Heart failure does not mean that your heart has stopped or is going to stop at any minute. It means that your heart is not functioning as well as it should. Heart failure can be caused by many different conditions. Symptoms include fluid retention, breathlessness and tiredness. Medication can usually ease symptoms and can often improve the outlook.
What is heart failure?
In a normal healthy heart, during each heartbeat a set amount of blood enters the heart and is pumped out again. If you have heart failure, your heart cannot cope with pumping the full amount of blood in each heartbeat.
Heart failure is divided into types according to how suddenly it has come on. It is called acute heart failure if it has made you unwell quite suddenly. If the symptoms have been going on for some time, it is called chronic heart failure. As a general rule, you will often be admitted to hospital if you have acute heart failure, whereas if you have chronic heart failure you will probably have tests done as an outpatient. If you have chronic heart failure, it is possible to develop acute heart failure if matters suddenly become worse.
Heart failure is also divided into types depending on how much blood the heart manages to pump out in each heartbeat. The term ejection fraction means the amount (percentage or fraction) of the blood in the biggest chamber of the heart (the left ventricle) that is pumped out (ejected) with each heartbeat before it fills up again for the next beat. It is normal for some of the blood to be left behind with each beat but usually at least half the blood is pumped out with every beat. If less than 40% of the blood is pumped out, this is called heart failure with reduced ejection fraction. If more than 40% is pumped out, it is called heart failure with preserved ejection fraction. Distinguishing between the two is important as it will affect the treatment which is used.
For further information about the heart itself, see the leaflet called Anatomy of the heart.
How common is heart failure?
About 920,000 people in the UK currently have heart failure.There are around 67,000 admissions to hospital for heart failure in England and Wales each year. Heart failure becomes more common as people become older. It is commonly diagnosed in people in their 70s. In the UK around one in seven people aged 85 or more have heart failure. In people aged 65-74, around one in 35 have heart failure.
What causes heart failure?
Heart failure is not an exact term. Heart failure is a general umbrella term and may develop as a complication of various conditions. Conditions that cause heart failure affect the ability of the heart to function well as a pump. Conditions that may cause heart failure include the following:
Coronary heart disease (CHD)
CHD is the most common, or main, cause of heart failure. In this condition, the blood flow to the heart muscle is reduced by narrowing of the coronary arteries that supply the heart muscle with blood and oxygen - eg, as a result of atheroma. (Atheroma are small fatty lumps which develop within the inside lining of arteries.) The heart muscle may then not function as well as normal. Other symptoms of CHD may occur, such as having heart pains (angina). CHD is common in the UK and heart failure is a complication that occurs in some cases.
In particular, heart failure may develop after a heart attack (myocardial infarction). A heart attack is a complication of CHD and causes part of the heart muscle to die. Scar tissue forms in the affected part of the heart muscle. The larger the heart attack (and area of scar tissue), the more the function of the heart is affected. See the separate leaflet called Heart Attack (Myocardial Infarction) for more details.
Various other conditions can also cause heart failure - for example:
- Diseases of the heart muscle (cardiomyopathy).
- High blood pressure (hypertension).
- Diseases of the heart valves.
- Some types of abnormal heart rhythms (arrhythmias).
- Medicines and other chemicals that may damage the heart muscle - for example, alcohol excess, cocaine and some types of chemotherapy.
- Various non-heart conditions that can affect the function of the heart - for example, severe anaemia, thyroid disease (hypothyroidism or hyperthyroidism) and Paget's disease of bone. Sometimes it can be caused by a lack of certain nutrients - for example, vitamins such as thiamine.
Sometimes the cause of heart failure is not known.
The cause will often have an effect on the type of heart failure (eg, reduced or preserved ejection fraction), the treatment, and whether or not it can be cured.
What are the symptoms of heart failure?
Symptoms of heart failure can vary. The most common symptoms are:
- Feeling breathless. This may occur when you exert yourself, when you lie flat, or even wake you when you are asleep.
- Retaining fluid. Most commonly this shows as swollen ankles. It can also cause swelling of your legs, bottom or tummy.
- Feeling tired
Other symptoms include:
- Having a cough.
- Feeling light-headed or dizzy or having fainting spells.
- Losing your appetite.
Depending on the underlying cause for the heart failure, you may also have other symptoms. For example, chest pains if you have angina, the sensation of having a 'thumping heart' (palpitations) if you have a heart rhythm problem, etc.
The severity of heart failure is often graded into four classes or stages:
- Class 1 (very mild) - ordinary physical activity does not cause breathlessness, extreme tiredness (fatigue), or palpitations. You may not have any symptoms at all. However, tests (perhaps done for other reasons) may have detected mild heart failure.
- Class 2 (mild) - you are comfortable at rest. However, ordinary physical activity such as walking causes some breathlessness, fatigue, or palpitations.
- Class 3 (moderate) - although comfortable at rest, slight physical activity such as dressing yourself causes breathlessness, fatigue, or palpitations.
- Class 4 (severe) - you are unable to carry out any physical activity without developing breathlessness, fatigue, or palpitations. Symptoms are often present even at rest. With any physical activity you have increased symptoms and discomfort.
How is heart failure diagnosed?
When a doctor examines you, he or she may find signs that occur with heart failure - for example:
- An enlarged heart.
- A faster than normal pulse.
- Signs of fluid retention (such as swollen ankles, an enlarged liver or crackles in the lungs when the chest is examined).
However, these signs and the symptoms mentioned above can be due to various conditions other than heart failure. If heart failure is suspected, tests are usually done to confirm the diagnosis. A blood test is usually done to measure a chemical called B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP). BNP is a hormone that helps to keep blood volume at a steady level. These substances are increased in heart failure, and the higher they are, the more severe the heart failure is likely to be. However, they can be high in other conditions also. You will usually also have a 'heart tracing' (electrocardiogram, or ECG).
If your own doctor suspects that you may have heart failure then you are likely to be referred to a specialist heart failure clinic at a hospital. If you are very unwell (if you have acute heart failure), you would be sent to hospital straightaway. Otherwise you are usually referred to be seen by a specialist within 2 or 6 weeks, depending on how high your BNP level is.
The specialist heart failure team will arrange an ultrasound scan of the heart (echocardiogram). This painless test can usually confirm the presence of heart failure and can often diagnose the cause of the heart failure. It also will measure the ejection fraction explained above, to determine which type of heart failure you have. Other tests such as a chest X-ray, a urine test or other blood tests may also be advised to rule out other causes of the symptoms.
What can I do to help?
- Diet. Weight should be within a healthy range (BMI 18.5 to 25). If you are overweight, try to lose weight to reduce the extra burden on your heart. If you are underweight, your specialist or GP may refer you to a dietician for advice about nutritional supplements.
- Do not smoke. The chemicals in tobacco cause blood vessels to narrow, which can make heart failure worse. Smoking can also make CHD worse. You may benefit from being referred to a local 'stop smoking' clinic if you are finding it hard to stop smoking.
- Exercise. For most people with heart failure, regular low-intensity exercise is advised. Exercise cannot reverse heart failure, but the fitter the heart, the better it will pump. The level of exercise to aim for will vary from person to person. Before you start to increase your exercise, get advice from your specialist, as some people with heart valve problems or more severe heart failure may not be able to do some forms of exercise. You may also be referred for a specialised heart failure rehabilitation programme which may include exercise.
- Immunisation. You should have an annual influenza jab and be immunised against the pneumococcal germ (bacterium).
- Weigh yourself regularly if you have moderate-to-severe heart failure. Your specialist will advise if you need to do this and if so, how often you should weigh yourself. If you retain fluid rapidly, your weight goes up rapidly too. So, if your weight goes up by more than 2 kg (about 4 lb) over 1-3 days, you should contact a doctor. You may need an increase in your medication.
- Alcohol. You should not exceed the recommended amount of alcohol, as more than the recommended upper limits can be harmful.
Can heart failure be cured?
In most people heart failure cannot be cured, but the symptoms and outlook can be improved with the right treatment. In some cases, however, where heart failure is due to a cause that can be reversed (for example, anaemia or a faulty heart valve that can be replaced) then heart failure can be cured or reversed. In most people, where the cause is a structural problem with the heart which can't be reversed (such as damage after a heart attack), heart failure cannot be reversed. However, the symptoms can be very much improved with the right treatment - discussed further below. The treatment used will depend on whether ejection fraction is reduced or preserved. Usually treatment is with one or more types of pills.
What medicines are used to treat heart failure?
The following medications are commonly used to treat heart failure. They will be tailored to the individual person, depending on the type, cause and severity of the heart failure.
Angiotensin-converting enzyme (ACE) inhibitors
Most people with heart failure are prescribed a type of pill called an ACE inhibitor. There are a number of different ones - common options include lisinopril and ramipril. ACE inhibitors also have a protective effect on the heart and may slow down the progression of heart failure. See the separate leaflet called ACE Inhibitors to read about these medicines.
Medicines called angiotensin-II receptor antagonists (or angiotensin receptor blockers) work in a similar way to ACE inhibitors. One may be used instead of an ACE inhibitor if you have problems or side-effects with taking an ACE inhibitor (such as a persistent cough). Examples are candesartan, losartan and valsartan.
A beta-blocker medicine such as bisoprolol or carvedilol is usually prescribed in addition to an ACE inhibitor. Like ACE inhibitors, beta-blockers have a protective effect on the heart. A low dose is started at first and then increased every few weeks until a regular dose is reached. See the separate leaflet called Beta-blockers for more information.
Research studies have shown that ACE inhibitors and beta-blockers not only help to ease symptoms but can improve the outlook and extend life expectancy for people with heart failure. Therefore, even if your symptoms go, you should continue to take these medicines if they are prescribed.
'Water tablets' (diuretics)
A diuretic is commonly needed to ease fluid retention. This is taken in addition to an ACE inhibitor and beta-blocker. Diuretics make you pass out extra urine. This helps to clear excess body fluid that builds up. There are different types and brands of diuretics. See the the separate leaflet called Loop Diuretics for more information, or the leaflet with the name of the specific type of diuretic you are prescribed.
Mineralocorticoid/aldosterone receptor antagonists (MRAs)
These medicines, such as spironolactone and eplerenone, also prevent the build-up of fluid. They interfere with the enzyme angiotensin which is involved in regulating body fluid. Research has shown that they improve your outlook. They may reduce your risk of needing to be in hospital and may extend your life expectancy. If your kidney function is not good, you may not be able to take these medicines. Regular blood tests are used to monitor how your kidneys are coping.
Ivabradine and sacubitril valsartan can be used by heart failure specialists for people with moderate or severe heart failure. Research has shown that people taking these medicines have a reduced risk of worsening heart failure, hospital admission and death compared with those who do not take them. One of the main effects of ivabradine is to reduce the heart rate, which may have a protective effect on the heart.
Taking fish oil supplements (a high-quality fish oil supplement containing 90% omega-3 polyunsaturated fatty acid ethyl esters, called Omacor®) has also been shown in past studies to possibly reduce the risk of worsening heart failure and death compared with those who did not take it. It is thought the fish oils may help to regulate heart rate and may have some effect on easing the workload on the heart. Recent studies have shown a less clear benefit however, so guidelines at this time do not recommend routine use of fish oil supplements.
Other medications are also used for some cases. For example, aspirin may be advised for people who have had a heart attack in the past. Anticoagulants may be advised for those who have had a clot in the past. Digoxin may be useful in some specific situations. Your specialist will be able to give you more information if you need additional medications.
Note: it is very important that you take the tablets that have been prescribed for you. You should discuss with your doctor if you stop taking any of your tablets.
Devices for heart failure
Various devices are implanted in a small number of people with heart failure. Examples include implantable cardioverter defibrillators (ICDs) and pacemakers.
ICDs work by detecting any abnormal heart rhythms that may occur. If your heart rhythm is too slow, the device can give your heart extra support by working as a normal pacemaker. If your heart beats too fast, the ICD can give you a burst of extra beats at a slightly faster rate which should return your heart back to a normal rhythm, or it can give you a shock (defibrillation) to restore a regular heartbeat.
Pacemakers work differently. In some cases, there is some damage to the specialised heart cells that carry the signals needed for your heart to squeeze (contract) properly. This can then cause the signals to travel out of synch which leads to your heart pumping less forcefully and less efficiently. The pacemakers work to control these signals so the heart can then beat more effectively. This is also known as cardiac resynchronisation therapy.
These different devices have dramatically altered the treatment of heart failure in selected cases and have improved both the outlook and quality of life. However, these devices are only suitable for certain people with heart failure. Your doctor will be able to discuss with you in more detail if you are suitable for one of these devices.
As mentioned above, heart failure usually develops as a complication of various conditions. Other treatments for the underlying condition may be advised in certain cases. For example:
- Treatment to lower blood pressure if you have high blood pressure (hypertension).
- Treatments to slow down the progression of CHD if this is the cause of the heart failure. For example, lowering a high cholesterol level.
- Surgery to replace or fix a heart valve may be done if a damaged heart valve is the cause of the heart failure.
- A heart transplant is an option in some cases.
What is the outlook?
It is difficult to give an outlook (prognosis) for an individual. It depends on the cause of the heart failure, whether you have other medical conditions, and how severe it is. Speak to your specialist about your individual case. In general, the more severe the heart failure, the worse the outlook. In many cases, the symptoms remain at a stable level for quite some time (months or years) before becoming worse. In some cases, where there is a reversible cause, heart failure can get completely better. In some cases, the severity and symptoms become gradually worse over time. Sadly in some cases, heart failure can be fatal. About half of those diagnosed with heart failure die within five years of the diagnosis.
If symptoms become very severe, and are not responding well to treatment, this is known as 'end-stage heart failure'. In this situation, palliative care (often at home) from a team of different health professionals may be helpful. The priority in this situation is keeping the person comfortable, and alleviating symptoms as much as possible. A person diagnosed with end-stage heart failure is likely to die over the following 6 to 12 months.
Over recent years, various new treatments have been introduced which have led to a much improved outlook for people with heart failure. Studies are ongoing to establish which treatment options improve outlook the most.
Further reading and references
; NICE Guidance (Sept 2018)
; NICE Clinical Guidelines (Oct 2014)
; European Society of Cardiology (ESC)
; Scottish Intercollegiate Guidelines Network - SIGN (2016)
; NICE CKS, January 2017 (UK access only)
; NICE Technology Appraisal Guidance, June 2014
; Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev. 2018 Jun 286:CD012721. doi: 10.1002/14651858.CD012721.pub2.
; British Society for Heart Failure, Published August 2017
; The Role of Omega-3 Polyunsaturated Fatty Acids in Heart Failure: A Meta-Analysis of Randomised Controlled Trials. Nutrients. 2016 Dec 309(1). pii: nu9010018. doi: 10.3390/nu9010018.
; Advances in the management of heart failure: the role of ivabradine. Vasc Health Risk Manag. 2016 Nov 1712:453-470. doi: 10.2147/VHRM.S90383. eCollection 2016.
; Sacubitril/Valsartan (LCZ696) in Heart Failure. Handb Exp Pharmacol. 2017243:133-165. doi: 10.1007/164_2016_77.
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