Understanding Heart Failure

What is heart failure?

Heart failure does not mean that your heart has stopped working. Heart failure means the left ventricle (lower chamber of the heart) is not pumping with enough force (systolic heart failure), or the ventricles are stiff and do not relax and fill properly (diastolic heart failure or heart failure with preserved pumping power).

With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. Therefore, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart respond by stretching to hold more blood to pump through the body or by becoming thicker and stiffer. This helps to keep the blood moving for a short while, but then the heart muscle walls weaken and are not able to pump as strongly. The heart muscle walls are damaged and do not pump or fill normally. The kidneys often respond by causing the body to retain fluid (water) and sodium.

If fluid builds up in the arms, legs, ankles, feet, lungs or other organs, the body becomes congested; congestive heart failure is the term used to describe this condition.

What are the symptoms of heart failure?

You may not have any symptoms of heart failure, or the symptoms may be mild to severe. Symptoms can be constant, or can come and go. The symptoms are related to the changes that occur in your heart and body, including:

  • Shortness of breath or difficulty breathing with exercise, at rest, or when lying flat in bed. Shortness of breath occurs when fluid backs up into the lungs (congestion) or when your body does not have enough oxygenated blood to allow you to continue your activity or exercise without a rest period. Even though you think of shortness of breath as a lung problem, it can be your heart condition that causes episodes of shortness of breath. In some cases, these symptoms may cause you to wake up suddenly at night, disrupting your normal sleep patterns.
  • A dry, hacking cough or wheezing.
  • Swollen ankles, legs and abdomen and weight gain. Less blood to the kidneys causes fluid and water retention, resulting in edema (swelling) and water weight gain.
  • Need to urinate while resting at night. This occurs because while lying down more blood gets to the kidneys due to gravity.
  • Tiredness (fatigue) and weakness during exercise or activities occur because the heart is not pumping enough oxygen-rich blood to major organs and muscles.
  • Dizziness, confusion, difficulty concentrating, or fainting may occur  because the heart is not pumping enough oxygen-rich blood to the brain.
  • Rapid or irregular heartbeats (palpitations): When the heart muscle does not pump well, the heartbeat speeds up to help the heart get enough oxygen-rich blood to major organs and muscles. An abnormal heartbeat can occur from many problems, including an enlarged heart, not enough oxygen-rich blood to the heart muscle, and too much volume or pressure in the heart. In addition, heart failure causes the electrical conduction system in the chambers of the heart to be sensitive, leading to abnormal heartbeats.

Other symptoms include a feeling of fullness (bloating) in your stomach, loss of appetite or nausea.

If you have heart failure, you may have one or all of these symptoms. Sometimes, people with heart failure do not have any symptoms.

What are the types of heart failure?

Systolic left ventricular dysfunction (or systolic heart failure) occurs when the left ventricle heart muscle doesn’t contract with enough force, so less oxygen-rich blood is pumped throughout the body.

Heart failure with preserved left ventricular function (diastolic heart failure) occurs when the heart contracts normally, but the ventricles do not relax properly or are stiff and less blood enters the heart during normal filling.

A test called the ejection fraction (EF) is used to measure how well your heart pumps with each beat to determine if systolic dysfunction or heart failure with preserved left ventricular function are present. Your doctor or nurse can discuss which condition is present in your heart.

How common is heart failure?

Heart failure affects an estimated 5.7 million Americans, and about 670,000 people are diagnosed with heart failure each year. Heart failure is the leading cause of hospitalization in people over age 65.

What is ejection fraction?

Ejection fraction (EF) is the measurement of how much blood is being pumped out of the left ventricle of the heart. It is reported as a percentage. Healthy hearts have an EF of 60-75%. Heart failure can occur due to a weakened heart muscle (systolic heart failure) or may be related to a stiff, inflexible heart muscle (diastolic heart failure). In diastolic heart failure, the EF can be normal (preserved ventricular function), but the stiff heart muscle causes increased pressure inside the heart and lungs, leading to symptoms.

Women and heart failure

Heart failure affects about 2.5 million women in the United States. Women tend to develop heart failure with preserved left ventricular function and with a more normal ejection fraction than men. Heart failure in women is often linked to high blood pressure, coronary artery disease, valve disease and diabetes.

Although the signs and symptoms of heart failure are the same among men and women, women tend to have more symptoms of lower exercise ability and shortness of breath than do men. Women also have ankle swelling more frequently than do men.

In general, women with heart failure live longer than men with heart failure.

What causes heart failure?

Heart failure is caused by many things that damage the heart muscle, including:

  • Coronary artery disease (also called coronary atherosclerosis) — a disease of the arteries that supply blood and oxygen to the heart. Coronary artery disease occurs when the normal lining of the arteries breaks down, the walls of the arteries thicken and deposits of fat and plaque block the flow of blood through the arteries. The arteries that supply blood to the heart become very narrowed and the heart can no longer respond to increased activity. Extra strain on the heart may result in chest pain (angina pectoris) and other symptoms of heart disease.
  • Heart attack — occurs when a coronary artery becomes blocked, stopping the flow of blood to the heart muscle and damaging it. All or part of the heart muscle becomes cut off from its supply of oxygen. A heart attack can damage the heart muscle, resulting in a scarred area which does not function.
  • Cardiomyopathy — damage to the heart muscle from causes other than artery or blood flow problems. Causes include viruses, alcohol or drug abuse, and genetics.
  • Heart defects present at birth
  • Diabetes
  • High blood pressure (hypertension) — Blood pressure is the force of blood pushing  against blood vessel walls. High blood pressure means the pressure in the arteries is above the normal range.
  • Arrhythmia (abnormal heart rhythms)
  • Kidney disease
  • Obesity (being overweight)
  • Medications — some chemotherapy agents

Heart failure often occurs when several diseases or conditions are present at once.

How is heart failure treated?

Together, you and your doctor or nurse will discuss your treatment options. Your doctor or nurse will determine which treatment methods are right for you. Heart failure management is a team effort, and you are the key player on the team.

Your heart doctor or nurse will prescribe your medications and manage other medical problems. Other team members, including nurses, dietitians, pharmacists, exercise specialists and social workers, will help you achieve success. Most important, it is up to YOU to take your medications, make dietary changes, live a healthy lifestyle, keep your follow-up appointments, and be an active member of the team.

What is the outlook?

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

Everyone with a long-term illness, such as heart failure, should discuss their desires for extended medical care with their doctor and family. An “advance directive” or “living will” is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are well in case you are unable to make these decisions at a later time.

Stage A
Definition of Stage

People at high risk of developing heart failure (pre heart failure), including people with:

  • Hypertension
  • Diabetes
  • Coronary artery disease
  • Metabolic syndrome
  • History of cardiotoxic drug therapy
  • History of alcohol abuse
  • History of rheumatic fever
  • Family history of cardiomyopathy
  • History of taking drugs that can damage heart muscle (e.g., some anti-cancer agents).
Usual Treatments
  • Exercise regularly
  • Quit smoking
  • Treat hypertension (medication and low-sodium diet)
  • Treat lipid disorders (cholesterol)
  • Discontinue alcohol or illegal drug use
  • An angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) is prescribed if you have coronary artery disease, or if you have diabetes, high blood pressure or other vascular or cardiac conditions
  • Beta-blockers may be prescribed if you have high blood pressure
Stage B
Definition of Stage

People diagnosed with systolic left ventricular dysfunction but who have never had symptoms of heart failure (pre heart failure) including people with:

  • Prior heart attack
  • Valve disease
  • Cardiomyopathy

The diagnosis is usually made when an ejection fraction of less than 40% is found during an echocardiogram test.

Usual Treatments

Treatment methods above for Stage A apply

  • All patients should take an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB)
  • A beta-blocker and an aldosterone inhibitor (eplerenone) should be prescribed after a heart attack
  • Surgery or interventional options for coronary artery blockage, heart attack, and valve repair or replacement (as appropriate) should be discussed
Stage C
Definition of Stage

Patients with known systolic heart failure and current or prior symptoms.

Most common symptoms include:

  • Shortness of breath
  • Fatigue
  • Reduced ability to exercise
Usual Treatments

Treatment methods above for Stage A apply

  • An angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker and a beta-blocker will be prescribed
  • Hydralazine/nitrate combination may be prescribe if symptoms persist
  • Diuretics (water pills) and digoxin may be prescribed if symptoms persist
  • An aldosterone inhibitor may be prescribed when symptoms remain severe with other therapies
  • Restrict dietary sodium (salt)
  • Monitor weight
  • Restrict fluids (as appropriate)
  • Drugs that worsen the condition should be discontinued
  • As appropriate, cardiac resynchronization therapy (biventricular pacemaker) may be recommended
  • An implantable cardiac defibrillator (ICD) may be recommended
Stage D
Definition of Stage

Patients with systolic heart failure and presence of advanced symptoms after receiving optimum medical care.

Usual Treatments

Treatment methods for Stages A, B & C apply

Patient should be evaluated to determine if the following treatments are available options:

  • heart transplant
  • ventricular assist devices
  • surgery options
  • research therapies
  • continuous infusion of intravenous inotropic drugs and end-of-life (palliative or hospice) care

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional written health information, please contact the Health Information Center at the Cleveland Clinic (216) 444-3771 or toll-free (800) 223-2273 extension 43771 or visit www.clevelandclinic.org/health/.

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