What Are Symptoms, Causes and Treatments for Heart Failure?

The average heart pumps 2,000 gallons of blood per day to provide oxygen to nourish cells in the body. Heart failure happens when the heart’s lower chambers, the left and right ventricles, have problems pumping blood to meet the body’s needs.

Doctors can measure how well the heart pumps blood, called ejection fraction. This is a measure of the percentage of blood pumped out of the heart into the body with every beat. A normal ejection fraction, or EF, is 55 to 60%.

Heart failure most often involves the left ventricle, the main pumping chamber of the heart. There are two types of left-sided heart failure:

Systolic heart failure: This occurs when the left ventricle is weak and does not contract properly, making it difficult to pump blood forward into the body. This condition is defined as an ejection fraction less than or equal to 40% and is referred to as systolic heart failure, also known as heart failure with reduced ejection fraction (HFrEF).

Diastolic heart failure: This occurs when the left ventricle becomes stiff. This stiffness makes it difficult for the heart to fill with oxygen-rich blood during the resting period between heartbeats. This can lead to fluid backing up into the lungs which can cause shortness of breath.

The ejection fraction in this condition is greater or equal to 50%. This is referred to as diastolic heart failure, also known as heart failure with preserved ejection fraction (HFpEF).

Heart failure with mid-range EF (HFmrEF): This is a newer term that refers to ejection fraction between 41 to 49% and is thought to exist on a spectrum between HFpEF and HFrEF.

This happens when the right side of the heart is weakened, often due to heart failure on the left side. However, it can also be caused by valve disease or high blood pressure in the lungs known as pulmonary hypertension.

When the right side of the heart loses its pumping power, blood can start to back up in the body. This can cause swelling in the legs and abdomen and can affect kidney and liver function.

People with heart failure often have other health conditions that can damage the heart, including:

• Coronary artery disease
• Congenital heart disease
• Cardiomyopathy
• High blood pressure
• Diabetes
• Kidney disease
• Thyroid disease
• Autoimmune disease
• Prior complications with pregnancy such as eclampsia or preeclampsia

The risk of developing heart failure increases with age and family history. Heart failure is more common in people over 65 but can affect people of all ages. Other risk factors include smoking, being overweight, alcohol and drug abuse, certain types of radiation and chemotherapy, viral infections, and genetic conditions.

Certain populations in the United States are at highest risk for a variety of reasons. Black and Hispanic individuals have a higher risk of developing heart failure compared to White individuals, according to the American Heart Association.

Data on heart failure in Asian individuals living in the United States are more limited but shows that people of South Asian descent are at higher risk for heart failure than the general population.

Having yearly check-ups is important to catch heart failure early, as it can go unnoticed for a long time.

Early on, the heart may beat faster, or blood vessels may narrow to maintain normal blood pressure. Patients may not notice any changes until the condition becomes more severe or advanced.

At first, you may feel out of breath and tired when you are active. As the disease gets worse, you may feel these symptoms even during normal daily tasks. Dr. Khedraki recommends seeing a doctor right away if you have ongoing symptoms to rule out heart failure as the cause.

Other common symptoms include:

• Swollen feet or ankles from fluid build-up
• Persistent coughing or wheezing, particularly when lying flat
• Impaired thinking
• Weight gain
• Heart palpitations
• Trouble sleeping
• Lack of appetite, nausea or abdominal bloating
• Lightheadedness

“Your heart team will inform you regarding which symptoms to watch for and how to best manage the condition at home if you do get diagnosed with heart failure. These include monitoring your blood pressure, heart rate, weight and fluid intake,” Dr. Khedraki says.

Doctors diagnose heart failure by thoroughly evaluating symptoms, medical history, blood pressure and heart rate. They may order blood tests as well, including the following diagnostic tests:

Electrocardiogram: Also known as ECG or EKG, it records the heart's electrical functions, including heart rate and rhythm.

Stress test: Also known as an exercise stress test, it is done to check for reduced blood flow to the heart. Stress tests can be done with exercise or can be chemically induced.

Echocardiogram: Also known as an echo, it uses ultrasound to create pictures of the heart. This helps doctors look for issues such as fluid accumulation in the heart's chambers and any problems with valve function.

Cardiac MRI: Uses magnetic fields to take very high-definition images of the heart.

Cardiac CT: Uses X-rays to create 3-dimensional images of the heart and arteries.

Cardiac catheterization: This is a procedure that involves inserting thin tubes called catheters into blood vessels. These catheters are guided to the heart to check for blockages in the heart arteries. The procedure can also measure pressure inside the heart chambers, which can assist with medical treatment.

Myocardial biopsy: This is a minimally invasive procedure in which small pieces of heart tissue are sampled and sent to the pathology lab to be examined under a microscope to help determine the cause of heart failure.

Treatment for heart failure depends on the underlying causes of the disease. Medications can help improve a patient's health and slow down the disease. “Fortunately, medical treatment using drugs for heart failure has advanced tremendously allowing people with heart failure to live longer and healthier lives and avoid going to the hospital,” Dr. Khedraki says.

“This form of treatment is referred to as guideline-directed medical therapy (GDMT), whereby a combination of drugs is used to help control symptoms and allow the heart to pump better and more efficiently.”

Medications for treatment of heart failures include:

Beta blockers: They slow heart rate and lower blood pressure to decrease the demand on the heart and can help regulate abnormal heart rhythms.

ACE inhibitors and ARBs: Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) help to lower blood pressure and reduce the heart's workload.

ARNI: Angiotensin receptor plus neprilysin inhibitor (ARNI) therapy is a combination of two drugs in one pill and helps to lower blood pressure and decrease salt and water retention.

Aldosterone antagonists: They block stress hormones that can lead to worsening of heart failure and have diuretic properties to decrease salt and water retention.

SGLT2 inhibitor: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of medications that help to improve glucose control in patients with heart failure even if they do not have diabetes and help to decrease sodium and water retention.

Diuretics: They help the body get rid of excess water by increasing urination. This can reduce fluid buildup in the lungs, legs, and abdomen. This is a common issue in heart failure that causes the kidneys to have difficulty disposing of salt and water.

Other medicines: Additional therapies may be prescribed by your doctor to relax blood vessels, prevent blood clots or manage cholesterol.

Heart failure can progress over time, causing symptoms of shortness of breath even at rest. Lifestyle changes, medications and careful supervision by your heart team can help prevent progression. More advanced cases may need surgery to implant a pump to help the heart or a heart transplant.

To prevent heart failure from worsening, follow these steps:

• Lose weight
• Exercise regularly
• Cut back on salt
• Quit smoking
• Reduce stress
• Get adequate sleep
• Take your prescribed medications

Your doctor may also recommend cardiac rehabilitation to help you exercise safely and maintain a heart-healthy lifestyle.

Heart medications can help with symptoms and disease progression; however devices and surgical procedures may also be necessary.

“Scripps cardiologists use cutting-edge procedures to treat heart failure. Many of these procedures are minimally invasive, using smaller incisions for faster recovery times,“ Dr. Khedraki says.

Procedures and surgeries may include:

Cardiac resynchronization therapy: CRT is a minimally invasive procedure. It helps improve the heart's pumping efficiency by synchronizing the contraction of both sides of the heart. It is used in patients with an electrical problem known as left bundle branch block, in which both sides of the heart do not contract simultaneously.

Implantable cardiac defibrillator (ICD): This device gives a shock to the heart if a life-threatening arrythmia is detected. Heart failure raises the risk of dangerous heart rhythms and cardiac arrest. ICDs can help prevent sudden cardiac death.

Pacemaker: Pacemaker implantation uses a small battery-powered device to deliver electrical impulses to treat slow heart rates.

Catheter-based heart valve procedures: These procedures use catheters inserted through blood vessels to repair narrow or leaky heart valves. It is a less invasive approach than open-heart surgery. Transcatheter aortic valve replacement (TAVR) is a procedure that uses a catheter to replace a narrowed aortic valve with a bioprosthetic valve. Other examples are mitral and tricuspid clips which address leaky heart valves.

Heart valve robotic surgery: Surgeons can perform some surgeries using robotic technology. This makes the procedure less invasive. It also helps patients to recover more quickly.

Coronary artery bypass grafting: Also known as CABG, pronounced "cabbage," this is a surgery that improves blood flow to the heart. It involves using healthy vessels, called grafts, from the chest, wrist, or leg. These healthy vessels are connected to the heart to bypass blocked arteries.

Left ventricular assist devices (LVADs): These pumps are surgically implanted in the body to help improve blood circulation in patients with severe heart failure. This requires open-heart surgery.

Heart transplant: This is an option for people with severe heart failure who have not improved with surgery or medications. This option involves taking medications for life to prevent the body from rejecting the donor heart.

Scripps is consistently recognized as having one of the best cardiovascular care programs in the nation.

To optimize your care, your heart team will typically take a multidisciplinary approach. Scripps cardiologists work with primary care physicians, specialists and surgeons to diagnose and treat a broad range of heart and vascular conditions.