Heart Failure: Symptoms, Causes & Treatment Guide

What Is Heart Failure?

Heart failure is a chronic condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen and nutrients. It does not mean the heart has stopped working, but rather that it is working less effectively than normal. Heart failure is also called congestive heart failure, cardiac insufficiency, or cardiac decompensation.

Heart failure is a serious medical condition that affects approximately 1-2% of adults in developed countries, with prevalence rising sharply with age to over 10% in people older than 70 years. According to the World Health Organization, heart failure affects an estimated 64 million people globally, representing a major public health burden that continues to grow as populations age.

The condition develops when the heart muscle becomes damaged or weakened, reducing its ability to fill with blood properly or pump blood out to the body with each contraction. This can occur in the left side of the heart (left-sided heart failure), the right side (right-sided heart failure), or both. The most common form is left-sided heart failure, which then often leads to right-sided failure as the condition progresses.

When the heart cannot pump efficiently, the body compensates through several mechanisms. The heart may enlarge, develop more muscle mass, or pump faster. Blood vessels narrow to maintain blood pressure, and blood flow is diverted away from less vital tissues toward the brain and heart. While these compensatory mechanisms help in the short term, they ultimately contribute to disease progression and worsening symptoms over time.

Types of Heart Failure

Heart failure is classified based on the heart's pumping ability, measured by the ejection fraction (EF) - the percentage of blood the heart pumps out with each beat. Understanding your type of heart failure is important because treatment approaches differ:

• Heart Failure with Reduced Ejection Fraction (HFrEF): Also called systolic heart failure, occurs when EF is 40% or less. The heart muscle has weakened and cannot contract forcefully enough.
• Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF): EF between 41-49%. This intermediate category may respond to similar treatments as HFrEF.
• Heart Failure with Preserved Ejection Fraction (HFpEF): Also called diastolic heart failure, occurs when EF is 50% or higher. The heart contracts normally but is stiff and cannot relax properly to fill with blood.

What Are the Symptoms of Heart Failure?

The main symptoms of heart failure include shortness of breath (especially during activity or when lying down), persistent fatigue and weakness, swelling in the legs, ankles, and feet, rapid or irregular heartbeat, reduced ability to exercise, and persistent cough. Symptoms often develop gradually and may be mistaken for normal aging.

Heart failure symptoms result from the heart's inability to pump blood effectively and the body's compensatory responses. When the heart cannot pump enough blood forward, fluid backs up into the lungs and body tissues, causing many of the characteristic symptoms. The severity of symptoms varies widely - some people have few symptoms while others experience significant limitations in daily activities.

Many people initially dismiss early heart failure symptoms as signs of aging, being out of shape, or other minor conditions. This is why heart failure is often not diagnosed until symptoms become severe. Recognizing these warning signs early and seeking medical evaluation can lead to earlier treatment and better outcomes.

Common Symptoms

• Shortness of breath (dyspnea): Difficulty breathing during physical activity, when lying flat (orthopnea), or waking up breathless at night (paroxysmal nocturnal dyspnea)
• Fatigue and weakness: Feeling tired all the time, even after rest, and lacking energy for normal activities
• Swelling (edema): Fluid accumulation in the legs, ankles, feet, and sometimes the abdomen
• Rapid or irregular heartbeat: Heart palpitations, racing heart, or irregular rhythm
• Persistent cough or wheezing: Often worse at night or when lying down, may produce white or pink-tinged mucus
• Reduced exercise tolerance: Getting tired more quickly during physical activities you used to do easily
• Increased need to urinate at night: The body tries to eliminate excess fluid when you lie down

When Symptoms Indicate an Emergency

Certain symptoms indicate that heart failure is becoming severe or that you're experiencing acute decompensation, which requires immediate medical attention. These situations can be life-threatening and should prompt an emergency call:

What Causes Heart Failure?

Heart failure is caused by conditions that damage or weaken the heart muscle. The most common causes are coronary artery disease (including heart attacks), high blood pressure, diabetes, and heart valve disease. Other causes include irregular heart rhythms, cardiomyopathy (heart muscle disease), congenital heart defects, and alcohol or drug abuse.

Heart failure typically develops after other conditions have damaged or placed excessive strain on the heart over time. Understanding the underlying cause is crucial for treatment, as addressing the root cause can sometimes improve or even reverse heart failure. In many cases, multiple factors contribute to the development of heart failure.

Coronary artery disease remains the leading cause of heart failure in developed countries, accounting for approximately 60-70% of cases. When the coronary arteries become narrowed or blocked by atherosclerosis, the heart muscle doesn't receive enough oxygen-rich blood. A heart attack (myocardial infarction) causes permanent damage to part of the heart muscle, which can significantly impair its pumping ability.

Primary Causes of Heart Failure

• Coronary artery disease: Narrowed arteries limit blood flow to the heart muscle, causing damage over time
• Heart attack: Sudden blockage causes permanent damage to heart tissue
• High blood pressure (hypertension): Forces the heart to work harder, eventually causing it to stiffen or weaken
• Diabetes: Significantly increases heart failure risk through multiple mechanisms
• Heart valve disease: Faulty valves force the heart to work harder to pump blood
• Cardiomyopathy: Diseases of the heart muscle itself, which may be inherited or acquired
• Irregular heart rhythms (arrhythmias): Especially atrial fibrillation, can weaken the heart over time
• Congenital heart defects: Heart problems present from birth

Additional Risk Factors

Beyond direct causes, several factors increase the risk of developing heart failure or can worsen existing heart failure:

• Age: Risk increases significantly after age 65
• Obesity: Excess weight puts additional strain on the heart
• Smoking: Damages blood vessels and contributes to coronary artery disease
• Alcohol abuse: Can directly damage the heart muscle (alcoholic cardiomyopathy)
• Sleep apnea: Untreated sleep apnea increases heart failure risk
• Certain medications: Some chemotherapy drugs and NSAIDs can affect heart function
• Viral infections: Some viruses can cause heart muscle inflammation (myocarditis)
• Thyroid disorders: Both overactive and underactive thyroid can affect the heart

How Is Heart Failure Diagnosed?

Heart failure is diagnosed through a combination of medical history, physical examination, and tests including blood tests (BNP/NT-proBNP), echocardiogram (heart ultrasound), electrocardiogram (ECG), and chest X-ray. The echocardiogram is particularly important as it measures ejection fraction and shows how well the heart is pumping.

Diagnosing heart failure requires a comprehensive evaluation because its symptoms can mimic other conditions. Your doctor will begin by asking about your symptoms, their duration and severity, your medical history, family history of heart disease, and lifestyle factors. A thorough physical examination will check for signs of fluid retention, abnormal heart sounds, and other indicators of heart failure.

Several tests are typically used to confirm the diagnosis and determine the type and severity of heart failure. These tests also help identify the underlying cause, which is essential for developing an effective treatment plan.

Blood Tests

A key blood test for heart failure measures natriuretic peptides (BNP or NT-proBNP). These substances are released by the heart when it is stretched or under stress. Elevated levels strongly suggest heart failure, while normal levels make heart failure unlikely. Other blood tests check for conditions that may cause or worsen heart failure, including kidney function, thyroid function, liver function, and diabetes.

Echocardiogram

The echocardiogram is the most important test for diagnosing heart failure. This ultrasound examination of the heart shows the heart's structure and function in real-time. It measures the ejection fraction, identifies which type of heart failure is present, evaluates heart valve function, and can show areas of the heart that have been damaged by a heart attack or other conditions.

Electrocardiogram (ECG)

An ECG records the electrical activity of the heart. While it cannot diagnose heart failure directly, it can show abnormal heart rhythms, evidence of previous heart attacks, and other electrical abnormalities that suggest heart problems. Changes on the ECG often prompt further investigation with echocardiography.

Additional Tests

• Chest X-ray: Shows heart size and fluid accumulation in the lungs
• Coronary angiography: X-ray imaging of heart arteries to detect blockages
• Cardiac MRI: Detailed imaging of heart structure and function
• Cardiac catheterization: Measures pressures inside the heart and lungs
• Exercise stress testing: Evaluates heart function during physical activity

How Is Heart Failure Treated?

Heart failure treatment combines medications (ACE inhibitors, beta-blockers, diuretics, SGLT2 inhibitors), lifestyle modifications (salt restriction, exercise, weight management), and sometimes devices (pacemakers, ICDs) or surgery. The goal is to improve symptoms, slow disease progression, reduce hospitalizations, and extend life.

Heart failure treatment has advanced significantly in recent decades, with multiple therapies proven to improve symptoms and survival. Treatment is highly individualized based on the type of heart failure, its severity, underlying causes, and other health conditions. Most people with heart failure will be prescribed several medications that work together, along with important lifestyle changes.

The foundation of heart failure treatment is what doctors call "guideline-directed medical therapy" (GDMT) - a combination of medications that have been proven in large clinical trials to improve outcomes. Starting and optimizing these medications is often the first priority after diagnosis.

Core Medications for Heart Failure

Several classes of medications form the cornerstone of heart failure treatment, particularly for heart failure with reduced ejection fraction (HFrEF):

• ACE inhibitors or ARBs: Relax blood vessels and reduce strain on the heart (examples: enalapril, lisinopril, losartan)
• ARNI (sacubitril/valsartan): A newer combination drug that may be more effective than ACE inhibitors alone
• Beta-blockers: Slow the heart rate and reduce blood pressure, allowing the heart to pump more efficiently (examples: metoprolol, bisoprolol, carvedilol)
• Mineralocorticoid receptor antagonists (MRAs): Block hormones that cause fluid retention and heart damage (examples: spironolactone, eplerenone)
• SGLT2 inhibitors: Originally diabetes medications, now proven to benefit heart failure patients regardless of diabetes status (examples: dapagliflozin, empagliflozin)
• Diuretics: Help remove excess fluid to relieve swelling and shortness of breath (examples: furosemide, bumetanide)

Device Therapy

Some patients with heart failure benefit from implanted devices that help the heart work more effectively or protect against dangerous heart rhythms:

• Cardiac Resynchronization Therapy (CRT): A special pacemaker that coordinates the beating of both sides of the heart, improving pumping efficiency. Recommended for certain patients with HFrEF and wide QRS on ECG.
• Implantable Cardioverter-Defibrillator (ICD): Monitors heart rhythm and delivers a shock if a dangerous rhythm occurs, preventing sudden cardiac death.
• CRT-D: Combines both resynchronization therapy and defibrillator functions in one device.

Surgical Options

In some cases, surgery may be needed to treat the underlying cause of heart failure or to support a severely damaged heart:

• Coronary artery bypass surgery or angioplasty: Restores blood flow to the heart if coronary artery disease is the cause
• Heart valve repair or replacement: Fixes faulty valves that are contributing to heart failure
• Left ventricular assist device (LVAD): A mechanical pump implanted to help the heart pump blood, used as a bridge to transplant or as long-term therapy
• Heart transplantation: For severe heart failure that doesn't respond to other treatments, in patients who are otherwise healthy enough for surgery

What Lifestyle Changes Help with Heart Failure?

Key lifestyle changes for heart failure include limiting sodium intake to less than 2,000 mg daily, maintaining a healthy weight, staying physically active within your limits, monitoring fluid intake, avoiding alcohol, quitting smoking, and getting vaccinated against flu and pneumonia. Daily weight monitoring helps detect fluid retention early.

Lifestyle modifications are an essential part of heart failure management, working alongside medications to improve symptoms and outcomes. These changes can significantly impact how you feel day-to-day and may help prevent hospitalizations. While making multiple lifestyle changes can seem overwhelming, even small improvements in one or two areas can make a meaningful difference.

Dietary Recommendations

Diet plays a crucial role in managing heart failure, particularly sodium (salt) intake:

• Limit sodium: Aim for less than 2,000 mg (about 1 teaspoon of salt) per day. Excess sodium causes fluid retention, worsening swelling and shortness of breath.
• Read food labels: Processed and restaurant foods are often high in sodium. Learn to identify hidden sources.
• Choose fresh foods: Fresh fruits, vegetables, and unprocessed meats are naturally low in sodium.
• Monitor fluid intake: If your doctor recommends it, limit fluids to 1.5-2 liters per day, including all beverages and liquid-containing foods.
• Eat a heart-healthy diet: Focus on fruits, vegetables, whole grains, lean proteins, and healthy fats.

Physical Activity

Regular physical activity is beneficial for most people with heart failure, despite what might seem counterintuitive. Exercise can improve symptoms, quality of life, and exercise capacity. However, the type and intensity should be tailored to your condition:

• Cardiac rehabilitation: Supervised exercise programs specifically designed for heart patients
• Walking: Start slowly and gradually increase duration and pace
• Low-impact activities: Swimming, cycling, or chair exercises may be appropriate
• Avoid overexertion: Stop if you feel unusually tired, short of breath, or have chest discomfort

Daily Monitoring

Regular self-monitoring helps you and your healthcare team catch problems early:

• Weigh yourself daily: Same time each morning, after using the bathroom, before eating. Rapid weight gain (1-2 kg in a day or 2-3 kg in a week) may indicate fluid retention.
• Track symptoms: Note changes in shortness of breath, swelling, or energy levels
• Check blood pressure: If recommended by your doctor
• Report changes promptly: Contact your healthcare team if symptoms worsen

Vaccinations

People with heart failure are at higher risk of serious complications from respiratory infections. Vaccination is an important preventive measure:

• Annual influenza vaccine: Get a flu shot every year
• Pneumococcal vaccines: Protect against pneumonia and related infections
• COVID-19 vaccines: Stay up to date with recommended boosters

When Should You Seek Medical Care?

Seek medical care if your heart failure symptoms worsen despite treatment, if you gain weight rapidly (1-2 kg in a day), if you have increased swelling, new or worsening shortness of breath, or feel more tired than usual. Seek emergency care for severe breathing difficulty, chest pain, or fainting.

Living with heart failure requires ongoing communication with your healthcare team. Regular follow-up appointments allow your doctors to monitor your condition, adjust medications, and address problems before they become serious. Between appointments, it's important to know when to contact your healthcare provider and when to seek emergency care.

Contact Your Healthcare Provider If:

• Your weight increases by 1-2 kg in one day or 2-3 kg in one week
• You have increased swelling in your legs, ankles, or abdomen
• Your usual activities make you more short of breath than before
• You feel more tired or weak than usual
• You have a persistent cough or it's getting worse
• You need to use more pillows to sleep comfortably
• You have side effects from your medications

What Is It Like Living with Heart Failure?

Living with heart failure requires daily self-management including taking medications, monitoring symptoms and weight, following dietary guidelines, and staying active within your limits. With proper treatment, many people maintain good quality of life for years. Support from healthcare teams, family, and support groups can help.

Being diagnosed with heart failure can feel overwhelming, but it's important to know that many people with this condition live full, active lives for many years. Heart failure is a chronic condition that requires ongoing management, much like diabetes or high blood pressure. The key is working closely with your healthcare team, taking your medications as prescribed, and making lifestyle adjustments that help you feel your best.

Quality of life with heart failure depends largely on the severity of the condition and how well it responds to treatment. Many people with well-controlled heart failure continue to work, travel, enjoy hobbies, and maintain relationships. As the condition progresses, some adjustments may be necessary, but support is available to help maintain independence and quality of life.

Practical Tips for Daily Life

• Plan activities: Schedule demanding tasks for times when you have the most energy
• Rest when needed: Listen to your body and take breaks
• Stay connected: Maintain social relationships for emotional support
• Organize medications: Use pill organizers and set reminders
• Communicate with your team: Don't hesitate to reach out with questions or concerns
• Seek support: Consider joining a heart failure support group

When You May Need Additional Help

As heart failure progresses, some people need additional support with daily activities. Home health services, cardiac rehabilitation programs, and palliative care teams can all provide valuable assistance. Don't hesitate to discuss these options with your healthcare team if you're finding it harder to manage daily tasks or if your symptoms are affecting your quality of life.