Heart failure

Heart failure is a condition where the heart muscle becomes weak and cannot pump blood and oxygen around the body as well as it usually does. In people with heart failure, the heart muscle tries to adapt by increasing in size and thickness, but over time it is no longer able to contract or relax properly.

When this happens, fluid can build up in other parts of the body, including the lungs, abdomen, legs and ankles. This causes many of the symptoms of heart failure.

Although heart failure is a lifelong condition, there are many things you can do to help yourself feel better and stay out of hospital.

Causes of heart failure#

Coronary heart disease is the major cause of heart attacks. A heart attack can cause scarring of the heart muscle, which means the muscle is no longer able to pump blood and oxygen around the body properly. Risk factors for coronary heart disease include high blood pressure, high cholesterol, diabetes, tobacco smoking, physical inactivity, not following a heart-healthy eating pattern, overweight or obesity, excess alcohol intake, and depression, anxiety or social isolation.

Heart failure can also develop because of other conditions that damage, weaken or stiffen the heart, including:

• Congenital heart disease – heart abnormalities present from birth that can affect the normal flow of blood through the heart.
• Heart valve disease – if the heart valves are damaged, blood cannot flow through the heart as normal, putting extra strain on the heart.
• Cardiomyopathy – a disease of the heart muscle that affects its function, size or shape, which can affect the heart’s pumping ability.
• Myocarditis (inflammation of the heart muscle) – viruses or other infections can damage the heart muscle.
• Abnormal heart rhythms – a fault in the heart’s electrical system can make it beat rapidly or irregularly, and over a long period this can lead to heart failure.
• Other conditions – including chronic conditions such as diabetes, HIV and thyroid conditions, toxins such as alcohol and illicit drugs, and less common conditions such as amyloidosis, sarcoidosis and some nutritional deficiencies.

Symptoms of heart failure#

Heart failure causes symptoms because of the reduced supply of blood and oxygen to your muscles and organs, and the build-up of fluid in your body. Symptoms can include:

• new or worsening shortness of breath or trouble breathing, particularly during physical activity or at night when lying flat
• coughing and wheezing
• fainting or dizziness
• weight gain
• fatigue, tiredness or weakness
• ankle or leg swelling
• abdominal swelling or bloating
• heart palpitations (a fluttering, racing, thumping or pounding feeling in your chest)
• chest pain or discomfort in parts of the upper body
• loss of appetite or nausea
• constipation

Factors that can worsen symptoms#

Several factors can make heart failure symptoms worse, including:

• not taking prescribed heart failure medicines
• anaemia (a condition where the blood doesn’t have enough healthy red blood cells)
• too much salt, fluid or alcohol in your diet
• pregnancy
• some viral and bacterial infections
• kidney diseases
• lung diseases

Diagnosis of heart failure#

If your doctor suspects you have heart failure, an echocardiogram (an ultrasound scan of the heart) is a very important test to assess how well the heart is pumping. Other tests may include:

• a physical examination, including listening to the heart with a stethoscope
• blood tests
• a chest X-ray
• an electrocardiogram (ECG) to monitor the heart rate, pick up any unusual heart rhythms and help assess whether the left ventricle is enlarged
• exercise tests or ‘stress tests’
• lung function tests, to assess how well the lungs are working

Treatment for heart failure#

Treatment may include heart failure management programs, cardiac rehabilitation, medicines, and devices or surgery.

Heart failure management programs#

Attending a specialised program for people with heart failure can reduce the risk of complications and the need to go to hospital. It can also help you live longer and improve your quality of life. These programs, sometimes called chronic disease management programs, are run by a team of health professionals who help you manage your condition. The team can include a heart failure nurse, a cardiologist, a pharmacist, a physiotherapist, a dietitian and a psychologist.

When you attend a program, you’ll get information to help you manage your condition, including:

• how to manage your heart failure medicines
• when to act if your symptoms get worse
• how to monitor your fluid levels and salt intake

If you have heart failure and haven’t been referred to a heart failure management program, ask your doctor to help you enrol. Some services are now available from your own home using telephone and internet services.

Cardiac rehabilitation and physical activity#

Attending a cardiac rehabilitation program is one of the best things you can do for heart failure. Many people benefit from it: it can improve your quality of life, keep you out of hospital and have a positive impact on your mental health and wellbeing.

Cardiac rehabilitation combines exercise and education sessions to help you make healthy changes. This includes exercise to build your strength, fitness and confidence — activities that make you slightly out of breath while you can still hold a conversation, such as walking or riding a stationary bike. It might also include exercises that use light weights or other equipment. You’ll get a tailored exercise program and can go at your own pace. Many cardiac rehabilitation services now offer home-based options by telephone and over the internet.

Walking for heart health#

Walking is a great activity for heart health and for managing blood pressure. Joining a walking group can be a fun and social way to stay active.

Medicines#

Heart failure medicines usually need to be taken long-term. Your doctor may increase the dose even if you feel well. It’s important that you do not stop taking your heart failure medicines without speaking to your doctor or pharmacist first.

Your doctor will prescribe certain medicines depending on the type of heart failure you have, and many people need a combination. Common types include:

• Angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) – help your blood vessels relax, putting less strain on your heart and making it easier to pump blood around your body.
• Angiotensin receptor-neprilysin inhibitors (ARNIs) – help manage your blood pressure and get rid of extra fluid.
• Beta blockers – slow your heart rate so it can pump more efficiently.
• Mineralocorticoid receptor antagonists (MRAs) – help prevent or reduce damage and changes to the heart muscle, and help manage blood pressure.
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors – can improve symptoms by reducing extra fluid in the body, and also help manage blood sugar levels in people with heart failure and diabetes.
• Diuretics – help remove extra fluid from your body, including your lungs, abdomen, legs, ankles and feet, by increasing the amount of urine you make. They reduce swelling and make it easier to breathe.

Pacemakers and other devices#

The heart has its own electrical system that regulates the heartbeat. With every beat, an electrical signal travels through your heart, causing it to contract and pump blood around the body. For some people with heart failure, this electrical system doesn’t work properly, and they have an increased risk of abnormal heart rhythms (arrhythmias), such as atrial fibrillation.

If you have an abnormal heart rhythm, you may need a pacemaker or device to regulate your heart rate and rhythm.

• Pacemaker – a small implantable device that electrically stimulates the heart to maintain a regular rhythm. It is inserted under the skin on your chest (or abdomen) and has one or more wires that connect to your heart, producing small electrical currents that stimulate the heart to pump regularly. Pacemakers are sometimes used in people with heart failure to reduce symptoms when the left and right sides of the heart don’t beat together. This special type is also called a cardiac resynchronisation therapy (CRT) device or a biventricular pacemaker, and it is often combined with an implantable cardioverter defibrillator (CRT-D). A pacemaker shouldn’t affect your day-to-day life, though you may need to make a few small changes for a short time. People with pacemakers and devices need regular follow-up appointments to make sure the device is working well. A pacemaker battery usually lasts between five and 15 years; your doctor will check it regularly, and when it is running low you will need to go back into hospital to have it replaced.
• Implantable cardioverter defibrillator (ICD) – a small battery-powered box (smaller than a matchbox) inserted under the skin, usually just below the collarbone (clavicle), with thin wires connecting it to the heart. It continuously monitors your heart and can correct dangerous abnormal rhythms by delivering controlled electrical ‘shocks’. There are different types of ICD, and your doctor will talk to you about which option is right for you.

Surgery and procedures#

Some people with heart failure may need other surgeries and procedures to improve symptoms and quality of life. The type of surgery depends on the cause of your heart failure, how severe your symptoms are, and any other medical conditions you have. Options include:

• Catheter ablation – helps regulate the heartbeat in people with abnormal heart rhythms by removing the small cells in the heart where the abnormal electrical signals come from.
• Heart valve surgery – to repair or replace damaged heart valves.
• Coronary artery bypass graft surgery (or ‘heart bypass surgery’) – for people with coronary heart disease.
• Heart transplant – only a very small number of heart transplants are performed each year.

Living well with heart failure#

There are many resources to support people living with heart failure and their families and carers, including information on what to do when you feel unwell, managing symptoms, monitoring your fluid and salt intake, questions to ask your health professional, changes you might need to make to daily life, and action plans to help you focus on the most important parts of your heart failure management right now. Ask your health professional about resources available in your area and your language.

Key points#

• Heart failure means the heart muscle cannot pump blood and oxygen around the body as well as it should, often leading to fluid build-up.
• Coronary heart disease and heart attack are major causes, but valve disease, cardiomyopathy, infections, abnormal rhythms and other conditions can also lead to heart failure.
• Diagnosis often relies on an echocardiogram, along with tests such as blood tests, a chest X-ray and an ECG.
• Treatment includes management programs, cardiac rehabilitation, long-term medicines, and sometimes devices or surgery.
• Do not stop taking your heart failure medicines without first speaking to your doctor or pharmacist.

Where to get help and trusted information#

For evidence-based global health guidance, see Source: World Health Organization (WHO).