

Sometimes this test is done both before and after the heart is put through physical stress (see stress testing below). Testing under stress helps show whether there's a lack of blood flow to the heart (a sign of CAD).

Doppler imaging. A Doppler test uses sound waves to measure the speed and direction of blood flow. It's often done with an echocardiogram to give a more complete picture of blood flow to the heart and lungs.

Doppler is often used to find out whether there is right-side heart failure (this is when the heart can't fill with enough blood).

Holter monitor. A Holter monitor is a small box that is carried in a pouch around the neck or clipped to a belt. It's attached to sticky patches called electrodes that are placed on the chest. The device records the heart rhythm for a full 24- or 48-hour period, while the wearer does his or her normal daily activities.

Nuclear heart scan. A nuclear heart scan is a test that shows how well blood is passing through the heart and how much blood is reaching the heart muscle.

The doctor will inject a radioactive substance into the bloodstream, which will make the heart chambers and vessels easy to see. Then, a special camera is used to show where the substance lights up (in healthy heart muscle) and where it doesn't (in damaged heart muscle).

The doctor may want to do this test while the heart is under physical stress (see stress testing below).

Cardiac catheterization. During cardiac catheterization a long, thin, flexible tube called a catheter is put into a blood vessel in the arm, groin (upper thigh), or neck and threaded to the heart. This allows the doctor to study the insides of the coronary arteries. Coronary arteries carry oxygen-rich blood to the heart.

During this procedure, the doctor can check the pressure and blood flow in the heart's chambers, collect blood samples, and use x rays to look at the coronary arteries.

Coronary angiography. Coronary angiography is usually done with cardiac catheterization. A dye that can be seen on x ray is injected into the blood through the tip of the catheter. The dye allows the doctor to see the flow of blood to the heart muscle. This test also shows how well the heart is pumping.

Stress test. Some heart problems are easier to diagnose when the heart is working harder and beating faster than when it's at rest. During stress testing, the patient exercises (or is given medicine if they can't exercise) to make the heart work harder and beat faster. He or she may walk or run on a treadmill or pedal a bicycle.

Heart tests, such as nuclear heart scanning and echocardiography, are done during stress testing.

Cardiac magnetic resonance imaging (MRI). A cardiac MRI scan shows, in detail, the structures and beating of the heart. An MRI scan can help the doctor see whether parts of the heart are damaged. Doctors also are using MRI in research studies to find early signs of heart failure, even before symptoms appear.

Positron emission tomography (PET). PET scanning shows the level of chemical activity in areas of the heart. This scan can help the doctor see whether enough blood is flowing to these areas. It can show blood flow problems that other types of scans may not pick up.

Thyroid function tests. Thyroid function tests show how well the thyroid is working. They include blood tests, imaging tests, and tests to stimulate the thyroid. These common tests are key in checking for heart failure. Having too much or too little thyroid hormone in the blood can cause heart failure.

Treatment

Early diagnosis and treatment can help people with heart failure live longer, more active lives. How heart failure is treated will depend on the type and stage of heart failure (how severe it is).

The goals of treatment for all stages of heart failure are to:

• Treat the underlying cause of heart failure, such as coronary artery disease (CAD), high blood pressure, or diabetes
• Reduce the symptoms
• Stop heart failure from getting worse
• Increase lifespan and improve the quality of life

For people with any stage of heart failure, treatment will include lifestyle measures, medicines, and ongoing care. People who have more severe heart failure also may need medical procedures and surgery.

Lifestyle Measures

It is possible to take simple steps to help feel better and control heart failure. The sooner these measures are started, the better.

Follow a Healthy Eating Plan

A diet low in salt, fat, saturated fat, trans fat, and cholesterol can help to prevent or control heart failure. Salt can cause extra fluid to build up in your body, making heart failure worse. Fat and saturated fat can increase blood cholesterol levels. Trans fat raises LDL ("bad") cholesterol and lowers HDL ("good") cholesterol. High blood cholesterol can cause heart disease, which in turn can cause heart failure.

A balanced diet with varied nutrients can help the heart work better. Getting enough potassium is key for people with heart failure. Some heart failure medicines deplete the potassium in the body. This can put people with heart failure in danger. Lack of potassium can cause very rapid heart rhythms that lead to sudden death.

Potassium is found in foods like bananas, strawberries, raisins, beets, and greens. Talk to a health care team about getting the correct amount of potassium.

Anyone with heart failure should not drink alcohol. If the heart failure is severe, the doctor may advise limiting the amount of fluid intake.

Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the Dietary Approaches to Stop Hypertension (DASH) eating plan].

The TLC diet is low in saturated fat and cholesterol to help lower blood cholesterol. The DASH eating plan contains less salt/sodium, sweets, added sugars, fats, and red meat than the typical American diet. Fruits, vegetables, fat-free or low-fat diary products, whole grains, fish, poultry, beans, seeds, and nuts are the focus of the plan.

Adopt Healthy Habits

Taking steps to control risk factors for CAD, high blood pressure, and diabetes also will help control heart failure.

• Lose weight if overweight or obese. Work with a health care team to lose weight safely.
• Do physical activity as the doctor directs to become more fit and stay as active as possible.
• Quit smoking and avoid using illegal drugs. Avoid exposure to secondhand smoke. Smoking and drugs can worsen heart failure.
• Get enough rest.

Medications

The doctor will base medicine treatment on the type of heart failure that exists, how severe it is, and the response to certain medicines. The following are the main medicines for treating heart failure.

• Diuretics (water or fluid pills) help reduce fluid buildup in the lungs and swelling in your feet and ankles.
• ACE inhibitors lower blood pressure and reduce strain on the heart. They also may reduce the risk of a future heart attack.
• Aldosterone antagonists trigger the body to get rid of salt and water through urine, which lowers the volume of blood that the heart must pump.
• Angiotensin receptor blockers relax the blood vessels and lower blood pressure, so the heart doesn't have to work as hard.
• Beta blockers slow the heart rate and lower blood pressure to decrease the workload on the heart.
• Isosorbide dinitrate/hydralazine hydrochloride helps relax the blood vessels, so the heart doesn't work as hard to pump blood. The Food and Drug Administration approved this medicine for use in African Americans after studies showed it worked well for this group.
• Digoxin makes the heart beat stronger and pump more blood.

Many people with severe heart failure must be treated in the hospital from time to time. In the hospital, patients may receive new or special medicines, but he or she will keep taking their other medicines too. Some people with very severe heart failure are given intravenous (IV) medicines, which are injected into veins in their arms.

The doctor also will order extra oxygen for anyone who has trouble breathing even with medication. The extra oxygen can be given in the hospital and at home.

Ongoing Care

It's important to watch for signs that heart failure is getting worse. Checking weight each day is very important. Let the doctor know right away if there is a sudden weight gain or weight loss. Either one can signal a need to adjust treatment. If the doctor advises limiting the intake of fluids, it will be necessary to carefully watch how much fluid is consumed during the day.

It's also important to get medical care for other related conditions. Anyone with diabetes and/or high blood pressure, work with a health care team to control your condition(s). Have blood sugar level and blood pressure checked. The doctor will determine how often to come in for tests and how often to take measurements at home.

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and congestive heart failure related hospitalisations in patients with congestive heart failure.[1]

Medical Procedures and Surgery

As heart failure worsens, lifestyle changes and medicines may no longer control heart failure symptoms. A special medical procedure or surgery may be necessary.

If heart damage has occurred and there are severe heart failure symptoms, one of the following may be needed:

• Cardiac resynchronization therapy. In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the heart's pumping. To correct this problem, doctors may implant a type of pacemaker near the heart. This device helps both sides of the heart contract at the same time, which may decrease heart failure symptoms.
• An implantable cardioverter defibrillator (ICD). Some people with heart failure have very rapid, irregular heartbeats. Without treatment, the problem can cause sudden cardiac arrest. Doctors implant ICDs to solve this problem. ICDs are similar to pacemakers. The device checks heart rate and corrects heart rhythms that are too fast.

People who have heart failure symptoms at rest despite other treatments may need:

• A mechanical heart pump, such as a left ventricular assist device. This device helps pump blood from the heart to the rest of the body. People may use pumps until they have surgery or as a long-term treatment.
• Heart transplant. When all other treatments fail to control symptoms, some people who have heart failure receive healthy hearts from deceased donors.
• Experimental treatments. Studies are under way to see whether open-heart surgery or angioplasty (a procedure used to unblock heart arteries and improve blood flow) can reduce heart failure symptoms.

Prevention

There are steps to be taken to prevent heart failure. The sooner these steps are started, the better the chances to avoid it or to stay healthier longer.

If the heart is healthy, there are actions that can be taken to prevent heart disease, which helps prevent heart failure. To prevent heart disease:

• Follow a heart healthy diet that focuses on fruits, vegetables, whole grains, low-fat diary products, and lean meat. It also should be low in salt, fat, saturated fat, trans fat, and cholesterol. Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the
• Quit smoking if you smoke. Avoid exposure to secondhand smoke.
• Lose weight if overweight or obese.
• Get regular physical activity. Aim for at least 30 minutes on most, and preferably all, days of the week.
• Avoid using illegal drugs.

Even someone at high risk for heart failure, can take steps to reduce their risks. People at high risk include those who have high blood pressure, coronary artery disease, or diabetes, or people who are obese.

• Follow all of the steps listed above.
• Treat and control any conditions that cause heart failure. Take medicines that the doctor prescribes.
• Avoid drinking alcohol.
• See a doctor for regular followup visits.

Anyone with heart damage but no signs of heart failure, can still reduce their risks. In addition to taking the steps above, take all of the medicines the doctor prescribes to reduce the heart's workload.

If there are side effects from a medicine, tell the doctor. It is important to never stop taking medicine without asking the doctor first.

Living With Heart Failure

Heart failure can't be cured. It may be necessary to take medicine and follow a treatment plan for life.

Despite treatment, symptoms may get worse over time. It may not be possible to do many of the things that were once easy to do before heart failure began . However, taking all the steps the doctor recommends, can mean staying healthier longer.

Researchers also may find new treatments that can help in the future. Treatment can relieve the symptoms and make daily activities easier. It also can reduce the chance of having to go to the hospital. For these reasons, it's vital to follow the treatment plan as directed.

• Take all medicines as prescribed. If there are side effects from a medicine, tell the doctor. Never stop taking medicine without asking the doctor first.
• Make all of the lifestyle changes that the doctor recommends.
• Get advice from the doctor about how activity levels. This includes advice on daily activities, work, leisure time, sex, and exercise. The level of activity will depend on the stage of the heart failure (how severe it is). Studies show that aerobic exercise improves heart function; other types of exercise don't.
• Keep all of medical appointments, including visits to the doctor and appointments to get tests and lab work. The doctor needs the results of these tests to adjust medicine doses and help avoid any harmful side effects.

Certain factors can cause heart failure to worsen. These include:

• Forgetting to take all medicines
• Not following diet as direceted (such as eating salty foods)
• Drinking alcohol

These factors can lead to a hospital stay. If having trouble following the diet, talk to the doctor. The doctor can help arrange for a dietitian to help with setting up a diet. Avoid drinking alcohol.

People with heart failure often have other serious conditions that require ongoing treatment. If you do, you're likely taking medicines for them as well as for heart failure. Taking more than one medicine raises the risk of side effects and other problems. Make sure your pharmacist has a complete list of all of the medicines and over-the-counter products that you're taking.

Tell your doctor right away about any problems with your medicines. Also, talk with your doctor before taking any new medicine another doctor prescribes or any new over-the-counter medicines or herbal supplements.

Try to avoid respiratory infections like the flu and pneumonia. Ask your doctor or nurse about getting flu and pneumonia vaccines.

Coping with heart failure and changing lifestyle to decrease symptoms can be hard. Some people feel depressed. If so, talk to the doctor. He or she may recommend treatment for depression. This treatment can improve outlook and make life more enjoyable.

Clinical Trials

• Current Research (ClinicalTrials.gov)
• Patient Recruitment for Studies Conducted by NHLBI, NIH

Research

Researchers continue to learn more about heart failure and how to treat it. As a result, treatments are getting better.

People with heart failure often can be treated in a research study. Patients get top care from heart failure experts and the chance to help advance heart failure knowledge and care.

It is also a good idea to take part in a heart failure registry, which tracks the course of disease and treatment in large numbers of people. These data help research move forward. A health care team can provide more information.

Expected Outcome

Heart failure is a very common condition. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year.

Both children and adults can have heart failure, although the symptoms and treatments differ. This article focuses on heart failure in adults.

Taking steps to prevent CAD can help prevent heart failure. These steps include following a heart healthy diet, not smoking, doing physical activity, and losing weight if overweight or obese. Working with the doctor to control high blood pressure and diabetes also can help prevent heart failure.

People who have heart failure can live longer and more active lives if it’s diagnosed early and they follow their treatment plans. For most, treatment includes medicines and lifestyle measures.

Currently, there’s no cure for heart failure. However, researchers are finding and testing new treatments. These treatments offer hope for better ways to delay heart failure and its complications.

Other Resources

• Cardiovascular Information for the Public
• "Your Guide to a Healthy Heart"
• "Your Guide to Living Well With Heart Disease"

Therapeutic Lifestyle Changes (TLC) diet

• Heart Failure (MedlinePlus)
• Heart Failure: Interactive Tutorial (MedlinePlus)
• Dietary Approaches to Stop Hypertension (DASH) eating plan.