Heart Failure: Understanding Heart Failure

Overview

What is heart failure?

The term "heart failure" can be frightening. It doesn't mean the heart has "failed" or stopped working. It means the heart doesn't pump as well as it should.

Heart failure is a major health problem in the United States, affecting about 5.7 million Americans. About 550,000 new cases of heart failure occur each year. It's the leading cause of hospitalization in people older than 65.

If you have heart failure, you'll enjoy better health and quality of life if you take care of yourself and keep yourself in balance. It's important to learn about heart failure, how to keep in good balance, and when to call the doctor.

How common is heart failure?

Almost 6 million Americans have heart failure, and more than 870,000 people are diagnosed with heart failure each year. The condition is the leading cause of hospitalization in people over age 65.

Heart failure and aging

Although the risk of heart failure does not change as you get older, you are more likely to have heart failure when you are older.

Women and heart failure

Women are just as likely as men to develop heart failure, but there are some differences:

  • Women tend to develop heart failure later in life compared with men.
  • Women tend to have heart failure caused by high blood pressure and have a normal EF (ejection fraction; see below).
  • Women may have more shortness of breath than men do. There are no differences in treatment for men and women with heart failure.

What are the types of heart failure?

There are many causes of heart failure, but the condition is generally broken down into two types:

Heart failure with reduced left ventricular function (HF-rEF)
The lower left chamber of the heart (left ventricle) gets bigger (enlarges) and cannot squeeze (contract) hard enough to pump the right amount of oxygen-rich blood to the rest of the body.

Heart failure with preserved left ventricular function (HF-pEF)
The heart contracts and pumps normally, but the bottom chambers of the heart (ventricles) are thicker and stiffer than normal. Because of this, the ventricles can't relax properly and fill up all the way. Because there's less blood in the ventricles, less blood is pumped out to the rest of the body when the heart contracts.

What is ejection fraction?

Ejection fraction (EF) refers to how well your left ventricle (or right ventricle) pumps blood with each heart beat. Most times, EF refers to the amount of blood being pumped out of the left ventricle each time it contracts. The left ventricle is the heart's main pumping chamber.

Your EF is expressed as a percentage. An EF that is below normal can be a sign of heart failure. If you have heart failure and a lower-than-normal (reduced) EF (HF-rEF), your EF helps your doctor know how severe your condition is.

Ejection Fraction

How is EF measured?

Ejection fraction can be measured using:

Why it’s important to know your EF

If you have a heart condition, it is important for you and your doctor to know your EF. Your EF can help your doctor determine the best course of treatment for you. Measuring your EF also helps your healthcare team check how well our treatment is working.

Ask your doctor how often you should have your EF checked. In general, you should have your EF measured when you are first diagnosed with a heart condition, and as needed when your condition changes.

What do the numbers mean?

Ejection Fraction (EF) 55% to 70%

  • Pumping Ability of the Heart: Normal.
  • Level of Heart Failure/Effect on Pumping: Heart function may be normal or you may have heart failure with preserved EF (HF-pEF).

Ejection Fraction (EF) 40% to 54%

  • Pumping Ability of the Heart: Slightly below normal.
  • Level of Heart Failure/Effect on Pumping: Less blood is available so less blood is ejected from the ventricles. There is a lower-than-normal amount of oxygen-rich blood available to the rest of the body. You may not have symptoms.

Ejection Fraction (EF) 35% to 39%

  • Pumping Ability of the Heart: Moderately below normal.
  • Level of Heart Failure/Effect on Pumping: Mild heart failure with reduced EF (HF-rEF).

Ejection Fraction (EF) Less than 35%

  • Pumping Ability of the Heart: Severely below normal.
  • Level of Heart Failure/Effect on Pumping: Moderate-to-severe HF-rEF. Severe HF-rEF increases risk of life-threatening heartbeats and cardiac dyssynchrony/desynchronization (right and left ventricles do not pump in unison).

Normal Heart. A normal left ventricular ejection fraction (LVEF) ranges from 55% to 70%. An LVEF of 65%, for example means that 65% of total amount of blood in the left ventricle is pumped out with each heartbeat. Your EF can go up and down, based on your heart condition and how well your treatment works.

HF-pEF. If you have HF-pEF, your EF is in the normal range because your left ventricle is still pumping properly. Your doctor will measure your EF and may check your heart valves and muscle stiffness to see how severe your heart failure is.

HF-rEF. If you have an EF of less than 35%, you have a greater risk of life-threatening irregular heartbeats that can cause sudden cardiac arrest/death. If your EF is below 35%, your doctor may talk to you about treatment with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). Your doctor may also recommend specific medications or other treatments, depending on how advanced your heart failure is. Less common treatment options include a heart transplant or a ventricular assist device (VAD). If your quality of life is very poor or your doctor has told you that your condition is very severe, please ask about other possible treatments.

Some patients have HF-rEF (and an EF lower than 40%) and signs of HF-pEF, such as a stiff (but not always enlarged) left ventricle.

Symptoms and Causes

What are the symptoms of heart failure?

There may be times that your symptoms are mild or you may not have any symptoms at all. This doesn't mean you no longer have heart failure. Symptoms of heart failure can range from mild to severe, and may come and go.

In general, heart failure gets worse over time. As it worsens, you may have more or different signs or symptoms. It is important to let your doctor know if you have new symptoms or if your symptoms get worse.

Common signs and symptoms of heart failure

  • Shortness of breath or trouble breathing. You may have trouble breathing when you exercise, or when you rest or lie flat in bed. Shortness of breath happens when fluid backs up into the lungs (congestion) or when your body isn't getting enough oxygen-rich blood. If you wake up suddenly at night to sit up and catch your breath, the problem is severe and you need medical treatment.
  • Feeling tired (fatigue) and leg weakness when you are active. When your heart does not pump enough oxygen-rich blood to major organs and muscles, you become tired and your legs may feel weak.
  • Swelling in your ankles, legs and abdomen; weight gain. When your kidneys don't filter enough blood, your body holds onto extra fluid and water. Extra fluid in your body causes swelling edema and weight gain.
  • Need to urinate while resting at night. Gravity causes more blood flow to the kidneys when you are lying down. So, your kidneys make more urine and you have the need to urinate.
  • Dizziness , confusion, difficulty concentrating, fainting. You may have these symptoms because your heart isn't pumping enough oxygen-rich blood to the brain.
  • Rapid or irregular heartbeats (palpitations): When your heart muscle does not pump with enough force, your heart may beat faster to try to get enough oxygen-rich blood to major organs and muscles. You may also have an irregular heartbeat if your heart is larger than normal (after a heart attack or due to abnormal levels of potassium in your blood).
  • A dry, hacking cough. A cough caused by heart failure is more likely to happen when you are lying flat and have extra fluid in your lungs.
  • A full (bloated) or hard stomach, loss of appetite or upset stomach (nausea).

It is very important for you to manage your other health conditions, such as diabetes, kidney disease, anemia, high blood pressure, thyroid disease and asthma or chronic lung disease. Some conditions have signs and symptoms that are similar to heart failure. If you have new or worsening non-urgent symptoms, tell your healthcare provider.

What causes heart failure?

Heart failure can be caused by many medical conditions that damage the heart muscle. Common conditions are:

  • Coronary artery disease (also called coronary atherosclerosis or “hardening of the arteries”) affects the arteries that carry blood and oxygen to the heart (coronary arteries). The normal lining inside the arteries breaks down, the walls of the arteries become thick, and deposits of fat and plaque partially block the flow of blood. Over time, the arteries become very narrow or completely blocked, which causes a heart attack. The blockage keeps the heart from being able to pump enough blood to keep your organs and tissues (including your heart) healthy. When arteries are blocked, you may have chest pain (angina) and other symptoms of heart disease.
  • Heart attack. A heart attack happens when a coronary artery suddenly becomes blocked and blood cannot flow to all areas of the heart muscle. The heart muscle becomes permanently damaged and muscle cells may die. Normal heart muscle cells may work harder. The heart may get bigger (HF-rEF) or stiff (HF-pEF).
  • Cardiomyopathy. Cardiomyopathy is a term that describes damage to and enlargement of the heart muscle not caused by problems with the coronary arteries or blood flow. Cardiomyopathy can occur due to many causes, including viruses, alcohol or drug abuse, smoking, genetics and pregnancy (peripartum cardiomyopathy).
  • Heart defects present at birth (congenital heart disease).
  • Diabetes.
  • High blood pressure (hypertension). Blood pressure is the force of blood pushing against the walls of your blood vessels (arteries). If you have high blood pressure, it means the pressure in your arteries is higher than normal. When blood pressure is high, your heart has to pump harder to move blood to the body. This can cause the left ventricle to become thick or stiff, and you can develop HF-pEF. High blood pressure can also cause your coronary arteries to become narrow and lead to coronary artery disease.
  • Arrhythmia (abnormal heart rhythms, including atrial fibrillation).
  • Kidney disease.
  • Obesity (being overweight).
  • Tobacco and illicit drug use.
  • Medications. Some drugs used to fight cancer (chemotherapy) can lead to heart failure.

Diagnosis and Tests

Heart Failure Diagnosis

In order to determine if you have heart failure, your doctor needs to know about your symptoms and medical history. Your doctor will ask you about things such as:

You will also have a physical exam. Your doctor will look for signs of heart failure and diseases that may have caused your heart muscle to become weak or stiff.

What types of tests are used to diagnose heart failure?

You will have tests to see how bad your heart failure is and what caused it. Common tests include:

  • Blood tests help us understand how well your kidneys and thyroid are working. We will check your cholesterol and red blood cell levels for high cholesterol and anemia. Anemia means the hemoglobin (HE-mo-globe-in) level in your blood is lower than normal. Hemoglobin is the part of your red blood cells that makes it possible for blood to carry oxygen through the body. Low hemoglobin levels cause you to be tired and have other symptoms that are similar to those of heart failure.
  • NT-pro**B-type Natriuretic Peptide (BNP) blood test**. BNP is a hormone that is released into the blood by the lower chambers of the heart (ventricles) in people with heart failure. NT-pro BNP is an inactive molecule that is released in the blood with BNP. The level changes based on how severe your heart failure is. Higher levels of NT-pro BNP mean the ventricles are more stressed. Low levels mean your heart failure is stable. If you have shortness of breath, the level of NT-pro BNP in your blood can help your doctor know if it is caused by heart failure. A level of more than 450 pg/mL for patients under age 50 or 900 pg/mL for patients 50 and older could mean you have heart failure.
  • Cardiac Catheterization. If you are scheduled for a catheterization, your doctor may check your EF during the procedure. A catheterization lets your doctor check your heart from the inside. A long, thin tube called a catheter is inserted into an artery in your arm or leg. The doctor uses a special X-ray machine to guide the catheter to your heart. There are two types of cardiac catheterization — left and right. If you have a left heart catheterization, your doctor may inject dye to record videos of your heart valves, coronary arteries and heart chambers (atria and ventricles). A right heart catheterization does not use dye; it lets your doctor know how well your heart is pumping blood.
  • Chest x-ray shows the size of your heart and any fluid build-up around your heart and lungs.
  • Echocardiogram (echo). This is an ultrasound to see how well your heart can pump and relax, to check your heart valves, measure your heart and check blood flow. Images are captured using an ultrasound wand that is moved around on the skin of your chest. An echo is often done with a Doppler test so your doctor can see changes in the pressure inside your heart chambers and in the way your blood flows across your heart valves. This is the most common way to determine your EF.
  • Ejection fraction (EF). Your EF is a measurement of the blood pumped out of your heart with each beat. Your EF can be measured using an echocardiogram (echo), multigated acquisition (MUGA) scan, nuclear stress test, magnetic resonance imaging (MRI) or during a cardiac catheterization. Ejection fraction is reported as a percentage. A normal EF is between 55% and 70%. Your EF can get better or worse based on how stable your heart failure is and how well your treatment for heart failure is working. It is important for your doctor to know your EF. You should have your EF measured when you are diagnosed with heart failure and as often as your doctor recommends.
  • Electrocardiogram (EKG or ECG). This test records the electrical activity in your heart by using electrodes that are connected with wires to an electrocardiograph monitor. Electrodes are small sticky patches that are placed on your body. The wires carry information to the monitor, and it creates a graph to show the electrical activity.
  • Multigated Acquisition Scan (MUGA scan) . This test shows your doctor how well the lower chambers of your heart (ventricles) are pumping blood. A small amount of a radioactive dye is injected into a vein. A special camera (gamma camera) is used to create video of your heart as it beats.
  • Stress test. This test shows how your heart reacts to stress. You will likely exercise on a treadmill or stationary bike at different levels of difficulty while your heart rate, electrocardiograph and blood pressure are recorded. If you cannot exercise, medication may be used to create the same effect as exercise on your heart (pharmacological stress test).

Other tests may be needed, depending on your condition.

Management and Treatment

How is heart failure treated?

Your treatment will depend on the type of heart failure you have and, in part, what caused it. Medications and lifestyle behaviors are part of every patient’s treatment plan. Your healthcare team will talk to you about the best treatment plan for you. Learn more about heart failure treatment.

What are the stages of heart failure?

Heart failure is a chronic long-term condition that gets worse with time. There are four stages of heart failure (Stage A, B, C and D). The stages range from "high risk of developing heart failure" to "advanced heart failure," and provide treatment plans. Ask your healthcare provider what stage of heart failure you are in. These stages are different from the New York Heart Association (NYHA) clinical classifications of heart failure (Class I-II-III-IV) that reflect the severity of symptoms or functional limits due to heart failure.

As the condition gets worse, your heart muscle pumps less blood to your organs, and you move toward the next stage of heart failure. You cannot go backwards through the stages. For example, if you are in Stage B, you cannot be in Stage A again. The goal of treatment is to keep you from progressing through the stages or to slow down the progression.

Treatment at each stage of heart failure may involve changes to medications, lifestyle behaviors and cardiac devices. You can compare your treatment plan with those listed for each stage of heart failure. The treatments listed are based on current treatment guidelines. The table outlines a basic plan of care that may apply to you. If you have any questions about any part of your treatment plan, ask a member of your healthcare team.

Stage A

Stage A is considered pre-heart failure. It means you are at high risk of developing heart failure because you have a family history of heart failure or you have one of more of these medical conditions:

  • Hypertension.
  • Diabetes.
  • Coronary artery disease.
  • Metabolic syndrome.
  • History of alcohol abuse.
  • History of rheumatic fever.
  • Family history of cardiomyopathy.
  • History of taking drugs that can damage the heart muscle, such as some cancer drugs.

Stage A treatment

The usual treatment plan for patients with Stage A heart failure includes:

  • Regular exercise, being active, walking every day.
  • Quitting smoking.
  • Treatment for high blood pressure (medication, low-sodium diet, active lifestyle).
  • Treatment for high cholesterol.
  • Not drinking alcohol or using recreational drugs.
  • Medications:
    • Angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) if you have coronary artery disease, diabetes, high blood pressure, or other vascular or cardiac conditions.
    • Beta-blocker if you have high blood pressure.

Stage B

Stage B is considered a pre-heart failure. It means you have been diagnosed with systolic left ventricular dysfunction but have never had symptoms of heart failure. Most people with Stage B heart failure have an echocardiogram (echo) that shows an ejection fraction (EF) of 40% or less. This category includes people who have heart failure and reduced EF (HF­ rEF) due to any cause.

Stage B treatment

The usual treatment plan for patients with Stage B heart failure includes:

  • Treatments listed in Stage A.
  • Angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) (if you aren't taking one as part of your Stage A treatment plan).
  • Beta-blocker if you have had a heart attack and your EF is 40% or lower (if you aren't taking one as part of your Stage A treatment plan).
  • Aldosterone antagonist if you have had a heart attack or if you have diabetes and an EF of 35% or less (to reduce the risk of your heart muscle getting bigger and pumping poorly).
  • Possible surgery or intervention as a treatment for coronary artery blockage, heart attack, valve disease (you may need valve repair or replacement surgery) or congenital heart disease.

Stage C

Patients with Stage C heart failure have been diagnosed with heart failure and have (currently) or had (previously) signs and symptoms of the condition.

There are many possible symptoms of heart failure. The most common are:

  • Shortness of breath.
  • Feeling tired (fatigue).
  • Less able to exercise.
  • Weak legs.
  • Waking up to urinate.
  • Swollen feet, ankles, lower legs and abdomen (edema).

Stage C treatment

The usual treatment plan for patients with Stage C HF-rEF includes:

  • Treatments listed in Stages A and B.
  • Beta-blocker (if you aren't taking one) to help your heart muscle pump stronger.
  • Aldosterone antagonist (if you aren't taking one) if a vasodilator medicine (ACE-I, ARB or angiotensin receptor/neprilysin inhibitor combination) and beta-blocker don't relieve your symptoms.
  • Hydralazine/nitrate combination if other treatments don't stop your symptoms. Patients who are African-American should take this medication (even if they are taking other vasodilator medications) if they have moderate­ to-severe symptoms.
  • Medications that slow the heart rate if your heart rate is faster than 70 beats per minute and you still have symptoms.
  • Diuretic ("water pill") may be prescribed if symptoms continue.
  • Restrict sodium (salt) in your diet. Ask your doctor or nurse what your daily limit is.
  • Keep track of your weight every day. Tell your healthcare provider if you gain or lose more than 4 pounds from your "dry" weight.
  • Possible fluid restriction. Ask your doctor or nurse what your daily fluid limit is.
  • Possible cardiac resynchronization therapy (biventricular pacemaker).
  • Possible implantable cardiac defibrillator (lCD) therapy.

If the treatment causes your symptoms to get better or stop, you still need to continue treatment to slow the progression to Stage D.

Stage D and reduced E

Patients with Stage D HF-rEF have advanced symptoms that do not get better with treatment. This is the final stage of heart failure.

Stage D treatment

The usual treatment plan for patients with Stage D heart failure includes:

  • Treatments listed in Stages A, B and C.
  • Evaluation for more advanced treatment options, including:
    • Heart transplant.
    • Ventricular assist devices.
    • Heart surgery.
    • Continuous infusion of intravenous inotropic drugs.
    • Palliative or hospice care.
    • Research therapies.

Stages C and D with preserved EF

Treatment for patients with Stage C and Stage D heart failure and reserved EF (HF-pEF) includes:

  • Treatments listed in Stages A and B.
  • Medications for the treatment of medical conditions that can cause heart failure or make the condition worse, such as atrial fibrillation, high blood pressure, diabetes, obesity, coronary artery disease, chronic lung disease, high cholesterol and kidney disease.
  • Diuretic ("water pill") to reduce or relieve symptoms.

YOU ARE THE MOST IMPORTANT PART OF YOUR TREATMENT PLAN!

It is up to you to take steps to improve your heart health. Take your medications as instructed, follow a low-sodium diet, stay active or become physically active, take notice of sudden changes in your weight, live a healthy lifestyle, keep your follow-up appointments, and track your symptoms. Talk to your healthcare team about questions or concerns you have about your medications, lifestyle changes or any other part of your treatment plan.

Outlook / Prognosis

What is the outlook?

With the right care, heart failure will not stop you from doing the things you enjoy. Your prognosis, or outlook for the future, will depend on how well your heart muscle is working, your symptoms and how well you respond to and follow your treatment plan.

Living With

How does heart failure affect quality of life and lifestyle?

With the right care and treatment plan, heart failure may limit your activities, but many adults still enjoy life. How well you feel depends on how well your heart muscle is working, your symptoms and how well you respond to and follow your treatment plan. This includes caring for yourself (taking medications, being active, following a low-sodium diet, keeping track of and telling your healthcare provider about symptoms that are new or get worse) and living a healthy lifestyle (regular follow-up visits with your healthcare provider, yearly flu shot).

Because heart failure is a chronic long-term illness, talk to your doctor and your family about your preferences for medical care. You can complete an advance directive or living will to let everyone involved in your care know your desires. A living will details the treatments you do or don’t want to prolong your life. It is a good idea to prepare a living will while you are well in case you aren’t able to make these decisions at a later time.

Reviewed by a Cleveland Clinic medical professional.

References

  • American Heart Association. Heart Failure. Accessed 5/20/2020.www.heart.org (http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp)
  • National Heart, Blood and Lung Institute. Accessed 5/20/2020.Heart Failure. (https://www.nhlbi.nih.gov/health-topics/heart-failure)
  • Malik A, Brito D, Chhabra L. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.Congestive Heart Failure (CHF) (https://www.ncbi.nlm.nih.gov/books/NBK430873/)

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