Heart Failure

Heart failure occurs when disease, injury, or prolonged strain hampers the heart’s ability to pump blood effectively. This condition sets off a chain reaction of physiological changes, ultimately leading to a reduced supply of blood to various parts of the body.

Despite the alarming name, “heart failure” doesn’t imply a sudden or total stop of the heart. Rather, it refers to a gradual decline in the heart’s ability to pump blood efficiently.

What is heart failure?

Heart failure is a condition where the heart cannot pump blood effectively to meet the body’s needs. Previously called “congestive heart failure (CHF),” this term highlighted the fluid buildup in the lungs (congestion), a common symptom of reduced heart function. However, “heart failure (HF)” is now the preferred term as it better reflects the wide range of symptoms that can occur.

Heart failure doesn’t mean the heart has stopped working entirely. Instead, it causes blood to back up in the veins leading to the heart, leading to fluid retention by the kidneys and swelling in the body’s tissues, particularly the legs. In some cases, fluid also accumulates in the lungs, causing breathing difficulties.

Heart failure can affect the entire heart or just one side—left or right. Most cases involve left-sided heart failure, where the left ventricle (the heart’s largest chamber) is either too weak or stiff to function properly.

Heart failure with reduced ejection fraction (HFrEF) occurs when the left ventricle weakens and cannot pump blood as forcefully.
Heart failure with preserved ejection fraction (HFpEF) happens when the heart muscle becomes thick and stiff, preventing the left ventricle from filling properly between beats.
Heart failure with mid-range ejection fraction (HFmEF) is a mix of both, where the heart is somewhat stiff and doesn’t pump as forcefully, with an ejection fraction between 40% and 49%.

Heart failure symptoms

Many symptoms of heart failure are often mistaken for signs of aging, such as fatigue, shortness of breath when climbing stairs, or a reduced ability to exercise. As heart failure progresses, shortness of breath and wheezing become more prominent, even during simple activities like walking. In later stages, breathing difficulties may occur even at rest.

Fluid buildup in the lungs may cause people with heart failure to sleep propped up on pillows to breathe easier. A persistent cough or wheezing may also occur due to fluid accumulation in the lungs.

Swelling in the legs and ankles is another common symptom. In less active individuals, fluid can accumulate around the abdomen. Some people may experience frequent nighttime urination as the kidneys attempt to flush out excess fluid. As fluid builds up, significant weight gain can also occur.

How is heart failure diagnosed?

Heart failure typically affects both sides of the heart, but in some cases, only one side may be impacted. Left-sided heart failure is more likely to cause breathing problems, while right-sided heart failure may lead to swelling in the legs and abdomen.

A standard heart failure evaluation includes blood tests, a chest x-ray, and an echocardiogram (an ultrasound of the heart). The echocardiogram is especially important for assessing whether the heart muscles have weakened or stiffened, which helps guide treatment options.

The ejection fraction (EF) is measured by the echocardiogram to determine the percentage of blood pumped out of the left ventricle with each contraction. A healthy heart has an EF of 50% to 70%.

People with HFrEF (weakened heart muscle) typically have an EF of less than 40%.
In HFpEF, the ejection fraction remains normal (50% or higher), but the heart’s stiffness prevents it from relaxing properly and filling with blood.
HFmEF presents an intermediate EF of 40% to 49%, showing characteristics of both heart stiffness and reduced pumping power.

Men are more likely to develop HFrEF, while women, particularly older women, are more prone to HFpEF. Both types share similar symptoms, including fatigue, shortness of breath, difficulty with physical activity, nighttime breathing problems, and swelling in the lower body.

What causes heart failure?

Several underlying conditions can lead to heart failure, including:

Coronary artery disease
High blood pressure (hypertension)
Heart valve disorders (e.g., rheumatic heart disease)
Congenital heart defects
Cardiomyopathy (heart muscle disease)
Heart attack
Cardiac arrhythmias (abnormal heart rates or rhythms)
Exposure to toxins, such as excessive alcohol
Other factors, like hyperthyroidism, diabetes, and long-term lung disease, can also increase the risk of heart failure.

How is heart failure treated?

The goals of heart failure treatment are to:

Alleviate symptoms
Reduce hospitalizations
Extend life expectancy

To achieve these goals, doctors often recommend a low-sodium diet and prescribe medication. Treatment options for HFrEF include:

Diuretics to remove excess fluid by increasing urine output
ACE inhibitors or angiotensin receptor blockers to reduce the heart’s workload
Beta-blockers to slow the heart rate and improve efficiency
Potassium-sparing diuretics, which can extend life when taken in low doses
A combination drug of sacubitril and valsartan (Entresto), which can reduce hospitalizations and improve survival
SGLT2 inhibitors, which help the heart function more effectively

For HFpEF, treatment options are more limited. The focus is on controlling blood pressure and using diuretics as needed. Recent research suggests that adding SGLT2 inhibitors can help alleviate symptoms and reduce hospitalizations.

Addressing the underlying cause of heart failure is also essential. For example, heart failure related to coronary artery disease may require additional medications, angioplasty, or surgery. If a malfunctioning heart valve is the culprit, surgical repair or replacement may be necessary.

In some cases, lifestyle changes, such as losing weight or quitting alcohol, can significantly improve symptoms. Balancing exercise with adequate rest is also crucial, especially in advanced stages of heart failure.

When medications and self-care are no longer effective, a left ventricular assist device or a heart transplant may be considered.