Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or other changes that may further weaken or stiffen the heart.
Heart failure develops when the contracting action or the relaxing action of the heart is inadequate, typically because the heart muscle is weak, stiff, or both.
Many disorders that affect the heart can cause heart failure.
Most people have no symptoms at first, and shortness of breath and fatigue develop gradually over days to months.
Fluid may accumulate in the lungs, abdomen, or legs.
Doctors usually suspect heart failure on the basis of symptoms, but tests, such as echocardiography (ultrasound of the heart), are usually done to evaluate heart function.
Treatment focuses on treating the disorder causing heart failure, making lifestyle changes, and treating heart failure with medications or with surgery or other interventions.
Causes of Heart Failure
Causes of heart failure include:
Disorders that directly affect the heart (cardiac causes)
Disorders of other body systems that indirectly affect the heart (non-cardiac causes)
Any disorder that directly affects the heart can lead to heart failure, as can some disorders that indirectly affect the heart. Some disorders cause heart failure quickly. Other disorders cause heart failure only after many years. Some disorders cause systolic heart failure, others cause diastolic heart failure, and some disorders, such as high blood pressure and some heart valve disorders, can cause both types of dysfunction.
Cardiac causes of heart failure
Cardiac disorders that cause heart failure may impair the entire heart or one area of the heart. In many cases, a combination of factors results in heart failure.
A common cardiac cause of heart failure is:
Coronary artery disease can impair large areas of heart muscle because it reduces the flow of oxygen-rich blood to the heart muscle, which needs oxygen for normal contraction. Blockage of a coronary artery can cause a heart attack, which destroys an area of heart muscle. As a result, that area can no longer contract normally.
Other cardiac causes of heart failure include:
Myocarditis (inflammation of heart muscle)
Some medications (for example, some chemotherapy drugs)
Some toxins (for example, alcohol)
Heart valve disorders
An abnormal connection between heart chambers (for example, ventricular septal defect)
Disorders that affect the heart's electrical conduction system and cause an abnormal heart rhythm
Some genetic disorders
Disorders that stiffen the heart
Myocarditis (heart inflammation) caused by a bacterial, viral, or other infection can damage all or part of the heart muscle, impairing its pumping ability.
Some medications used to treat cancer and some toxins (such as alcohol) may also damage heart muscle.
Heart valve disorders—narrowing (stenosis) of a valve, which hinders blood flow through the heart, or leakage of blood backward (regurgitation or insufficiency) through a valve—can cause heart failure. Both stenosis and regurgitation of a valve can severely stress the heart, so that over time, the heart enlarges and cannot pump adequately.
An abnormal connection (for example, ventricular septal defect) between the heart chambers can allow blood to recirculate within the heart, increasing the workload of the heart, and thus can cause heart failure.
Disorders that affect the heart’s electrical conduction system (see figure Tracing the Heart's Electrical Pathway) and cause prolonged changes in heart rhythms (especially if these are fast or irregular) can cause heart failure. When the heart beats abnormally, it cannot pump blood efficiently.
Some genetic disorders can affect the heart and cause heart failure. For example, Duchenne muscular dystrophy causes weakness of the heart muscle (along with many other muscles). Down syndrome can cause birth defects of the heart.
Heart failure may result from disorders that cause the heart’s walls to stiffen, such as infiltrations and infections. For example, in amyloidosis, amyloid, an abnormal protein passes into (infiltrates) many tissues in the body. If amyloid infiltrates the heart’s walls, they stiffen, and heart failure results. In tropical countries, infiltration of heart muscle by certain parasites (such as in Chagas disease) can cause heart failure, even in young people.
In constrictive pericarditis, the sac that envelops the heart (pericardium) stiffens, preventing even a healthy heart from pumping and filling normally.
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Non-cardiac causes of heart failure
The most common non-cardiac cause of heart failure is:
Inadequately treated high blood pressure
High blood pressure stresses the heart because the heart must pump blood more forcefully than normal to eject blood into the arteries against the higher pressure. Eventually, the heart’s walls thicken (hypertrophy) and/or stiffen. The stiff heart does not fill quickly or adequately, so that with each contraction, the heart pumps less blood than it normally does. Diabetes and obesity also cause changes that stiffen the walls of the ventricle.
As people age, the heart’s walls also tend to stiffen. The combination of high blood pressure, obesity, and diabetes, which are common among older adults, and age-related stiffening makes heart failure particularly common among older adults.
Less common non-cardiac causes of heart failure include:
High blood pressure in arteries to the lungs (pulmonary hypertension, sometimes caused by pulmonary embolism)
Anemia
Thyroid gland disorders
Kidney failure
Some medications
Some lung disorders, such as pulmonary hypertension, may alter or damage blood vessels in the lungs (pulmonary arteries). As a result, the right side of the heart, which pumps blood into the lungs, has to work harder. The person may then develop cor pulmonale, in which the right ventricle (lower heart chamber) is enlarged and there is right-sided heart failure.
Sudden, severe blockage of a pulmonary artery by one or more blood clots (pulmonary embolism) also makes pumping blood into the pulmonary arteries difficult and can cause right-sided heart failure.
Anemia is a severe deficiency of red blood cells (low blood count). Red blood cells carry oxygen from the lungs to body tissues. Anemia reduces the amount of oxygen the blood carries, so that the heart must work harder to provide the same amount of oxygen to tissues. Anemia has many causes, including heart failure itself.
An overactive thyroid gland (hyperthyroidism) overstimulates the heart, so that it pumps too rapidly and does not empty normally during each heartbeat. When the thyroid gland is underactive (hypothyroidism), all muscles, including the heart, become weak because muscles depend on thyroid hormones to function normally.
Kidney failure strains the heart because the kidneys cannot remove excess fluid from the bloodstream, so the heart has a larger volume of blood to pump. Eventually, the heart cannot keep up, and heart failure develops.
Some medications, such as nonsteroidal anti-inflammatory drugs, may cause the body to retain fluid, which increases the workload of the heart and may precipitate heart failure.
Symptoms of Heart Failure
Symptoms of heart failure may begin suddenly (acute heart failure), especially if the cause is a heart attack. However, most people have no symptoms when the heart first begins to develop problems. Symptoms then develop gradually over days to months or years (chronic heart failure). Heart failure may stabilize for periods of time but often progresses slowly and insidiously. However, people may become aware of symptoms suddenly, as when symptoms restrict an activity for the first time or when symptoms occur while at rest.
Some common symptoms are:
Fatigue
Fluid accumulation (edema) in the legs
Inability to exercise or do other activities that require exertion
In older adults, heart failure sometimes causes vague symptoms such as sleepiness, confusion, and disorientation.
The severity of heart failure is usually classified based on how well the person is able to carry out activities of daily life. The New York Heart Association (NYHA) classification is an important tool for people and their caregivers to understand the severity of the illness and its impact on their life (see table New York Heart Association Heart Failure Classification).
Right-sided heart failure and left-sided heart failure cause different symptoms. Although both types of heart failure may be present, the symptoms of failure of one side often predominate. Eventually, left-sided heart failure causes right-sided failure.
Right-sided heart failure symptoms
The main symptom of right-sided heart failure is fluid accumulation, leading to swelling (edema) in the feet, ankles, legs, lower back, liver, and abdomen. Where the fluid accumulates depends on the amount of excess fluid and the effects of gravity. If a person is standing, fluid accumulates in the legs and feet. If a person is lying down, fluid usually accumulates in the lower back. If the amount of fluid is large, fluid also accumulates in the abdomen. Fluid accumulation in the liver or stomach can cause nausea, bloating, and loss of appetite. Severe right-sided heart failure can result in loss of weight and muscle. This condition is called cardiac cachexia.
Left-sided heart failure symptoms
Left-sided heart failure leads to fluid accumulation in the lungs, which causes shortness of breath. At first, shortness of breath occurs only during exertion, but as heart failure progresses, it occurs with less and less exertion and eventually occurs even at rest. People with severe left-sided heart failure may be short of breath when lying down (a condition called orthopnea) because gravity causes more fluid to move into the lungs. Such people often wake up, gasping for breath or wheezing (a condition called paroxysmal nocturnal dyspnea). Sitting up causes some of the fluid to drain to the bottom of the lungs and makes breathing easier. People with left-sided heart failure also feel tired and weak when doing physical activities, because their muscles are not receiving enough blood.
Symptoms of severe heart failure
When heart failure is severe, a type of periodic breathing called Cheyne-Stokes respiration may develop. In this unusual pattern of breathing, a person has a period of not breathing for a few seconds, and then begins to breathe progressively faster and deeper, then slower and shallower until they again briefly stop breathing and repeat the cycle over and over. Cheyne-Stokes respiration develops because blood flow to the brain is reduced and the areas of the brain that control breathing therefore do not receive enough oxygen. Cheyne-Stokes respiration is considered a form of central sleep apnea.
Obstructive sleep apnea (in which airway blockage interrupts sleep, resulting in daytime sleepiness) is a different and more common breathing disorder that can occur in people with or without heart failure. Severe obstructive sleep apnea can make heart failure worse. A related condition called central sleep apnea, is also more common in people with heart failure and can make heart failure worse.
Acute pulmonary edema is a sudden accumulation of a large amount of fluid in the lungs. It causes extreme difficulty breathing, rapid breathing, bluish skin, and feelings of restlessness, anxiety, and suffocation. Some people have severe spasms of the airways (bronchospasms) and wheezing. Acute pulmonary edema is a life-threatening emergency that can occur when people with heart failure develop very high blood pressure, have a heart attack, or sometimes just stop taking their heart failure drugs or eat salty food.
Blood clots can form in the heart chambers when the heart is severely damaged. The blood clots can form because blood flow within the chambers is sluggish. Clots may break loose (becoming emboli), travel through the bloodstream, and partially or completely block an artery elsewhere in the body. If a clot blocks an artery to the brain, a stroke may result.
Depression and decline in mental function are common in people with severe heart failure, particularly in older adults, and require careful evaluation and treatment.
Diagnosis of Heart Failure
Chest x-ray
Electrocardiography (ECG)
Echocardiography, cardiac magnetic resonance imaging (MRI), and other imaging tests
Blood tests
Doctors usually suspect heart failure on the basis of symptoms alone. The diagnosis is supported by the results of a physical examination, including a weak, often rapid pulse, reduced blood pressure, abnormal heart sounds and murmurs and fluid accumulation in the lungs both heard through a stethoscope, an enlarged heart, swollen neck veins, an enlarged liver, and swelling in the abdomen or legs.
Procedures to evaluate heart function are usually done. Testing is also needed to identify the cause of heart failure.
Chest x-ray
A chest x-ray can show an enlarged heart, and congested blood vessels and fluid accumulation in the lungs.
Electrocardiography
Electrocardiography (ECG) is almost always done to determine whether the heart rhythm is normal and to tell quickly whether a person has had a heart attack.
Echocardiography
Echocardiography, which uses sound waves to produce an image of the heart, is one of the best procedures for evaluating heart function, including the pumping ability of the heart and the functioning of heart valves. Echocardiography can show the following:
Whether the heart walls are thickened and relax normally
Whether the valves are functioning normally
Whether contractions are normal
Whether any area of the heart is contracting abnormally
Echocardiography may help determine whether heart failure is due to systolic or diastolic dysfunction by enabling doctors to estimate the thickness and stiffness of the heart walls and the ejection fraction. The ejection fraction, an important measure of heart function, is the percentage of blood pumped out by the heart with each beat. A normal left ventricle ejects about 55 to 60% of the blood in it. If the ejection fraction is low (less than 40%), systolic heart failure is confirmed. If the ejection fraction is normal or high in a person who has symptoms of heart failure, diastolic heart failure is likely.
Cardiac MRI can show more detail about certain aspects of the heart than echocardiography, including the degree of inflammation, the presence of scarring, and information about the size and function of the right ventricle.
Blood tests
Blood tests are almost always done. Doctors frequently measure natriuretic peptides. Natriuretic peptides are substances that accumulate in the blood when heart failure is present but less often when other disorders that cause shortness of breath are present. Other blood tests may be done to look for disorders that may be causing heart failure, or conditions that may be making heart failure worse or may complicate its treatment.
Other tests
Other procedures, such as radionuclide imaging, computed tomography (CT), cardiac catheterization with angiography, and exercise (stress) testing may be done to identify the presence or cause of heart failure.
Rarely, a biopsy of heart muscle is needed, usually when doctors suspect infiltration of the heart (as occurs in amyloidosis) or myocarditis due to a bacterial, viral, or other infection.
Treatment of Heart Failure
Stabilization of acute heart failure
Diet and lifestyle changes
Treatment of the cause of heart failure
Medications
Sometimes an implantable cardioverter-defibrillator, cardiac resynchronization therapy, or mechanical circulatory support
Sometimes heart transplantation
Treatment of heart failure requires several general measures, along with treatment of the disorder causing heart failure, lifestyle changes, and medications for heart failure. Most of the discussion in this section applies to left heart failure. See Right Heart Failure for more information on that topic.
Stabilization and treatment of acute heart failure
Heart failure that develops or worsens quickly requires emergency treatment in a hospital. Treatment of acute heart failure, whether a new diagnosis or the worsening of an existing disease, focuses on:
Supporting breathing and providing other life support
Identifying treatable causes
Medication and other therapy to relieve congestion and support heart function
Transitioning to long-term (chronic) management
Doctors will provide oxygen and breathing support as well as other life support measures, for people who are critically ill. Respiratory support can range from simple oxygen tubing to a breathing tube and ventilator. If the heart has stopped or is not pumping effectively, cardiopulmonary resuscitation and defibrillation may be necessary.
Doctors will also try to identify causes of acute heart failure, such as a heart attack or a heart rhythm problem, that can be treated quickly, either to make the heart failure better or prevent it from getting worse. In the case of a heart attack, this may mean a cardiac catheterization with angioplasty and stent placement. In the case a rhythm problem, this may mean treatment with a medication or an electrical shock.
In most cases, diuretic medication will be given to relieve congestion (pulmonary edema). In many cases additional medication will be given to support heart function and rapidly control high or low blood pressure. For people who have severe symptoms and have not responded well to treatments, medications that are similar to epinephrine and norepinephrine (such as dopamine or dobutamine) or other medications that make cardiac muscle contract more forcefully (such as milrinone) are sometimes used for a short time to enhance the pumping function of the heart. These medications are not useful for long-term treatment. Sometimes mechanical devices are needed to help the heart function adequately.(such as dopamine or dobutamine) or other medications that make cardiac muscle contract more forcefully (such as milrinone) are sometimes used for a short time to enhance the pumping function of the heart. These medications are not useful for long-term treatment. Sometimes mechanical devices are needed to help the heart function adequately.
The early steps of treatment may be administered very quickly or even all at the same time. Once the person's condition is stabilized, usually in the hospital setting, doctors will start their chronic heart failure treatment, which is described in the rest of this section.
Acute pulmonary edema
Acute pulmonary edema is a sudden accumulation of a large amount of fluid in the lungs. It causes extreme difficulty breathing, rapid breathing, bluish skin (or lips, tongue, and nailbeds), and feelings of restlessness, anxiety, and suffocation. Some people have severe spasms of the airways (bronchospasms) and wheezing. Acute pulmonary edema is a life-threatening emergency that can occur when people with heart failure develop very high blood pressure, have a heart attack, or sometimes just stop taking their heart failure medications or eat salty food.
If acute pulmonary edema (rapid accumulation of fluid in the lungs) develops, oxygen is given through a face mask. Diuretics given intravenously and other medications such as nitroglycerin given intravenously or under the tongue can give rapid, dramatic improvement. Morphine relieves the anxiety that usually accompanies acute pulmonary edema but it also decreases the rate of breathing and is not used often. If these measures do not adequately improve breathing, a specialized mask to deliver oxygen at controlled pressures may be used or a tube may be inserted into the person’s airway so that a mechanical ventilator can assist breathing.If acute pulmonary edema (rapid accumulation of fluid in the lungs) develops, oxygen is given through a face mask. Diuretics given intravenously and other medications such as nitroglycerin given intravenously or under the tongue can give rapid, dramatic improvement. Morphine relieves the anxiety that usually accompanies acute pulmonary edema but it also decreases the rate of breathing and is not used often. If these measures do not adequately improve breathing, a specialized mask to deliver oxygen at controlled pressures may be used or a tube may be inserted into the person’s airway so that a mechanical ventilator can assist breathing.
General measures for chronic heart failure
Although for most people heart failure is a chronic disorder, much can be done to make physical activity more comfortable, improve the quality of life, minimize the risk of sudden worsening (acute heart failure), and prolong life. Affected people and their family members should learn all they can about heart failure because much care occurs at home. In particular, they should know how to recognize the early warning symptoms of worsening heart failure and should be aware of the actions they need to take (for example, reduce salt intake, take an extra dose of a diuretic, or contact their doctor).
Regular communication with health care professionals and examinations by doctors are critical because heart failure can worsen suddenly. For example, nurses may regularly call people who have heart failure to ask about changes in weight and in symptoms. Thus, they can gauge whether people need to see a doctor.
People may also go to specialized heart failure clinics. These clinics have doctors with expertise in heart failure who work closely with specially trained nurses and other health care professionals, such as pharmacists, dietitians, and social workers, to care for people with heart failure by teaching self-care skills to people and their caregivers. These clinics can also help decrease symptoms, reduce hospitalizations, and improve life expectancy by making sure that people receive the most effective treatments and by teaching people how to fully participate in their care. This care complements rather than replaces care provided by primary care doctors.
People with heart failure should always check with their doctor before taking a new medication, even a nonprescription medication. Some medications (including many used to treat arthritis) can cause salt and fluid retention. Other medications may make the heart function less efficiently. Forgetting to take necessary medications is a common cause of worsening symptoms, and people should be given ways to remind themselves to take their medications.
Because influenza can cause a sudden worsening of a person's heart failure, doctors recommend a yearly influenza vaccination for people with heart failure. Vaccination against COVID-19 is also recommended.
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Treatment of the cause
For example, if the cause of heart failure is a narrowed or leaking heart valve or an abnormal connection between heart chambers, surgery can often correct the problem. Blockage of a coronary artery may require treatment with medications, surgery, or angioplasty with placement of a coronary stent. Antihypertensive medications can reduce and control high blood pressure. Antibiotics can eliminate some infections.
Lifestyle changes
Changes in lifestyle can help people with heart failure feel and function better.
People who have heart failure should stay as physically fit as possible, even if they cannot exercise vigorously. People who have mild heart failure should follow an exercise program as prescribed by a doctor. People with more severe heart failure may need to exercise in a cardiovascular rehabilitation facility under the supervision of a trained attendant.
If people with heart failure are overweight, the heart has to work harder during activity, worsening heart failure. Such people should follow a healthy weight loss diet to attain and maintain ideal weight.
Smoking damages blood vessels. Large amounts of alcohol can act as a direct toxin to the heart. Thus, smoking and drinking alcohol can worsen heart failure and should be stopped or at least minimized.
Excess salt (sodium) in the diet can cause fluid retention, which counteracts medications given to increase the excretion of water (such as diuretics) and relieve fluid accumulation. Thus, consuming excess salt worsens symptoms. Almost all people with heart failure should limit their intake of table salt and salty foods and their use of salt in cooking. The sodium content of packaged foods can be determined by reading the label. People with severe heart failure are usually given detailed information about how to limit salt intake. Instruction by a dietitian can be helpful. People who limit their salt intake can usually consume a normal amount of water unless fluid retention is severe. Drinking extra amounts of water is not recommended.
A simple, reliable way to check whether the body is retaining fluid is to check body weight daily. Doctors often ask people with heart failure to weigh themselves as accurately as possible every day, typically once in the morning, after they arise and urinate and before they eat breakfast. Trends are easier to spot when people weigh themselves at the same time every day, use the same scale, wear a similar amount of clothing, and keep a written record of their daily weight. Increases of more than 2 pounds (about 1 kilogram) per day are early warning signs of fluid retention. A consistent, rapid weight gain (such as 2 pounds per day) is a clue that heart failure is worsening.
Many people who limit their salt intake still have swelling. Swollen legs should be kept elevated on a stool when sitting. This position helps the body reabsorb and eliminate the excess fluid. Some people also need to wear full-length supportive stockings that help prevent accumulation of fluid. If fluid accumulates in the lungs, sleeping with several pillows or elevating the head of the bed makes sleeping easier.
Medications for chronic heart failure
Medication treatment of chronic heart failure involves:
Medications to help improve survival: Beta-blockers, angiotensin receptor/neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors
Medications to help relieve symptoms: Diuretics, digoxin, or vasodilators
The type of medication used depends on the type of heart failure. In systolic heart failure (HFrEF), all 4 medication classes shown to help improve survival are typically used. In HFmrEF, some or all may be used although they have not been shown by research to be as helpful to people. In diastolic heart failure (HFpEF), SGLT2 inhibitors are recommended for all people, diuretics for those with ongoing congestion, and other classes such as ARNIs and mineralocorticoid receptor antagonists for only some people.
It is important for people to take their medications regularly and be sure not to let the prescriptions run out.
Beta-blockers
Beta-blockers (such as carvedilol, metoprolol, and bisoprolol) are often used with angiotensin-converting enzyme (ACE) inhibitors to treat heart failure and are another mainstay of heart failure treatment. These medications block the action of the hormone Beta-blockers (such as carvedilol, metoprolol, and bisoprolol) are often used with angiotensin-converting enzyme (ACE) inhibitors to treat heart failure and are another mainstay of heart failure treatment. These medications block the action of the hormonenorepinephrine (which increases stress on the heart) and produce long-term improvement in heart function and survival. They are an essential treatment in people with systolic heart failure. Beta-blockers may reduce the force of the heart’s contractions initially, so they are usually introduced after heart failure has first been stabilized with other medications.
Angiotensin receptor/neprilysin inhibitors and related medications
Angiotensin receptor/neprilysin inhibitors (ARNIs, such as sacubitril/valsartan) are a combination medication for the treatment of heart failure. They include an angiotensin receptor blocker (ARB) and a neprilysin inhibitor. Angiotensin receptor/neprilysin inhibitors (ARNIs, such as sacubitril/valsartan) are a combination medication for the treatment of heart failure. They include an angiotensin receptor blocker (ARB) and a neprilysin inhibitor.Angiotensin II is a hormone that triggers release of aldosterone and vasopressin, both of which cause the kidneys to retain salt and water. ARBs and ACE inhibitors, which block the production or effect of angiotensin II, thus help limit fluid retention and are one of the mainstays of systolic heart failure treatment. ARBs and ACE inhibitors also reduce the workload of the heart by widening (dilating) the blood vessels. These medications not only reduce symptoms and the need for hospitalization but also prolong life. Neprilysin is an enzyme involved in the breakdown of certain substances (peptides) that signal the body to excrete sodium. By inhibiting the breakdown of these peptides, these medications lower blood pressure and increase sodium excretion, lowering the heart's workload. The combination medications prolong life better than ACE inhibitors or ARBs alone in people with systolic heart failure.
Mineralocorticoid receptor antagonists
Aldosterone is a hormone called a mineralocorticoid that causes the kidneys to retain salt and water. Mineralocorticoid receptor antagonists (such as spironolactone and eplerenone), also known as aldosterone antagonists (blockers), directly block the effects of aldosterone and help limit fluid retention. These medications improve survival and reduce hospitalization in people with heart failure. Aldosterone is a hormone called a mineralocorticoid that causes the kidneys to retain salt and water. Mineralocorticoid receptor antagonists (such as spironolactone and eplerenone), also known as aldosterone antagonists (blockers), directly block the effects of aldosterone and help limit fluid retention. These medications improve survival and reduce hospitalization in people with heart failure.
Sodium-glucose cotransporter-2 inhibitors (SGLT2s)
Sodium-glucose cotransporter-2 inhibitors (such as empagliflozin, dapagliflozin, and sotagliflozin) are used in the treatment of Sodium-glucose cotransporter-2 inhibitors (such as empagliflozin, dapagliflozin, and sotagliflozin) are used in the treatment ofdiabetes. In addition to lowering the blood sugar (glucose) level in the blood, they also have beneficial effects on the heart muscle and blood vessels. One medication in this class, dapagliflozin, was shown to decrease heart failure symptoms and improve quality of life in people with systolic heart failure. Another medication in this class, empagliflozin, was shown to reduce hospitalizations for diastolic heart failure.. In addition to lowering the blood sugar (glucose) level in the blood, they also have beneficial effects on the heart muscle and blood vessels. One medication in this class, dapagliflozin, was shown to decrease heart failure symptoms and improve quality of life in people with systolic heart failure. Another medication in this class, empagliflozin, was shown to reduce hospitalizations for diastolic heart failure.
Diuretics
Diuretics ("water pills") are often prescribed when salt restriction alone does not reduce fluid retention. These medications help the kidneys eliminate salt and water by increasing urine formation and thus decreasing fluid volume throughout the body.
Loop diuretics, such as furosemide, torsemide, or bumetanide, are the diuretics most commonly used for heart failure. These diuretics are usually taken by mouth on a long-term basis, but in an emergency, they are very effective when given intravenously. Loop diuretics are preferred for moderate to severe heart failure. such as furosemide, torsemide, or bumetanide, are the diuretics most commonly used for heart failure. These diuretics are usually taken by mouth on a long-term basis, but in an emergency, they are very effective when given intravenously. Loop diuretics are preferred for moderate to severe heart failure.
Thiazide diuretics, such as hydrochlorothiazide, which have milder effects and can lower blood pressure, may be prescribed particularly for people who also have high blood pressure. such as hydrochlorothiazide, which have milder effects and can lower blood pressure, may be prescribed particularly for people who also have high blood pressure.
Loop and thiazide diuretics can cause potassium to be lost in the urine, resulting in hypokalemia. Consequently, a diuretic that causes potassium levels to increase (a potassium-sparing diuretic) or a potassium supplement may be given as well. For all people with heart failure, spironolactone is the preferred potassium-sparing diuretic and can be used unless kidney function is severely reduced. It can prolong life in people with heart failure. . Consequently, a diuretic that causes potassium levels to increase (a potassium-sparing diuretic) or a potassium supplement may be given as well. For all people with heart failure, spironolactone is the preferred potassium-sparing diuretic and can be used unless kidney function is severely reduced. It can prolong life in people with heart failure.
Taking diuretics can worsen urinary incontinence. However, a dose of a diuretic can usually be timed so that the risk of incontinence does not occur when a bathroom is unavailable or when access to one is inconvenient.
Other medications used for chronic heart failure
Other medications are sometimes helpful.
DigoxinDigoxin, one of the oldest treatments for heart failure, increases the force of each heartbeat and slows a heart rate that is too rapid. Digoxin helps relieve symptoms for some people with systolic heart failure but, unlike other heart failure medications discussed here, it does not prolong life. Doctors have also tried using medications besides digoxin that increase the heart's pumping power, but thus far, none have proved helpful and some increase risk of death.
The sinus node is the part of the heart that triggers the beat and sets the heart rate. Sinus node inhibitors, such as ivabradine, slow down the rate of the sinus node. Slowing the heart reduces the workload of the heart and can help reduce how often certain people with heart failure need to be hospitalized., such as ivabradine, slow down the rate of the sinus node. Slowing the heart reduces the workload of the heart and can help reduce how often certain people with heart failure need to be hospitalized.
Vasodilators (medications that widen blood vessels) make it easier for the heart to pump blood. These medications include hydralazine, isosorbide dinitrate, and nitroglycerin patches or spray. People who do not respond to or cannot take ARNIs, ACE inhibitors, or ARBs can benefit from vasodilators. In some people with advanced symptoms, these medications may improve quality and quantity of life when added to ARNIs.(medications that widen blood vessels) make it easier for the heart to pump blood. These medications include hydralazine, isosorbide dinitrate, and nitroglycerin patches or spray. People who do not respond to or cannot take ARNIs, ACE inhibitors, or ARBs can benefit from vasodilators. In some people with advanced symptoms, these medications may improve quality and quantity of life when added to ARNIs.
If the heart rhythm is abnormal, antiarrhythmic medications (see table Some Medications Used to Treat Arrhythmias) may be given.
Other measures for acute and chronic heart failure
Sometimes doctors implant a small monitoring device in the chest of people with severe heart failure. The monitor continuously measures the pressures in their lungs, which can help their doctor make adjustments to their medications. The device is especially useful in people with recurrent episodes of heart failure and coexisting kidney failure.
Heart transplantation may be an option for people who have very severe, worsening heart failure and who have not responded to medications.
Mechanical devices that help pump blood are used for certain people with very severe heart failure that is not responding to medications. Types of devices include:
Intra-aortic counterpulsation balloon pump (IABP, also sometimes just called a balloon pump): A sausage-shaped balloon on the end of a catheter is placed in the aorta. A machine monitors the heart beat and inflates the balloon when the heart relaxes and deflates it when the heart contracts, which makes it easier for the heart to pump blood.
Ventricular assist devices: Different mechanical pumps can be implanted in or near the left or right ventricle to help the heart pump blood.
Intravascular assist devices: Small pumps can be implanted within large vessels such as the aorta to help pump blood.
Extracorporeal membrane oxygenation (ECMO): A device similar to a heart-lung bypass machine takes blood from a large artery and pumps it past a membrane that allows oxygen into the blood and then pumps it back into a large vein.
Heart rhythm problems can sometimes be helped with medications, but some people require a pacemaker. One type of pacemaker with 2 or 3 wires can restore the normal sequence of heart chamber contractions (cardiac resynchronization therapy) and improve outcome in some people with heart failure. Doctors may consider an implantable cardioverter-defibrillator in people with very poor heart function because their risk of sudden death is increased.
If heart failure is caused by a problem with a heart valve, doctors may repair or replace the valve.
End-of-life issues
Life expectancy depends on many factors, including how severe the heart failure is, whether its cause can be corrected, and which treatment is used. However, once people have needed to be hospitalized for heart failure, only about 1 in 3 live another 5 years. Life expectancy does improve with treatment.
Eventually, for a person whose heart failure has been present for some time, quality of life deteriorates and the possibilities for further treatment may become limited, especially for an older adult for whom heart transplantation may not be feasible. Keeping the person comfortable may eventually become more important than trying to prolong life. The person and the family members should be involved in these decisions. In fact, many studies show that people with severe heart failure and their families want to discuss these issues and that doing so does not cause undue distress. Much can be done to provide compassionate care, relieve symptoms, and maintain the person’s dignity (see Death and Dying).
Heart failure can cause death suddenly and unexpectedly, without symptoms worsening. Consequently, when possible, people who have heart failure should prepare advance directives about the type of care desired in case they are no longer able to make decisions about their care. Also, making or updating a will is important.
Prevention of Heart Failure
Preventing heart failure involves treating disorders that can cause heart failure before they lead to heart failure. Disorders that can be treated include the following:
High blood pressure
Obesity
Obstructive sleep apnea
Blockage of a coronary artery
Heart valve disorders
Some abnormal heart rhythms
Alcohol use disorder (or heavy alcohol use)
Anemia
Thyroid disorders
More Information
The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.
