Heart Failure

Causes, symptoms and stages of heart failure

A male doctor in a white coat represents heart failure treatment at Scripps Health.

J. Thomas Heywood, MD, Advanced Heart Failure, Scripps Clinic

Causes, symptoms and stages of heart failure

Scripps cardiovascular teams are nationally recognized for breakthrough work in diagnosing and treating heart failure, the life-threatening condition that affects more than 5 million people in the US. Our doctors have decades of highly specialized experience helping people overcome heart problems and managing serious conditions which, if left unchecked, can be fatal.


Scripps’ heart care program is consistently recognized as one of the best cardiology and heart surgery programs in San Diego and the nation by U.S. News & World Report.

About heart failure

Heart failure is the heart’s inability to pump blood properly to deliver enough oxygen to the body. This complex condition is most common among patients age 65 or older, but it can affect people at any age.


Doctors can measure the heart’s pumping capacity, which is known as ejection fraction. A normal ejection fraction is more than 55%, according to the National Heart, Lung and Blood Institute. Enlargement of the heart’s left ventricle can reduce its ability to pump the necessary amount of oxygen-rich blood to the body, resulting in a lower ejection fraction. Heart failure is not the same as heart attack, which happens when there is a blockage in one of the arteries that supplies blood to the heart.

Types of heart failure

The heart has four main chambers: two upper and two lower. Heart failure can be traced to the left bottom chamber (left ventricle), the right bottom chamber (right ventricle), or both. In left-sided heart failure, fluid can back up into the lungs causing shortness of breath. In right-sided heart failure fluid can back up into the abdomen and legs. The most commonly encountered type of heart failure is due to a problem with the left ventricle and is classified as:


  • Systolic heart failure in which the left ventricle cannot pump blood forward well enough to meet the body’s demands. This is also called heart failure with reduced ejection fraction.
  • Diastolic heart failure in which the left ventricle cannot relax well to properly fill with oxygen-rich blood. This is also called heart failure with preserved ejection fraction. 

Heart failure causes

According to the National Heart, Lung and Blood Institute, leading causes of heart failure include:


  • Coronary artery disease
  • Heart attack
  • High blood pressure
  • Diabetes


Other causes include:


  • Lifestyle choices (diet, activity level, smoking, stress)
  • Family history 


Some types of heart disease can be inherited, putting family members at risk of developing heart problems. Scripps offers genetic testing to help patients and their family members identify potential heart trouble and take proactive steps with their physician to address it.

Heart failure symptoms

Common symptoms of heart failure include:


  • Swelling of the feet or ankles due to fluid build-up
  • Weight gain
  • Shortness of breath due to fluid in the lungs
  • Weakness
  • Lightheadedness
  • Fatigue with little exertion


Heart failure can exist for years before symptoms develop. Seeing your physician for annual physical exams is an important way to catch heart problems early.

Heart failure stages

According to the American Heart Association, there are four stages or classes of heart failure referred to as the New York Heart Association (NYHA) Functional Classification:


  1. No limitation of physical activity; ordinary activity does not cause symptoms.
  2. Ordinary physical activity causes fatigue or shortness of breath. 
  3. Marked limitation of physical activity; less than ordinary activity causes symptoms and patients are comfortable only at rest. 
  4. Patients are unable to carry on any physical activity and have symptoms even at rest.


Congestive heart failure occurs when fluid builds up leading to symptoms such as shortness of breath and swelling. Advanced or end-stage heart failure occurs when the heart’s pumping capacity is severely decreased and can no longer be managed by medical therapies.


Patients with advanced or end-stage heart failure may benefit from mechanical assist therapies, including implantable pumps, such as left ventricle assist devices (LVADs), which help the heart pump blood to the body or even a heart transplant.

Diagnosing heart failure

Scripps cardiology teams use the most advanced heart screening technologies and procedures to detect and diagnose heart failure. These may include:


  • Medical history, including family history and review of medications
  • Physical exam including heart rate, blood pressure, weight, lungs and breathing, and any noticeable signs of swelling in the legs or belly region
  • Blood tests to detect other undiagnosed risk factors, such as diabetes, and to check if the kidneys and liver have been affected
  • An electrocardiogram (EKG or ECG) to record the heart’s electrical functions, such as heart rate, heartbeat rhythm, and strength and timing of electrical signals as they pass through each part of the heart
  • Stress EKG, a physical test typically involving a treadmill, that can detect reduced blood flow to the heart
  • Chest X-ray to provide a picture of the heart, lungs and major blood vessels
  • Echocardiogram (ECHO) using sound waves to create moving pictures of the heart — particularly its chambers and valves — and detect possible blood clots, fluid buildup or other problems
  • Cardiac blood pool scan (also called nuclear ventriculography) that shows how well the heart pumps blood to the rest of the body
  • Cardiac catheterization using the insertion of a long, thin flexible tube to check blood vessels that supply blood to the heart and check the pressures in the heart chambers

Heart failure treatment at Scripps

Thanks to advancements in cardiovascular medicine, heart failure can be managed and potentially reversed in some cases. This is possible when heart failure is diagnosed early, treated successfully and patients make necessary lifestyle changes. These changes can include modifying diet, increasing exercise, reducing alcohol consumption or quitting smoking.

Medications and procedures for heart failure

Scripps heart specialists treat heart failure with the latest therapies and surgical procedures performed in state-of-the-art hospitals and facilities. Treating heart failure may involve one or more of the following:

Medications for heart failure

One or more medications may be prescribed to treat heart failure. Patients who respond well to one medication may not do as well with others, which is why your physician may recommend a combination or a change, based on results and follow-up.


Medications to manage heart failure symptoms or prevent the condition from becoming worse can include:


  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) to relax the blood vessels, resulting in a reduction of the heart’s workload and lower blood pressure
  • Angiotensin-receptor neprilysin inhibitors (ARNIs) combine two types of drugs to help replace ACE inhibitors and ARBs and also help to improve blood flow and reduce strain on the heart
  • Aldosterone receptor antagonists to help block the hormone aldosterone and help rid the body of extra fluid, reduce swelling, improve breathing and lower blood pressure
  • Sodium-glucose co-transporter 2 (SGLT2) inhibitors target cardiometabolic pathways and help to lower blood sugar and are used for patients both with and without diabetes
  • Beta-blockers that can slow heart rate and reduce blood pressure rates
  • Isosorbide dinitrate/hydralazine hydrochloride to help relax blood vessels so the heart is more efficient
  • Diuretics that help rid the body of extra fluid and salt (sodium) to reduce swelling associated with heart failure

Medical procedures and surgery for heart failure

We offer patients with heart failure leading-edge treatments and access to the most advanced FDA-approved heart devices. Our teams are at the forefront of clinical trials and have extensive experience with new minimally invasive techniques.


Learn more about the medical procedures offered at Scripps to treat heart failure.


  • Left ventricular assist devices (LVADs) are surgically implanted pumps that improve the circulation of oxygen-rich blood to organs when a patient’s left ventricle has become weakened and no longer functions properly.
  • Heart transplant is a major operation that is used to replace a failing heart with a healthy donor heart in patients with end-stage heart failure. Scripps heart failure experts evaluate and manage heart transplant patients along with partner programs to provide this service to patients who are good candidates for this treatment. 
  • Cardiac resynchronization therapy (CRT) helps increase the heart’s pumping efficiency.
  • Implantable cardiac defibrillator (ICD) implantation helps keep the heart beating at a healthy rate. The ICD is implanted under the skin and delivers a shock to stop abnormal heart rhythms when detected.
  • Pacemaker implantation uses a small battery-powered device to maintain healthy heart beat and rhythm for patients with a slow heart rate (bradycardia) or a condition known as heart block, in which electrical impulses from the heart’s top chambers (atria) cannot reach the lower chambers (ventricles). In early 2014, Scripps became the first health system in Southern California to implant a new wireless pacemaker that is one-tenth the size of a traditional pacemaker.
  • Arrhythmia treatments include ablation procedures, such as cryoablation, which uses cold to correct abnormal heart rhythms without surgery. Heat and electricity also may be used.
  • Angioplasty and stent placement help open blocked or narrowed arteries and restore healthy blood flow.
  • Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that doesn’t require a traditional chest incision and open surgery to replace the aortic valve.
  • Heart valve repair or replacement can be performed through a percutaneous procedure (catheter inserted into an artery) or robot-assisted minimally invasive surgery.
  • Coronary bypass surgery, in which surgeons graft a healthy vessel from another part of your body (usually arm, leg or chest) to “bypass” a blocked coronary artery, restores healthy blood flow to the heart.
  • Interventional cardiology treatments include using catheters for minimally invasive access through the artery of the heart to perform procedures on the heart.

Cardiac rehabilitation for heart failure

Our cardiac rehabilitation programs can help you recover faster and make necessary lifestyle changes to guard against repeat heart problems. Scripps can help you adopt a healthier lifestyle, including an exercise program and healthy diet designed to improve your health and help you move forward in a positive way after surgery, or interventional cardiology procedures to treat a heart condition.


Scripps Center for Integrative Medicine offers complementary therapies for heart failure. The customized Lifestyle Change Program combines complementary therapies with medical therapies in a holistic mind-body approach.


As part of our commitment to the community, Scripps also offers wellness and heart health classes free of charge to the public.

Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is a life-support treatment for patients who are very ill. ECMO works by helping to pump and oxygenate blood outside the patient’s body to help support and rest the heart and lungs. Scripps cardiac experts implement this strategy as a short-term option for patients with massive heart attacks, or those who experience a sudden significant decrease in heart function and may suffer end-organ damage if not treated immediately.


ECMO is used only after medications and a breathing machine (ventilator) have failed.


A highly experienced Scripps multidisciplinary team cares for patients receiving ECMO. The treatment of these patients requires expert physicians and team members in intensive care cardiology, neurology, infectious disease, pulmonology and other specialties.

Home care for heart failure

The first step to managing your heart failure symptoms is knowing what’s normal for you. This is considered your baseline. Knowing your baseline and tracking your heart failure symptoms every day can help you quickly identify signs of your condition worsening.

Symptoms to track at home

Symptoms you should track at home include:


Rapid weight gain

This may mean that your body is retaining fluids. Weigh yourself at the same time every day, on the same scale and alert your doctor if you gain more than two pounds in one day or more than five pounds in a week.


Blood pressure and heart rate

You should take these measurements daily and alert your cardiologist if the readings are different from your baseline.


Shortness of breath

This can include getting winded during easy activities, having difficulty breathing when lying down or needing to sit up to breathe better. If your shortness of breath is greater than normal during your usual activities, alert your physician.


Swelling

This means your body is retaining excess fluid, especially if the swelling is in your legs or feet. If your swelling is greater than normal, alert your physician. If your swelling is greater than normal, alert your physician.


Fatigue

Fatigue can be a sign that your body is not circulating enough blood. If your fatigue is greater than normal, alert your physician.


Talk to your physician about developing an action plan if your symptoms become worse.

Lifestyle changes to consider

Lifestyle changes are an important part of managing heart failure and reducing symptoms. Many patients find that setting goals helps them keep heart failure under control without feeling overwhelmed.


Here are goals to consider when developing a plan with your physician:


  • Maintain a heart-healthy diet that is low in sodium, fat and cholesterol.
  • Take your medications as prescribed by your cardiologist.
  • Stay active by engaging in activities that are approved by your heart failure doctor. If you feel signs of overexertion, stop your activity and seek immediate medical attention.
  • Quit smoking immediately. If you need help, talk to your doctor about smoking cessation programs.
  • Reduce your stress by learning stress management techniques, such as meditation, relaxation exercises, spending time with friends or taking up a hobby.
  • Get plenty of rest and listen to your body for signs of fatigue.


Your doctor will help you create a healthy lifestyle plan that includes exercise and dietary options that are right for you. It is important to take all medications as prescribed and to schedule regular appointments with your doctor.

What to expect at your first appointment

During your first appointment with our heart failure specialists, you’ll meet our heart failure team, including a heart failure physician and a nurse practitioner/physician assistant. We will review your medical history and any medical test results.


During the visit, you can expect to:


  • Learn more about your condition
  • Receive diet and lifestyle recommendations 
  • Have your medications adjusted 
  • Obtain orders for follow-up tests


We usually perform the following tests:


  • Echocardiogram (ultrasound imaging of the heart) to measure your heart and valve function
  • Electrocardiogram (EKG) to assess the rhythm of your heart
  • Blood tests to check your kidney and liver function
  • Device check of your cardiac defibrillator or pacemaker to make sure it is working appropriately


Depending on the severity of your condition, several diagnostic tests may be performed after your appointment, including cardiopulmonary exercise stress testing and cardiac catheterization.


  • Please bring your medication list and the actual pill bottles for those medications.
  • Bring any test results, including laboratory tests. It is best to obtain the images on CD for echocardiograms, angiograms and stress tests.
  • We usually obtain notes from your physician before your appointment, but encourage you to bring any medical documentation available to you.
  • If you need any diagnostic tests, our clinic will help you set up appointments.
  • Plan to be at the clinic for at least one hour.

Research and clinical trials

Scripps is consistently on the leading edge of cardiovascular research and clinical trials, working to bring the most innovative treatments and care options to patients. Locally and regionally, we’ve led the way with many firsts for cardiovascular breakthroughs.


Our physicians and scientists are actively involved in research and studies to provide greater understanding of heart disease and enable a faster availability of new treatments to patients. If you are interested in participating in clinical trials, please discuss with your physician about potentially appropriate matches.