heart failure

Heart Failure: Symptoms, Causes, Stages & Treatment

Heart failure is a condition where the heart function is reduced, meaning that the heart’s ability to pump blood effectively is weakened. Learn more about the causes, symptoms and treatment of heart failure.

by Elaine Francis, R.N.

Heart failure is a condition where the heart function is reduced, meaning that the heart’s ability to pump blood effectively is weakened. Learn more about the causes, symptoms and treatment of heart failure.

What is Heart Failure?

When someone has heart failure, their heart is not pumping with enough strength to fully meet their body’s needs. There are several different reasons why this might happen, including damage or structural problems with the heart. Some medical conditions can also increase a person’s risk of developing heart failure.

While the phrase ‘heart failure’ can sound dire and overwhelming, it actually just means that there is a degree of reduced heart function; it does not mean that the heart has stopped, or is about to stop working. Heart failure can be mild or severe, and there are ways to manage the condition.

Heart failure is also sometimes referred to as chronic or congestive heart failure (CHF) or congestive cardiac failure (CCF). More specifically, we might refer to types of heart failure as left ventricular systolic dysfunction (LVSD); left-sided heart failure, right-sided heart failure or cor pulmonale.

Heart Failure Symptoms

The symptoms of heart failure can range from mild to debilitating, and can include:

  • Pulmonary oedema: This is a condition where fluid collects in the tissues of the lungs. It makes breathing difficult, and people with severe pulmonary oedema sometimes cough up frothy white or pinkish sputum. Having fluid in the lungs can cause rapid breathing. The breathing difficulties people experience with heart failure tend to be worse at night, especially when lying flat.
  • Peripheral oedema (swelling): The reduced pumping action of the heart allows fluid to pool in the tissues of the body, particularly in the lower legs. ‘Pitting oedema’ is a phrase used to describe this build-up of fluid, and applying a little pressure with a finger leaves a dent.
  • Fatigue: One of the most common symptoms is tiredness. Everyday tasks can become extremely hard work. Heart failure and some of the treatments for heart failure can also make it hard to sleep well.
  • Reduced exercise tolerance: Having reduced heart function means that even the slightest exertion – such as getting out of bed or getting to the bathroom – can be very difficult. This is exacerbated by the other symptoms of heart failure such as heavy and swollen legs, sleepless nights and breathing difficulties.
  • Weight gain: Fluid build-up increases a person’s weight. Heart failure and some of the treatments given for heart failure can affect how much urine is passed, and monitoring weight can be a good way to assess how much fluid is building up in the body.

Diagnosing Heart Failure

Heart failure is often diagnosed by observing the symptoms one experiences. At an examination, a doctor will listen to the chest with a stethoscope, and look and feel for swelling, particularly in the lower limbs and abdomen. A medical history will be taken, where the doctor asks about previous heart problems, health, lifestyle, and family history of heart disease.

Other tests for heart failure can include:

  • Pulse oximetry: A small device is placed on the fingertip which measures the amount of oxygen in the blood.
  • Chest X-ray: This can show whether there is fluid in the lungs, and gives doctors an idea of the extent of any fluid build-up.
  • Trans-thoracic echocardiogram (TTE), or ‘echo’: This is an ultrasound scan of the heart which can show any structural or movement abnormalities.
  • Trans-oesophageal echocardiogram (TOE) or trans-esophageal echo (TEE): This is another type of ultrasound imaging where a fine tube is inserted partially into the oesophagus to get a closer look at the heart.
  • Blood tests: Blood tests are performed routinely for people with heart function to assess their heart and kidney function, short- and long-term damage to the heart muscle, and monitor other vital systems and health conditions.
  • Arterial blood gas (ABG): When someone is having acute and severe breathing problems, a blood sample taken from an artery gives doctors a good idea of how much oxygen and carbon dioxide is in the arterial blood.

Heart Failure Causes & Risk Factors

People are also more at risk of developing heart failure if they have:

Smoking, being overweight, a poor diet, and a high alcohol intake also increase a person’s likelihood of developing heart failure.

Types of Heart Failure

The way doctors describe heart failure depends on which part of the heart is affected, what symptoms the individual experiences, and the severity of those symptoms. 

Left-sided Heart Failure

The most common type of heart failure is left-sided. The left side of the heart comprises the left atrium (the chamber which receives oxygenated blood from the lungs) and the left ventricle (the chamber which pushes blood into the rest of the body). When the pumping action of the left ventricle is reduced, heart failure may be referred to as LVSD, or left ventricular systolic dysfunction

The ejection fraction (the amount of blood pumped out of the left ventricle with each heartbeat) is a useful measure for the extent of this type of heart failure. Doctors may refer to LVSD as mild, moderate, or severe heart failure, depending on the ejection fraction, usually measured during an echocardiogram. Sometimes heart failure occurs without a reduced ejection fraction – this is referred to as heart failure with preserved ejection fraction (HFpEF).

Left-sided heart failure particularly causes problems with fluid in the lungs, as the reduced function of the left side of the heart forces fluid back up into the blood vessels of the lungs.

Right-sided Heart Failure

Right-sided heart failure usually develops as a secondary complication of left-sided heart failure, and reduced function in both sides of the heart is referred to as biventricular failure. Right-sided heart failure can also develop independently, often as a result of serious lung disease. People with right heart failure tend to build up fluid in the tissues of their lower limbs, and sometimes inside the abdomen and around the genitals.

Stages of Heart Failure

Heart failure can develop very suddenly after a cardiac event such as a heart attack or heart rhythm disturbance. It can also develop more slowly, either for the same reasons, or other conditions which put strain on the heart, such as chronically raised blood pressure. Acutely reduced heart function can improve when the cause is treated.

Chronic heart failure is described according to the effect it has on a person’s life and is classified using the New York Heart Association (NYHA) scale:

  • Class I: No symptoms — underlying reduced heart function may be an incidental finding.
  • Class II: Mild symptoms — able to go about normal activities with minimal limitations or adaptations.
  • Class III: Moderate symptoms — Reduced exercise tolerance, meaning that it is impossible to continue normal activities without significant adaptations; comfortable only at rest.
  • Class IV: Severe symptoms — extremely limited functional abilities and symptoms even when resting.

Chronic heart failure is a degenerative condition. The disease trajectory often follows a ‘stepped’ pattern — periods of stability interspersed with periods of deterioration.

Heart Failure Treatment

The sooner heart failure is diagnosed and treated, the better the prognosis. Treatment usually takes the form of lifestyle changes to help reduce deterioration and manage symptoms, and medications to support the heart.

Medications

Medications commonly used in heart failure include:

  • Angiotensin-converting enzyme (ACE) inhibitors (e.g. ramipril): These can lower blood pressure and reduce strain on the heart.
  • Beta blockers (e.g. bisoprolol): These slow the heart rate down and are commonly used after a heart attack or for people who have fast, irregular heart rates.
  • Diuretics: there are several types of diuretics used in heart failure; these act on the kidneys to help pump fluid away and reduce oedema. Some diuretics can cause strain on the kidneys, and electrolyte levels need to be closely monitored, but they are essential for managing fluid retention in heart failure.

Pacemaker

Some people with heart failure have problems with the heart beating in a normal coordinated pattern. For them, symptoms can be improved with a specific type of implanted pacemaker called a cardiac resynchronisation therapy (CRT) device which makes the heart beat in a more synchronised way.

Surgery

Heart failure symptoms caused by structural problems with the heart, particularly valve disease, may require surgery to repair or replace valves. Underlying causes like arrhythmias or coronary artery disease may also need to be treated, which may entail further investigations, medications, and procedures.

More extensive interventions may be appropriate in some circumstances, and options include heart transplants and mechanical devices to maintain the heart’s output.

Acute respiratory failure caused by heart failure may need intensive treatment, sometimes including mechanical ventilation and life support.

Medical and surgical innovations are improving as modern science advances, and the life expectancy of people diagnosed with heart failure is getting better all the time.

Heart Failure Prevention

The best way to prevent heart failure is to know your underlying risk factors and live as healthy a life as possible. Attending regular health checks and managing any other medical conditions is key to preventing or reducing the impact of heart failure. Regular health checks should include routine observations, blood pressure and oxygen levels, and blood tests including cholesterol and kidney function checks.

A healthy lifestyle means a good diet, plenty of exercises, and reaching or maintaining a healthy weight. This can help prevent cardiovascular diseases, type 2 diabetes, and other serious conditions. Stopping smoking and keeping alcohol intake at a minimum are essential for healthy living.

Living with Chronic Heart Failure: What to Expect

People with chronic heart failure usually have to take medications for the rest of their lives and make lifestyle adjustments to support the heart and manage symptoms.

One of the best ways to monitor heart function at home is to track weight. Reduced heart function can cause fluid to build up quickly and so doing a daily fasting weight every morning can show a trend — rapid weight gain often means that fluid is building up. Every litre of fluid retained is a kilo on the scales, and that retained fluid tends to build up in the legs, abdomen, and lungs. 

To combat fluid buildup, a doctor or specialist nurse might recommend increasing diuretics or other treatments. However, take note that diuretics (water tablets) like furosemide can mean passing lots of urine, so do plan for frequent toilet breaks, especially when you are out and about.

Fatigue and breathlessness can restrict an individual’s ability to go about their usual lives. Those who need support with their activities of daily living like washing, dressing, preparing food and getting outside, can engage a professional caregiver to help.

Living with heart failure can be easier with some small adjustments to help manage symptoms; if it is difficult to breathe when lying flat, propping up the head of the bed or using lots of pillows can help. One simple way is to use an adjustable hospital bed at home.

For people with heart failure, symptoms and treatment require careful monitoring, including regular blood tests. Hence, regular follow up with a specialist is recommended. Managing heart failure means more than just managing the physical condition; heart failure affects every aspect of life and can be emotionally, as well as physically, taxing.

Advanced and severe chronic heart failure is a serious, degenerative condition, and the life expectancy in the later stages is poor. Some people with advanced organ failure can find it helpful to discuss the kinds of treatment that would be appropriate for them going forward. 

Involving family in discussions about treatment options can help people plan for the future and make the right choices as conditions worsen. The time may come when invasive or intensive treatments would be inappropriate, so making an Advanced Medical Directive can be a way to ensure that treatment towards the end of life is rationalised, supportive, and designed for comfort and quality of life.

References

  1. McMurray JJ, Stewart S (2000) Epidemiology, aetiology, and prognosis of heart failure. Heart. http://dx.doi.org/10.1136/heart.83.5.596
  2. Ekman, I., Cleland, J. G., Andersson, B., & Swedberg, K. (2005). Exploring symptoms in chronic heart failure. European Journal of Heart Failure. https://doi.org/10.1016/j.ejheart.2005.07.003
  3. Khatibzadeh, S., Farzadfar, F., Oliver, J., Ezzati, M., & Moran, A. (2013). Worldwide risk factors for heart failure: a systematic review and pooled analysis. International journal of cardiology, 168(2), 1186-1194. https://doi.org/10.1016/j.ijcard.2012.11.065
  4. The Criteria Committee of the New York Heart Association. (1994). Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels (9th ed.). Boston: Little, Brown & Co. https://www.jacc.org/doi/full/10.1016/j.jacc.2012.12.047
  5. T Fahey, S Jeyaseelan, C McCowan, E Carr, BM Goudie, SD Pringle, PT Donnan, FM Sullivan, AD Struthers, Diagnosis of left ventricular systolic dysfunction (LVSD): development and validation of a clinical prediction rule in primary care, Family Practice, Volume 24, Issue 6, December 2007, Pages 628–635, https://doi.org/10.1093/fampra/cmm055
  6. Lekavich, C. L., Barksdale, D. J., Neelon, V., & Wu, J. R. (2015). Heart failure preserved ejection fraction (HFpEF): an integrated and strategic review. Heart failure reviews, 20(6), 643-653. https://doi.org/10.1007/s10741-015-9506-7
  7. Ponikowski, P., Anker, S. D., AlHabib, K. F., Cowie, M. R., Force, T. L., Hu, S., … & Filippatos, G. (2014). Heart failure: preventing disease and death worldwide. ESC heart failure, 1(1), 4-25. https://doi.org/10.1002/ehf2.12005
  8. Malhotra, C., Cheng Sim Wong, G., Tan, B. C., Ng, C. S. H., Lee, N. C., Lau, C. S. L., … & Finkelstein, E. A. (2016). Living with heart failure: Perspectives of patients from Singapore. Proceedings of Singapore Healthcare, 25(2), 92-97. https://journals.sagepub.com/doi/pdf/10.1177/2010105815624121


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About the Writer
Elaine Francis, R.N.
Elaine Francis is a registered nurse with 17 years’ experience in healthcare. She turned to writing to follow her passion for realistic medical communication. She loves translating medical jargon into accessible language for the people who need to understand it most. When she’s not writing or working on a busy cardiology unit, she spends her time telling her children to hurry up.
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