Heart Failure

What is heart failure?

Heart failure a condition in which the heart cannot pump efficiently enough to meet the body's need for blood. The previous name for heart failure, “congestive heart failure (CHF),” refers to the buildup of fluid in the lungs (congestion)—a telltale sign of impaired heart function. However, the name CHF does not capture the variety of other symptoms that often occur, so the pre¬ferred term has been changed to simply “heart failure (HF).”

Contrary to its name, heart failure does not mean the heart has failed completely. Instead, the inefficient pumping associated with heart failure causes a backup of blood in the veins leading to the heart. The kidneys begin to retain fluid and the body's tissues swell. The swelling most commonly affects the legs. But it also can occur in other tissues and organs. When it occurs in the lungs, it causes breathing difficulty.

Impairments in pumping action can develop in the entire heart or just one side — left or right. Most heart failure is caused by left-sided problems: the left ventricle (the heart’s largest chamber) is either too weak or too stiff to pump normally.

In some people with heart failure, the left ventricle heart muscle becomes weaker. It cannot pump as well. This is known as heart failure with reduced ejection fraction (HFrEF).

In other people, the heart muscle becomes thick and stiff, leading to heart failure with preserved ejection fraction (HFpEF). As a result, the left ventricle cannot fill with enough blood between heartbeats.

People can also have heart failure with some features of both weak heart muscle and stiff heart muscle, known as heart failure with mid-range ejection fraction (HFmEF).

Heart failure symptoms

Many people with heart failure have symptoms they attribute to getting older, like fatigue, getting winded when walking stairs, or decreased exercise capacity. As the condition worsens, shortness of breath and wheezing occur even with walking on a flat surface. At late stages, shortness of breath starts to occur at rest.

As fluid accumulates in the lungs, people with heart failure may begin to sleep propped up with pillows. This makes breathing easier. There also can be a persistent cough or wheeze due to fluid accumulation in the lungs.

Fluid also can collect in the legs and ankles, causing swelling. In people who are less active, collected fluid can accumulate in the middle of the body. Some people urinate several times during the night as the kidneys drain off some of this excess fluid. As the body accumulates more and more fluid, the person may experience significant weight gain.

How is heart failure diagnosed?

Heart failure usually affects both sides of the heart. But in some people it affects only one side. When heart failure affects mainly the left side of the heart, the symptoms are more likely to involve breathing difficulties. When mainly the right side is affected, the main symptoms may be leg swelling and abdominal swelling.

Standard initial evaluation of suspected heart failure includes blood tests, a chest x-ray and an echocardiogram (an ultrasound of the heart).

The echocardiogram is particularly important. It can determine whether the heart muscles have weakened or become stiff. Treatment can differ depending on the type of heart failure.

The echocardiogram can distinguish between the two types by measuring the ejection fraction (EF), which refers to the percentage of blood in the left ventricle (the heart’s main pumping chamber) that is pumped out each time the ventricle contracts.

For a healthy heart, a normal ejection fraction is 50% to 70%. A person with a heart failure from weak heart muscle that can’t contract very well typically has an EF of less than 40%. This is called heart failure with reduced ejection fraction (HFrEF).

Heart failure from thick and stiff muscle prevents the ventricles from completely relaxing and filling up with blood. The muscles contract normally so the ejection fraction is normal or close to normal, at 50% or greater. But the heart muscle’s inability to relax completely can still lead to fluid backing up into the lungs, as with HFrEF. This is known as heart failure with preserved ejection fraction (HFpEF).

Men are more likely to have the first type (HFrEF), whereas the other form (HFpEF) is about twice as common in women, particularly older women. The symptoms of both are similar: fatigue, shortness of breath, difficulty being physically active, trouble breathing at night, and swelling in the lower body.

People can have heart failure with a mixed picture, a somewhat stiff heart that pumps less forcefully than normal. They tend to have an EF between 40% and 49%, which is called heart failure with mid-range ejection fraction (HFmEF).

What causes heart failure?

Heart failure has many possible underlying causes, including:

• Coronary artery disease
• High blood pressure (hypertension)
• Heart valve disorders (including rheumatic heart disease)
• Congenital heart disorders
• Cardiomyopathy (disease of the heart muscle)
• Heart attack
• Cardiac arrhythmias (problems with the heart rate and/or rhythm)
• Exposure to toxins, including excessive alcohol

Hyperthyroidism, diabetes and prolonged lung disease also increase the risk of heart failure.

How do you treat heart failure?

The treatment of heart failure focuses on:

• Lessening symptoms
• Decreasing hospitalizations
• Improving life expectancy

To accomplish these goals, your doctor will advise a low-salt diet and medication.
Today, there are many more medication options for HFrEF. They include:

• A diuretic to remove excess body fluid by increasing urine output
• An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker to help the heart work less hard
• A beta-blocker to help the heart work less hard
• A potassium-sparing diuretic, which can help people live longer when taken in low doses
• Combination drug containing sacubitril and valsartan (Entresto), which can help people live longer and reduce hospitalizations
• An SGLT2 inhibitor that helps a weak heart function more efficiently

Proven drug therapies for HFpEF are more limited. The primary goal is keeping blood pressure well controlled and using diuretics as needed. Recent studies suggest adding an SGLT2 inhibitor can also reduce symptoms and help prevent hospitalization.

Your doctor also will address the underlying cause of your heart failure. Heart failure related to coronary artery disease may require additional medications, angioplasty or surgery. When heart failure is caused by a poorly functioning heart valve, your doctor may advise surgical repair and valve replacement.

For some heart failure patients, losing weight or avoiding alcohol can dramatically improve symptoms. Your doctor will tell you how much exercise is appropriate. Balancing physical activity with rest is important in more advanced stages of heart failure.

Eventually medications and self-treatment may no longer be helpful. At this point, a left ventricular assist device or heart transplant may be considered.

Can you prevent heart failure?

To avoid heart failure, you must prevent the various forms of heart disease that lead to it.

To prevent heart disease:

• Eat a healthy, balanced diet
• Control your blood pressure and cholesterol level
• Maintain a normal body weight
• Exercise regularly
• Don't smoke
• Limit alcohol use to one to two drinks per day

Some types of heart failure cannot be prevented.