Heart Failure

Overview

What is heart failure?

Heart failure means your heart muscle does not pump as much blood as your body needs. Failure does not mean that your heart has stopped. It means that your heart is not pumping as well as it should.

Because your heart cannot pump well, your body tries to make up for it. To do this:

• Your body holds on to salt and water. This increases the amount of blood in your bloodstream.
• Your heart beats faster.
• Your heart gets bigger. See a picture of an enlarged heart.

Your body has an amazing ability to make up for heart failure. It may do such a good job that you don't know you have a disease. But at some point, your body will no longer be able to keep up. Your heart gets worn out. Then fluid starts to build up in your body, and you have symptoms like feeling weak and out of breath.

This fluid buildup is called congestion. It is why some doctors call the disease congestive heart failure.

Heart failure usually gets worse over time. But treatment can slow the disease and help you feel better and live longer.

What causes heart failure?

Anything that damages your heart or affects how well it pumps can lead to heart failure. The most common causes of heart failure are:

• Coronary artery disease (CAD).
• Heart attack.
• High blood pressure.

CAD and heart attack are the most common causes of heart failure in men. In women, high blood pressure is the most common cause.¹

Other conditions that can lead to heart failure include:

• Diabetes.
• Diseases of the heart muscle (cardiomyopathies).
• Heart valve disease.
• Disease of the sac around the heart (pericardial disease), such as pericarditis.
• A slow, fast, or uneven heart rhythm (arrhythmia).
• A heart problem that you were born with (congenital heart defect).
• Long-term alcohol abuse, which can damage your heart.

What are the symptoms?

Symptoms of heart failure start to happen when your heart cannot pump enough blood to the rest of your body. In the early stages, you may:

• Feel tired easily.
• Be short of breath when you exert yourself.
• Feel like your heart is pounding or racing (palpitations).
• Feel weak, very tired, or dizzy.

As heart failure gets worse, fluid starts to build up in your lungs and other parts of your body. This may cause you to:

• Feel short of breath even at rest.
• Have swelling (edema), especially in your legs, ankles, and feet.
• Gain weight. This may happen over just a day or two, or more slowly.
• Cough or wheeze, especially when you lie down.
• Need to urinate more at night.
• Feel bloated or sick to your stomach.

If your symptoms suddenly get worse, you will need emergency care.

How is heart failure diagnosed?

Your doctor may diagnose heart failure based on your symptoms and a physical exam. But you will need tests to find the cause and type of heart failure so that you can get the right treatment. These tests may include:

• Blood tests.
• A chest X-ray.
• An electrocardiogram (EKG or ECG) to check your heart’s electrical system.
• An echocardiogram to see the size and shape of your heart and how well it is pumping.
• Cardiac catheterization to check your heart and its blood vessels (coronary arteries).

Echocardiogram is the best and simplest way to find out if you have heart failure, what type it is, and what is causing it. Your doctor can also use it to see if your heart failure is getting worse. It can measure how much blood your heart pumps to your body. This measurement is called the ejection fraction. If your ejection fraction gets lower and you are having more symptoms, it means your heart failure is getting worse.

How is it treated?

Most people with heart failure need to take several medicines. Your doctor may prescribe medicines to:

• Help keep heart failure from getting worse. These include ACE inhibitors, angiotensin II receptor blockers (ARBs), beta-blockers, and vasodilators like hydralazine and nitroglycerin.
• Reduce symptoms so you feel better. These include diuretics (water pills), digoxin, and potassium.
• Treat the problem that caused your heart failure.

It is very important to take your medicines exactly as your doctor tells you to. If you don't, your heart failure could get worse.

Depending on the cause of your heart failure, you might need surgery to help your heart work better. For example, you might have bypass surgery or angioplasty to open clogged arteries or surgery to repair or replace a heart valve. If you have a problem with your heart rhythm, you might need to have a pacemaker or defibrillator placed in your chest. These help your heart keep a steady rhythm.

Lifestyle changes are an important part of treatment. They can help slow down heart failure. They may also help control other diseases that make heart failure worse, such as high blood pressure, diabetes, or coronary artery disease. The best steps you can take are to:

• Eat less salt (sodium). Sodium causes your body to retain water and makes it harder for your heart to pump. Your doctor may also ask you to watch how much fluid you drink.
• Get regular exercise. Your doctor can tell you what level of exercise is safe for you, how to check your pulse rate, and how to know if you are doing too much.
• Take rest breaks during the day.
• Lose weight if you are overweight. Even a few pounds can make a difference.
• Stop smoking. Smoking damages your heart and makes it hard to exercise.
• Limit alcohol. Ask your doctor how much, if any, is safe.

To stay as healthy as possible, work closely with your doctor. Have all your tests, and go to all your appointments. It is also important to:

• Talk to your doctor before you take any new medicine, including nonprescription and prescription drugs, vitamins, and herbs. Some of them make your heart failure worse.
• Keep track of your symptoms. Weigh yourself every day, and write down your weight. Call your doctor if you have a sudden weight gain, a change in your ability to exercise, or any sudden change in your symptoms.

What can I expect if I have heart failure?

Medicines and lifestyle changes can slow or even reverse heart failure for some people. But heart failure often gets worse over time.

Early on, your symptoms may not be too bad. As heart failure progresses, you may need to limit your activities. Treatment can often help reduce symptoms, but it usually does not get rid of them.

Heart failure can also lead to other health problems. These may include trouble with your heart rhythm (arrhythmia), stroke, heart attack, mitral valve regurgitation, or blood clots in your leg or lungs (deep vein thrombosis or pulmonary embolism). Your doctor may be able to give you medicine or other treatment to prevent or treat these problems.

Heart failure can get worse suddenly. If this happens, you will need emergency care. To prevent sudden heart failure, you need to avoid things that can trigger it. These include eating too much salt, missing a dose of your medicine, and exercising too hard.

You may want to think about planning for the future. A living will lets doctors know what type of life-support measures you want if your health gets much worse. You can also choose a health care agent to make decisions in case you are not able to. It can be comforting to know that you will get the type of care you want.

Knowing that your health may get worse can be hard. It is normal to sometimes feel sad or hopeless. But if these feelings last, talk to your doctor. Antidepressant medicines or counseling may help you cope.

Health Tools

Health tools help you make wise health decisions or take action to improve your health.

	Actionsets are designed to help people take an active role in managing a health condition.
	Activity and exercise for heart failure
	Avoiding triggers for sudden heart failure
	Checking your weight when you have heart failure
	Eating a steady amount of vitamin K when you take warfarin (Coumadin)
	Eating less sodium when you have heart failure
	Eating out when you are on a low-sodium diet
	Taking your medicines properly when you have heart failure
	Using oxygen at home
	Watching your fluid intake when you have heart failure

Frequently Asked Questions

Cause

Heart failure is caused by diseases or other factors that affect the pumping ability of the heart, specifically the left lower chamber (left ventricle). When the heart cannot pump well, it is called systolic heart failure. Things that affect how the heart pumps include:

• Coronary artery disease (CAD) and heart attack (most common causes).
• Damage from poorly controlled high blood pressure or diabetes.
• Cardiomyopathy, alcoholic cardiomyopathy, or infection or inflammation of the heart muscle (such as myocarditis).
• Illegal drugs (such as a stimulant, like cocaine).
• Disease of the sac surrounding the heart (pericardial disease).
• Heart disease that is present from birth (congenital heart disease).
• Heart valve disease.
• Fast, slow, or irregular heart rhythms (arrhythmias).
• Aging. As you age, your heart muscle tends to stiffen, which can prevent your heart from filling properly with blood.
• A rare kind of heart failure called postpartum heart failure. This can happen late in the pregnancy or within the first 5 months after delivery.

When the left ventricle cannot fill properly, it is called diastolic heart failure. High blood pressure, coronary artery disease, and heart valve problems can cause diastolic heart failure.

Specific triggers may suddenly make heart failure worse and may sometimes cause life-threatening conditions such as pulmonary edema or cardiogenic shock.

Symptoms

In the earliest stages of heart failure, you may not have any symptoms. Shortness of breath with exertion and fatigue often develop when the weakened heart is not pumping enough blood to meet your body's needs for oxygen and nutrients.

The body's efforts to make up for heart failure eventually cause symptoms to get worse.

Heart failure is classified as:

• Systolic heart failure, which means your heart does not pump well enough.
• Diastolic heart failure, which means your heart does not relax properly to fill up with blood.

Heart failure may affect one or both sides of the heart. Right- and left-sided heart failure often are present at the same time. If mainly the left side of the heart is affected, it may not be able to pump enough blood to all of the organs in the body (left-sided heart failure), including the heart itself, and can lead to fluid buildup in the lungs. Blood may back up behind the right ventricle as well (right-sided heart failure) and cause fluid to build up in the legs.

Heart failure is grouped according to symptoms. It is important to be familiar with these groups because they may be referred to during the course of your care.

A newer classification system defines heart failure based on the typical progression of the disease using stages A to D.²

Sudden heart failure

Sudden heart failure causes rapid fluid buildup in the lungs (congestion, pulmonary edema). Symptoms develop suddenly and may include:

• Severe shortness of breath.
• An irregular or rapid heartbeat.
• Coughing up foamy, pink mucus.

Sudden heart failure is a medical emergency and requires immediate care.

Complications

Long-standing heart failure can cause complications, such as:

• An irregular heartbeat.
• A stroke.
• A heart attack.
• A blood clot in the leg (deep vein thrombosis).
• A blood clot in the lung (pulmonary embolism).
• Anemia.
• Cognitive impairment.
• Mitral valve regurgitation.

These complications often can be prevented or treated with medicine or other treatment.

What Increases Your Risk

Heart failure is generally the result of another disease, often coronary artery disease. Anything that increases your risk for developing that underlying disease is a risk factor for heart failure. This includes:

• Risk factors for coronary artery disease and heart attack.
• Risk factors for high blood pressure.
• Risk factors for heart valve disease.
• Risk factors for diabetes (because diabetes can increase the risk of coronary artery disease and also can cause a condition called diabetic cardiomyopathy).

A recent study suggests that people with rheumatoid arthritis have twice the risk of developing congestive heart failure as people without the condition.³

When to Call a Doctor

Call 911 or other emergency services immediately if you have:

• Chest pain that has not gone away within 5 minutes after taking one nitroglycerin dose and/or resting, especially if the pain is pressing or crushing and occurs with shortness of breath, sweating, and nausea.
• Symptoms of a stroke. These include:
  • Sudden onset of tingling, numbness, weakness, or inability to move (paralysis) part or all of one side of your body (face, arm, and leg).
  • Sudden dimmed or blurred vision.
  • Difficulty speaking or understanding speech.
  • Dizziness, vomiting, or seizures.
  • Clumsiness.
  • Loss of consciousness.
  • Headache (severe and in a specific area).

Seek emergency medical care for symptoms of sudden heart failure, such as:

• Severe shortness of breath (trouble getting a breath even when resting).
• A sudden episode of a prolonged, irregular heartbeat or a very rapid heartbeat associated with dizziness, nausea, or fainting.
• Foamy, pink mucus with a cough and shortness of breath.

Call your doctor soon if you have symptoms of heart failure, which include:

• Fatigue or weakness that prevents you from doing your usual activities.
• Difficulty breathing during routine activities or exercise that did not previously cause problems.
• Shortness of breath when you lie down.
• Waking up at night with shortness of breath or feeling as though you are suffocating.
• A dry, hacking cough, especially when you lie down.
• Sudden weight gain, such as 3 lb (1.4 kg) in 2 to 3 days.
• Increased fluid buildup in your body (most often in the legs).

Also call your doctor soon if you have a diagnosis of heart failure and your symptoms get worse. In general, it is a good idea to call your doctor anytime you have a sudden change in symptoms.

Watchful waiting

There are many less serious causes of some of the more minor symptoms that are common to heart failure. It is reasonable to try home treatment for symptoms such as fatigue and mild fluid buildup (edema). However, sudden shortness of breath, even if it is mild, should always be checked by your doctor.

• If symptoms go away completely and do not return, you may not need additional treatment.
• If you need continued home treatment to keep even minor symptoms under control, make an appointment with your doctor.

Shortness of breath caused by being out of shape does not require immediate medical attention. However, you may want to consult a health professional for advice on improving your physical condition. Being in better shape can help improve the quality of your life and possibly can lower your risk of new, serious heart problems, such as a heart attack, or sudden death.⁴

Who to See

The following health professionals can evaluate early symptoms of heart failure:

• Family medicine doctor
• Internist
• Nurse practitioner (NP)
• Physician assistant (PA)
• Cardiologist

A cardiovascular surgeon may perform surgical repair of heart valves or a heart transplant.

Exams and Tests

Heart failure is a complex medical condition. There are several types of heart failure and a variety of causes. For these reasons, you will likely have several different tests over a period of time to help diagnose the cause of the disease and find out how severe it is. In some cases the cause of heart failure can be fixed (such as a heart valve defect) or is easily treatable (such as a thyroid problem), but this is usually the exception.

If you have symptoms that suggest heart failure, you may have the following tests:

• A review of your medical history and a physical exam.
• Lab tests.
• Electrocardiogram (EKG, ECG).
• Chest X-ray.
• Echocardiogram (echo).
• Brain natriuretic peptide (BNP). This test is currently available only at specialized medical research centers.
• Cardiac catheterization.

An echocardiogram is the best and simplest way to find out whether you have heart failure and whether it is systolic or diastolic heart failure.² An echocardiogram also can help determine the cause of heart failure and help guide treatment decisions.

The following tests also may be done to identify areas of the heart that are not getting enough blood (ischemic areas) and help assess how well the left ventricle is working. These tests include:

• Cardiac perfusion scan. This test can detect poor blood flow to the heart.
• Cardiac blood pool scan (radionuclide ventriculogram). This test is often used when echocardiogram results are less likely to be accurate (caused by a person's weight or breast size or the presence of severe lung disease). It checks the pumping ability of the left ventricle. However, it is less useful for finding heart valve disease and thickening of the heart muscle.
• Cardiac catheterization. This test can be used to check for blocked or narrowed heart arteries and to measure pressures inside the heart. Test results can help diagnose conditions that might cause heart failure symptoms or make them worse.

You will need regular appointments with your doctor to monitor your condition and how well your treatment is working. Depending on the severity of the disease and its progression, your doctor may want to see you within days to weeks after your diagnosis.

Testing will help your doctor determine which type of heart failure you have. Your heart failure may also be classified according to its severity or its stage.

Early Detection

Identifying people who are at high risk of developing heart failure before they show any evidence of heart failure on an echocardiogram is important so that they can be monitored, any underlying conditions (such as high blood pressure or high cholesterol) can be treated, and medicines such as angiotensin-converting enzyme (ACE) inhibitors can be started when needed.²

Talk to your doctor if you are concerned that you may be at risk for heart failure.

Treatment Overview

Treatment depends on the cause of heart failure, which type you have, the severity of your symptoms (classification), and how well your body is able to compensate.

Treatment of heart failure that is caused by a filling problem (diastolic heart failure) may differ from treatment of heart failure that is caused by a pumping problem (systolic heart failure). Identifying the type of heart failure you have will help guide proper treatment.

Sometimes, heart failure can be fixed if an underlying problem can be corrected, such as through heart valve replacement surgery or treatment to correct hyperthyroidism.

If heart failure develops shortly after a heart attack, it can sometimes be reversed with coronary artery bypass surgery or angioplasty, medicine, and cardiac rehabilitation.

Initial treatment

The goal of treatment for early stage heart failure is to relieve symptoms and prevent additional heart damage. You will probably take a diuretic first to reduce blood pressure and fluid buildup. Next, your doctor will probably prescribe one or more other medicines, including an ACE inhibitor. This medicine reduces the heart's workload, lowers blood pressure, and reduces fluid retention and swelling.

You may also take a beta-blocker medicine. These drugs can keep heart failure from getting worse and, in some cases, will improve your heart function and prolong life.² Some people can't take beta-blockers because of their side effects.

Lifestyle recommendations include the following:

• Watch your fluid intake.
• Eat less sodium.
• Exercise under the direction of your doctor.
• Lose weight if you are overweight.
• Stop smoking, because smoking increases your risk of heart disease and makes it more difficult to exercise. For more information, see the topic Quitting Tobacco Use.
• Avoid overuse of alcohol. Moderate drinking means no more than 2 drinks a day for men and 1 drink a day for women.
• Control your high blood pressure. Exercising, limiting alcohol intake, and controlling stress will help keep your blood pressure in a healthy range too. For more information, see the topic High Blood Pressure (Hypertension).
• Control your diabetes.

Your doctor will also need to treat the underlying cause of your heart failure. You may need to take additional medicine for coronary artery disease, high blood pressure, diabetes, or an abnormal heart rhythm (arrhythmia).

Ongoing treatment

Although some causes of heart failure are reversible, in most cases heart failure cannot be cured. Most likely you will have to take medicine for the rest of your life. Ongoing treatment is aimed at decreasing the progression of the disease and preventing complications and hospital stays. Treatment should also improve symptoms and help you live longer.

ACE inhibitor medicines are the cornerstone of treatment for most people with heart failure. These drugs prolong life and reduce symptoms.²

If you have continued swelling, you may need to take a diuretic medicine, such as furosemide (Lasix) or bumetanide (Bumex). If you have moderate to severe heart failure, you may need to take the diuretic spironolactone (Aldactone), which has properties that can prevent heart failure from getting worse in addition to improving your symptoms.⁵

Beta-blocker medicines are often prescribed because they can keep heart failure from getting worse and, in some cases, will improve your heart function and prolong life.² However, some people are not able to take them because of their side effects.

If your heart failure is getting worse or you have been hospitalized for sudden heart failure, your doctor might add digoxin (such as Lanoxin or Crystodigin) to your treatment. Digoxin has been proven to reduce the number of times that people have to go to the hospital for heart failure that gets worse.⁴ If symptoms are not controlled with the other medicines, ARBs (angiotensin II receptor blockers), nitrates, and hydralazine may be added.

If you have not made diet and lifestyle changes already, these changes are important in managing your symptoms.

Activity and exercise for people with heart failure are very important. If you are not already active, your doctor will want you to begin an exercise program. Prescribed exercise is often part of a cardiac rehabilitation program. For more information on starting and maintaining an exercise program, see:

Exercise for heart failure.

Getting too much sodium, not taking medicines as directed, and having an illness such as pneumonia or influenza are some of the most common reasons that people with heart failure have to be hospitalized. Getting immunizations for pneumonia and flu infections, watching your sodium intake, and taking medicines as prescribed all are important to reduce the chance that your condition will get worse.

Watch your fluid intake when you have heart failure.

Take your medicines properly when you have heart failure.

Your doctor will likely work with you to develop some guidelines for managing weight gain caused by fluid buildup. For example, if you suddenly gain weight—such as 3 lb (1.4 kg) in 2 to 3 days—your doctor may recommend that you take an additional diuretic (water pill) that day. Your doctor may give you a slightly different weight gain to watch for.

Checking your weight when you have heart failure.

Biventricular pacemakers, which make the heart’s lower chambers (ventricles) contract together, may be an option for people who have heart failure and problems with the heart's electrical system. Doctors call this treatment cardiac resynchronization therapy, or CRT. CRT can reduce complications and the risk of death in people with heart failure.⁶ One study suggests that biventricular pacemakers improve heart function, the ability to exercise, and your quality of life beyond that seen with medicine alone.⁷

Another device called an implantable cardioverter-defibrillator (ICD) shows promise for some people who have heart failure. ICDs can sense when the heart starts beating dangerously fast. The device then sends an electrical shock to the heart to bring it back to a normal rhythm. (Fast heart rhythms, such as ventricular tachycardia, are a common cause of death in people with heart failure.) ICD's cannot improve symptoms of heart failure. But, studies show that ICDs can lower the risk of death in people with moderate to severe heart failure.⁸

Combining the biventricular pacemaker and the ICD into one device significantly reduced hospital stays and death rates in people with advanced heart failure.⁹

Your doctor may also recommend oxygen therapy to reduce shortness of breath and increase your ability to exercise. For more information, see:

Using oxygen at home

You will probably need to continue treatment to correct or control any underlying problems (such as high blood pressure, diabetes, or coronary artery disease) or sudden heart failure triggers (such as fever, arrhythmia, anemia, or infection).

You will have regular appointments with your doctor so that he or she can monitor how you are responding to treatment and manage any changes in how your body responds. Gradual adjustments and frequent monitoring are a normal part of the treatment of heart failure and will help you avoid sudden heart failure or other complications.

Treatment if the condition gets worse

In some cases when standard medical treatment does not help, other measures are considered. These include heart transplant and left ventricular assist devices (LVADs), which are mechanical pumping devices that are implanted into the chest. However, these are options only for a very small number of people.

Palliative care

As your condition gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End of life

Thousands of people in the United States die from heart failure each year despite the best efforts of doctors and modern medicine. Since the disease can quickly progress to a more severe form, many people (and their families) are not prepared for decisions that they must make regarding the type of care they wish to receive at the end of their lives. You will need to decide whether you want life-support measures if your condition becomes more severe. An advance directive is a legal document that instructs doctors on how to care for you at the end of your life. Advance directives can include the ability to refuse treatment in specific situations. For more information, see the topic Care at the End of Life.

Prevention

The best way to prevent heart failure is to make changes in your lifestyle that lower your risk of developing heart disease. It is also important to control certain medical conditions, such as high blood pressure or diabetes, to lower your chances of developing heart failure.

Heart disease caused by narrowing and hardening of the arteries (atherosclerosis) in the blood vessels of the heart and by heart attack are leading causes of heart failure. To reduce your risk of atherosclerosis:

• Do not smoke. If you smoke, quit. Smoking greatly increases your risk for heart disease. Avoid secondhand smoke too.
• Lower your cholesterol. If you have high cholesterol, follow your doctor's advice for lowering it. Eating a low-cholesterol diet, exercising, and quitting smoking will help keep your cholesterol low.
• Control your blood pressure. If you have high blood pressure, your risk of developing heart disease increases. Studies have shown that lowering blood pressure to normal levels in people who have high blood pressure could reduce the cases of heart failure by half.¹⁰ Exercising, limiting alcohol intake, and controlling stress will help keep your blood pressure in a healthy range.
• Get regular exercise. Exercise will help control your weight, blood pressure, and stress levels, all of which will help keep your heart healthy. Try to do activities that raise your heart rate. Exercise for at least 30 minutes on most, preferably all, days of the week.
• Control diabetes. Taking your medicines as directed and working with your doctor to manage your diet will help control diabetes.
• Limit alcohol intake. A recent study found that moderate alcohol consumption decreased the risk of heart failure in older people.¹¹ Moderate drinking means no more than 2 drinks a day for men and 1 drink a day for women. Heavy consumption of alcohol, however, can lead to heart failure.

Identifying people who are at high risk of developing heart failure before they show any signs of structural heart disease (stage A) is important so that they can be monitored, underlying conditions (such as high blood pressure or high cholesterol) can be controlled, and medicines such as angiotensin-converting enzyme (ACE) inhibitors can be given if appropriate.²

Living With Heart Failure

Your attitude and level of participation in your treatment can strongly impact how you feel. Taking care of yourself will help you feel better and improve your health so that you can enjoy life. Taking your medicines as directed, controlling your diet, and getting regular exercise are lifestyle changes that are key to controlling heart failure symptoms and preventing sudden heart failure.

• Limit sodium intake. Your doctor also may want you to monitor your fluid intake.

  Watch your fluid intake when you have heart failure.

  Eat less sodium when you have heart failure.

  Eating out when you are on a low-sodium diet

• Take your medicines as directed. If you don't, your heart failure may get worse, or you may develop sudden heart failure. For more information, see:

  Taking your medicines properly when you have heart failure.

• Try to avoid nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, and be careful using nonprescription medicines because they may make your heart failure worse.
• Your doctor may advise you to take a low-dose aspirin every day to prevent a stroke or heart attack. But higher doses of aspirin may make your heart failure worse.
• Exercise regularly. If you aren't already active, your doctor may want you to begin an exercise program. Exercise programs have been shown to improve quality of life and reduce the rate of adverse cardiac events in people with heart failure.⁴ Try to do activities that raise your heart rate. Exercise for at least 30 minutes on most, preferably all, days of the week. For more information, see the topic Cardiac Rehabilitation. For information on starting and maintaining an exercise program, see:

  Activity and exercise for heart failure.

• Try to lose weight if you are overweight. Eating a heart-healthy diet and exercising regularly should naturally help you lose weight.
• Stop smoking, because smoking increases your risk for heart disease and makes it more difficult to exercise. Avoid secondhand smoke too.
• Avoid overuse of alcohol. Moderate drinking means no more than 2 drinks a day for men and 1 drink a day for women.
• Try some tips for easier breathing, such as elevating your upper body to allow fluid to drain from your lungs.
• Monitor your weight. For information on ways to check your weight, see:

  Checking your weight when you have heart failure.

• Avoid respiratory infections. Stay up to date on vaccinations for flu and pneumonia.
• Avoid triggers for sudden heart failure. For more information, see:

  Avoiding triggers for sudden heart failure.

Throughout the course of your heart failure, you may need to cope with both physical limitations and emotional issues that affect your ability to lead an active life.

Because heart failure is a lifelong condition, you will have dozens—perhaps even hundreds—of appointments with various health professionals during your experience with the disease. Learning how to work with health professionals who are treating your heart failure will benefit you by allowing them to better control your symptoms and tailor your treatment to your own needs.

Many hospitals and insurers have disease management (DM) programs to help people learn about their heart failure and reduce the overall cost for medical care.

Medications

You probably will need to take a combination of medicines to treat heart failure, even if you do not have symptoms yet. Medicines do not cure heart failure. However, they can help you manage your symptoms.

The goals of drug treatment are to relieve or control symptoms of heart failure, improve daily function and quality of life, slow the progression of the disease, and reduce the risk of complications, hospital stays, and premature death.

Medicines are used to treat the problems associated with heart failure, including:

• Fluid buildup, swelling, and water retention (edema).
• The reduced pumping ability of the heart.
• The effects of the body's attempt to compensate for heart failure.
• Underlying conditions that can lead to heart failure, such as coronary artery disease, high blood pressure, or diabetes.
• Prevention of complications, such as stroke.

It is extremely important that you take your medicines exactly as recommended by your doctor. If you don't, your heart failure may get worse or you may develop sudden heart failure. For more information, see:

Taking your medicines properly when you have heart failure.

Medicine Choices

A combination of medicines is often needed to control symptoms and slow the progression of heart failure. Some medicines are used to treat pumping problems (systolic heart failure), and others are used to treat problems with filling (diastolic heart failure). The most commonly used and effective classes of medicines are as follows:

Medicines for pumping problems (systolic heart failure)

These include:

• ACE inhibitors (angiotensin-converting enzyme inhibitors). ACE inhibitors allow blood vessels to relax and widen (dilate), making it easier for blood to flow through the vessels.
• ARBs (angiotensin II receptor blockers). Like ACE inhibitors, ARBs allow blood vessels to relax and widen (dilate), making it easier for blood to flow through the vessels.
• Diuretics. Diuretics stimulate the kidneys to remove more water and salt (sodium) from the body.
• Aldosterone receptor antagonists. These medicines cause the kidneys to get rid of extra salt and fluid, and they help hold on to (retain) potassium by inhibiting the action of the hormone aldosterone.
• Digoxin. Digoxin slows and strengthens heart contractions, enabling the heart to pump more blood with each beat.
• Beta-blockers. Beta-blockers control symptoms of heart failure by either slowing the heart rate or making the blood vessels wider so blood flows more easily.
• Vasodilators. Vasodilators lower blood pressure and reduce the workload on the heart.

A new medicine called BiDil significantly decreases death rates in African Americans who have advanced heart failure, according to the first major trial to test a drug only in African Americans. BiDil is a combination of hydralazine and isosorbide, two older drugs that have been used in the past to treat various heart conditions. When taken along with standard medicines for heart failure, BiDil was found to decrease the number of hospital stays and increase survival rate.¹²

Medicines for filling problems (diastolic heart failure)

• Beta-blockers
• Diuretics
• ACE inhibitors
• ARBs (angiotensin II receptor blockers)
• Calcium channel blockers
• Direct renin inhibitors

If your heart failure is related to another condition, such as irregular rapid heartbeats (arrhythmias), impaired blood flow to the heart muscle (ischemia), or high blood pressure, you may take specific drugs for these conditions.

• Anticoagulants thin the blood and make it less likely to clot. These drugs may help prevent strokes.
• Antiarrhythmics prevent rapid and sometimes irregular heart rhythms.
• Antianginals (nitrates) control chest pain (angina) caused by impaired blood flow to the heart muscle.
• Antihypertensives lower blood pressure.

If you take the anticoagulant warfarin, don't suddenly change your intake of foods that are rich in vitamin K. Vitamin K can interfere with the action of anticoagulants, making it more likely that your blood will clot. For more information, see:

Eating a steady amount of vitamin K when you take warfarin (Coumadin).

What to Think About

• Taking medicines used only to treat diastolic dysfunction may be harmful if you have systolic dysfunction, and vice versa.
• Different people will take different medicines depending on the cause of heart failure and other related conditions.
• Medicines for arthritis can cause sodium and water retention and can make heart failure worse. Ask your doctor before taking anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil or Motrin), naproxen (Aleve), or cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib (Celebrex).

Surgery

People who have heart failure with chest pain (angina) or who have had a heart attack in the past may benefit from coronary artery bypass surgery or angioplasty to open clogged arteries.

Some people may have surgery to repair specific underlying causes of heart failure, such as damaged valves. In cases that have a specific treatable cause, surgery sometimes can greatly improve or eliminate heart failure symptoms.

Doctors may only consider a heart transplant if you have severe, life-limiting symptoms of heart failure that do not respond to available treatments. In addition, you must be unlikely to benefit from coronary artery bypass surgery, and you must not have any other serious medical conditions that would reduce your life expectancy.

Experts are studying several different experimental treatments for heart failure, including:

• Cardiomyoplasty, a procedure in which the surgeon tries to make the heart pump better. The surgeon takes muscle from the back and abdomen and wraps it around the heart. A pacemaker makes the muscle beat with the heart.
• Ventricular assist devices (VADs), which are mechanical pumping devices that are inserted into the chest to help the heart pump more blood. VADs are used to keep people alive until a donor heart is available for transplant. VADs may also be used as an alternative to heart transplant for long-term treatment of severe heart failure. These devices require surgery to place the device and to make the connections between the heart and the device. See an illustration of a ventricular assist device.

Surgery Choices

Coronary artery bypass (CABG) surgery

Angioplasty (with or without other procedures, such stents or atherectomy)

Heart transplant

For more information on procedures to restore blood flow (called revascularization) to the heart muscle, see the topic Coronary Artery Disease.

What to Think About

Some people with heart failure may want to consider specific testing to find out whether they would benefit from angioplasty or bypass surgery. The decision to have more testing is difficult. It is not clear that restoring blood flow (revascularization) improves heart failure symptoms and prolongs life in people who do not have chest pain.

Evidence shows that starting ACE inhibitor medicines after a heart attack can help lower the risk of heart failure.

Other Treatment

Biventricular pacing

Several new medical advances benefit people with heart failure. One is the biventricular pacemaker, which synchronizes the rhythm of the heart's chambers (cardiac resynchronization). It has been shown to improve quality of life in people who have severe heart failure and problems with the heart's electrical system.⁷ New guidelines from the American Heart Association recommend biventricular pacing for people with severe heart failure.¹³ Further studies are ongoing to see whether this therapy might also benefit those with less severe heart failure.

Implantable defibrillators (ICDs)

A device that combines an implantable cardioverter-defibrillator (ICD) with a biventricular pacemaker is now available for some people with heart failure. The ICD part of the device continuously monitors the heart for life-threatening, rapid heart rhythms. When these dangerous heart rhythms occur, the device delivers an electric shock to the heart to restore a normal rhythm. The biventricular pacing part sends weak electrical shocks that make the left and right lower chambers (ventricles) contract at the same time. This double contraction helps the heart to pump blood better. Studies show better quality of life, improved capacity for exercise, and longer life in people with this combination pacemaker/ICD device compared with those who had only a biventricular pacemaker.¹⁴

Other Treatment Choices

Pacemakers, including biventricular pacemakers (resynchronization therapy)

Enhanced external counterpulsation (EECP), a treatment sometimes used for heart failure

Cardiac rehabilitation is often recommended in the treatment of heart failure before or after pacemaker implantation or other surgical interventions. For more information, see the topic Cardiac Rehabilitation.

Doctors also may use an intra-aortic balloon pump to stabilize a person during sudden heart failure.

What to Think About

Complementary or alternative therapy

No convincing evidence shows that nutritional or certain vitamin supplements are effective for treating heart failure.² Some European studies from the early 1990s suggest that the supplement coenzyme Q10 improves heart failure symptoms; more recent studies have shown no effect.¹⁵ In any case, coenzyme Q10 should not be a substitute for the standard treatment for heart failure.

Hawthorn is an herbal supplement that contains flavonoids. It dilates blood vessels to increase blood flow to the heart. German studies have shown improvement of mild heart failure in some people who took hawthorn. It is sometimes recommended in Europe and Asia for treatment of heart failure.¹⁶

Talk to your doctor about whether supplements are safe for you.

End-of-Life Decisions

Although heart failure treatment is increasingly successful at prolonging life and reducing complications and hospital stays, heart failure can be a progressive, fatal condition. Many important end-of-life decisions can be made while you are active and able to communicate your wishes.

For more information, see the topic Care at the End of Life.

Other Places To Get Help

Organizations

Related Information

• Alcohol Abuse and Dependence
• Aortic Valve Regurgitation RLP
• Aortic Valve Stenosis
• Atrial Fibrillation
• Cardiac Rehabilitation
• Care at the End of Life
• Congenital Heart Defects
• Coronary Artery Disease
• Family Life Cycle
• Heart Attack and Unstable Angina
• High Blood Pressure (Hypertension)
• High Cholesterol
• Quitting Tobacco Use