The name “heart failure” sounds as if the heart has stopped working. It has not. Heart failure means the heart is not pumping as well as the body needs, so fluid builds up and organs get less oxygen-rich blood. It is a long-term condition, but modern treatment has improved outlook dramatically, and many people live active lives for years after diagnosis.
Types of heart failure
Doctors usually classify heart failure by the ejection fraction (EF), the percentage of blood the main pumping chamber pushes out with each beat. A normal EF is roughly 50 to 70 percent.
- Heart failure with reduced ejection fraction (HFrEF): EF of 40 percent or less. The heart muscle is weak and does not squeeze strongly.
- Heart failure with mildly reduced ejection fraction: EF between 41 and 49 percent.
- Heart failure with preserved ejection fraction (HFpEF): EF of 50 percent or more. The heart squeezes normally but is stiff and does not fill properly. This type is common in older adults, women, and people with high blood pressure, obesity or diabetes.
Common causes
- Coronary artery disease and previous heart attacks
- Long-standing high blood pressure
- Heart valve disease
- Cardiomyopathy (disease of the heart muscle), which can be inherited or caused by alcohol, infections or some cancer treatments
- Atrial fibrillation and other rhythm problems
- Diabetes and obesity
Symptoms
- Shortness of breath, first with exertion, later with less activity or when lying flat
- Waking at night breathless, or needing extra pillows to sleep
- Swelling of the ankles, legs or abdomen
- Rapid weight gain from fluid, such as 2 to 3 pounds in a day or 5 pounds in a week
- Tiredness and weakness
- A persistent cough or wheeze, sometimes with frothy sputum
- Reduced appetite and feeling full quickly
- A fast or irregular heartbeat
How it is diagnosed
- Blood tests, including BNP or NT-proBNP, hormones released when the heart is under strain
- An echocardiogram, an ultrasound that shows the heart’s structure, valves and ejection fraction
- An ECG to look at heart rhythm and signs of previous heart attacks
- A chest X-ray to check for fluid in the lungs and an enlarged heart
- Further tests may include stress testing, cardiac MRI or coronary angiography to find the cause
Stages of heart failure
American heart guidelines describe four stages:
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| Stage | What it means |
|---|---|
| A | At risk (for example high blood pressure or diabetes) but no heart damage yet |
| B | Structural heart changes but no symptoms yet |
| C | Heart changes with current or past symptoms |
| D | Advanced heart failure with severe symptoms despite treatment |
The aim is to catch people early and keep them from progressing to later stages.
Modern treatment
Treatment for heart failure with reduced ejection fraction has improved more in the past decade than in decades before. Guidelines now recommend four groups of medicines, often called the “four pillars”:
- ARNI, ACE inhibitor or ARB: sacubitril-valsartan is usually preferred. These relax blood vessels and reduce strain on the heart.
- Beta blockers, such as carvedilol, metoprolol succinate or bisoprolol, which slow the heart and protect it over time.
- Mineralocorticoid receptor antagonists, such as spironolactone or eplerenone.
- SGLT2 inhibitors, such as dapagliflozin or empagliflozin. Originally diabetes drugs, they reduce hospital stays and deaths in heart failure, including in people without diabetes.
Together, these medicines significantly reduce the risk of hospitalization and death. Doses are usually started low and increased step by step.
Diuretics (“water pills”) such as furosemide relieve swelling and breathlessness by removing extra fluid. SGLT2 inhibitors also benefit people with preserved ejection fraction, and GLP-1 medicines have shown benefits for some patients with obesity-related HFpEF.
Devices and procedures
- Implantable cardioverter-defibrillators (ICDs) protect people at risk of dangerous heart rhythms.
- Cardiac resynchronization therapy (CRT), a special pacemaker, helps both sides of the heart beat together in selected patients.
- Valve repair or replacement if a valve problem is driving heart failure.
- Left ventricular assist devices (LVADs) and heart transplant for advanced heart failure.
Daily habits that matter
- Weigh yourself every morning after using the bathroom and before breakfast. Call your care team if your weight rises quickly.
- Limit salt, which makes the body hold on to fluid.
- Follow fluid advice if your doctor has given you a limit.
- Take medicines exactly as prescribed, and do not stop them because you feel better.
- Stay active. Cardiac rehabilitation programs improve fitness, symptoms and quality of life.
- Avoid NSAID painkillers such as ibuprofen and naproxen, which can worsen fluid retention, unless your doctor approves them.
- Get vaccinated against flu, COVID-19 and pneumonia.
- Stop smoking and limit alcohol.
When to get urgent help
Call 911 if you have severe shortness of breath, chest pain, fainting, or you are coughing up pink frothy mucus. Call your doctor promptly if your weight rises suddenly, swelling gets worse, or you need more pillows to breathe at night.
The bottom line
Heart failure is a serious condition, but it is far more treatable than its name suggests. With the right combination of medicines, regular monitoring and healthy habits, many people stay out of hospital and live well for years. Know your symptoms, weigh yourself daily, and work closely with your heart team.
This article is for general information and is not a substitute for advice from your own cardiologist or doctor.