Heart failure

Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen. It does not mean the heart has stopped working; rather, the heart cannot keep up with its workload. Blood and fluid can back up into the lungs, causing shortness of breath, and fluid can accumulate in the legs, feet, and abdomen.

Heart failure is a major public-health problem that becomes more common with age. It can result from many different heart conditions, including coronary artery disease, high blood pressure, prior heart attack, cardiomyopathy, and heart-valve disease. Although it is a serious condition, many people live full lives for years with proper treatment, lifestyle changes, and close medical follow-up. Modern therapies have significantly improved survival and quality of life.

Symptoms of heart failure may develop slowly or appear suddenly. Common signs and symptoms include:

• Shortness of breath (dyspnea) during activity or when lying down
• Fatigue and weakness
• Swelling (edema) in the legs, ankles, and feet
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged mucus
• Increased need to urinate at night
• Swelling of the abdomen (ascites)
• Sudden weight gain from fluid retention
• Lack of appetite and nausea
• Difficulty concentrating or decreased alertness
• Chest pain if heart failure is caused by a heart attack

Symptoms are often graded by how much they limit daily activities (New York Heart Association classification).

Heart failure often develops after other conditions have damaged or weakened the heart. Common causes include:

• Coronary artery disease and prior heart attack — the most common causes
• High blood pressure (hypertension) — forces the heart to work harder over time
• Cardiomyopathy — damage to the heart muscle from infection, alcohol, drug use, or genetic factors
• Heart-valve disease — stenosis or regurgitation that overloads the heart chambers
• Myocarditis — inflammation of the heart muscle, often from viral infection
• Congenital heart defects
• Abnormal heart rhythms (arrhythmias)
• Other conditions — diabetes, thyroid disease, obesity, severe anemia, and certain cancer treatments

Heart failure is often categorized by the side of the heart affected (left-sided, right-sided, or both) and by whether the ejection fraction is reduced (HFrEF) or preserved (HFpEF).

Factors that increase the risk of developing heart failure include:

• High blood pressure
• Coronary artery disease
• Heart attack
• Diabetes
• Sleep apnea
• Congenital heart defects
• Valvular heart disease
• Viruses that injure heart muscle
• Alcohol or drug misuse
• Obesity
• Irregular heartbeats
• Certain cancer treatments (chemotherapy, radiation)
• Age — risk rises with advancing age

Possible complications of heart failure include:

• Kidney damage or failure
• Heart-valve problems
• Heart-rhythm problems (arrhythmias), including sudden cardiac arrest
• Liver damage
• Malnutrition
• Pulmonary hypertension
• Increased risk of blood clots and stroke

Hospitalizations for heart-failure exacerbations are common and contribute to reduced quality of life and higher mortality.

The key to preventing heart failure is controlling the conditions that lead to it:

• Manage high blood pressure and keep it in the target range
• Control cholesterol and treat coronary artery disease
• Manage diabetes carefully
• Maintain a healthy weight
• Do not smoke or use tobacco
• Limit alcohol
• Treat sleep apnea
• Stay physically active and eat a heart-healthy diet
• Take prescribed medicines for heart conditions exactly as directed

Diagnosis involves a combination of clinical evaluation and tests:

• Medical history and physical examination (listening for abnormal heart sounds or lung crackles, checking for swelling)
• Blood tests, including B-type natriuretic peptide (BNP or NT-proBNP), which is elevated in heart failure
• Chest X-ray
• Electrocardiogram (ECG)
• Echocardiogram — the most useful test for assessing heart structure, function, and ejection fraction
• Stress testing, cardiac catheterization, MRI, or CT in selected cases
• Classification by ejection fraction (reduced, mildly reduced, or preserved) and functional capacity

See a healthcare professional if you experience persistent shortness of breath, unexplained fatigue, swelling in the legs, or sudden weight gain. These symptoms warrant evaluation even if mild.

Seek emergency care for:

• Severe shortness of breath or gasping for breath
• Chest pain
• Fainting or severe weakness
• Rapid or irregular heartbeat accompanied by other symptoms
• Sudden, severe shortness of breath with coughing up pink, frothy mucus

Treatment aims to relieve symptoms, slow progression, reduce hospitalizations, and prolong survival. Core therapies include:

• Lifestyle measures — sodium restriction, fluid management when advised, daily weight monitoring, regular physical activity as tolerated, and smoking cessation
• Medicines — foundational therapies for reduced-ejection-fraction heart failure include ACE inhibitors / ARBs / ARNIs, beta-blockers, mineralocorticoid-receptor antagonists, SGLT2 inhibitors, and diuretics for fluid overload. Additional agents (hydralazine-nitrate, ivabradine, vericiguat, digoxin, etc.) are used in selected patients. Treatment of preserved-ejection-fraction heart failure focuses on symptom relief, blood-pressure control, and SGLT2 inhibitors.
• Devices — implantable cardioverter-defibrillators (ICDs) for prevention of sudden death, cardiac-resynchronization therapy (CRT) for selected patients with dyssynchrony, and remote monitoring devices
• Advanced therapies — left-ventricular assist devices (LVADs) or heart transplantation for carefully selected patients with advanced disease
• Management of comorbidities (atrial fibrillation, iron deficiency, sleep apnea, diabetes, kidney disease)

Daily self-management is critical:

• Weigh yourself every morning and report rapid weight gain (typically 2–3 pounds in a day or 5 pounds in a week)
• Take all medicines exactly as prescribed
• Limit sodium intake (usually to less than 2,000–2,300 mg per day or as advised)
• Monitor fluid intake if recommended by your care team
• Stay as active as your doctor recommends; cardiac rehabilitation is often beneficial
• Avoid tobacco and limit alcohol
• Recognize early warning signs of decompensation and contact your care team promptly
• Keep all follow-up appointments and laboratory tests

Bring the following:

• List of all symptoms and when they began
• Complete medication and supplement list
• Recent weight changes and home blood-pressure or heart-rate readings if available
• Personal and family history of heart disease
• Questions about ejection fraction, medication options, sodium and fluid limits, exercise recommendations, and advanced therapies if relevant
• Any previous echocardiogram or cardiac test results