Heart Failure Causes, Symptoms, and Treatments

Heart failure is a complex clinical condition in which the heart is not able to pump enough blood to support the body's needs. Cardiomyopathy refers to the condition where the muscle of the heart is weak and unable to contact or pump blood at a normal capacity. It is often used interchangeably with heart failure. However, heart failure refers to presence of symptoms, whereas cardiomyopathy may or may not be associated with symptoms.

Types and Stages of Heart Failure

There are two types of heart failure:

• Systolic – When muscle function of the heart is decreased and pumping capacity is reduced.
• Diastolic (HFPEF) – When pumping capacity is still preserved but the heart muscle is more stiff and does not relax well, which leads to abnormalities in the way it fills with blood.

The terms left-sided heart failure and right-sided heart failure are also occasionally used. They refer to weakness on that side of the heart. The symptoms may differ based on which side of the heart is experiencing weakness.

The American College of Cardiology (ACC) and the American Heart Association (AHA) classify heart failure in four stages:

• Stage A – Patient does not yet have heart failure but is at risk of developing it due to the presence of risk factors such as diabetes, hypertension, coronary artery disease and renal disease.
• Stage B – Patient has not developed any symptoms of heart disease but there is a presence of structural changes in the heart such as decreased pumping capacity or increased stiffness of the heart muscle.
• Stage C – Patient has structural changes in the heart and is now experiencing symptoms of heart failure. A wide range of medications and treatment options are used for these patients.
• Stage D – Patient has an advanced illness. Most of the previous medications and treatment options have failed and their condition keeps getting worse. Patient is usually considered for advanced therapies like heart transplantation or artificial heart pumps such as a left ventricular assist device (LVAD).

Causes

The most common causes of heart failure are:

• Coronary artery disease (CAD). CAD is the most common type of heart disease and occurs when the arteries that supply blood to the heart harden and become narrow. In time, this can lead to heart failure, heart attack and an irregular heartbeat.
• High blood pressure (hypertension), which is a common condition where the blood flows through the veins or arteries at a higher pressure than normal. If left untreated, high blood pressure can lead to serious issues, including heart attack, heart failure, stroke and kidney failure.
• Congenital heart disease, where patients may be born with a certain type of defect in the heart.
• Heart attack, where the heart muscle suffers damage due to a clot in the arteries of the heart causing obstruction to blood flow.
• Leaky or narrowed heart valves, where some valves within the heart may have been damaged, thus resulting in blood flowing back or causing obstruction.
• Some types of abnormal heart rhythms (arrhythmias)
• Inflammation, in which the heart muscle may have been damaged due to previous inflammation or viral infection.
• Peripartum, a condition affecting a small number of pregnant women, resulting in a weak heart muscle.
• Infiltrative cardiomyopathy, a condition where the heart muscle is infiltrated by certain types of protein or inflammatory cells.
• Chemotherapy induced, which is a result of certain types of chemotherapy drugs which may have been used to treat cancer.
• Familial. In certain patients there may be genetic causes of a weak heart muscle and it may run in families.

Risk Factors

According to the AHA, one in five Americans 40 years of age and older will develop heart failure in their lifetime. Things that impact your risk of developing heart failure include:

• Age – As we get older, the heart muscle can weaken. Older people also are more likely to have other diseases that can lead to heart failure.
• Race – Black people are more likely to have heart failure than people of other races. They’re also more likely to have symptoms at a younger age, have more hospital visits due to heart failure, and die from heart failure.
• Weight – Excess weight puts strain on the heart and increases your risk of developing heart disease and type 2 diabetes, which can lead to heart failure.
• Heart attack – A heart attack can weaken the heart muscle and make you more susceptible to developing heart failure.

Symptoms

People with heart failure can experience a wide range of symptoms. They are mostly caused by fluid buildup in the body. When symptoms start, you may feel tired and short of breath after routine physical effort, like climbing stairs. As your heart grows weaker, symptoms get worse.

The most common signs and symptoms of heart failure include:

• Shortness of breath or trouble breathing (dyspnea), most often during activity but also at rest or while sleeping
• Tiredness or fatigue because the heart can't pump enough blood to meet the body's needs
• Swelling in the ankles, feet, legs, abdomen, and veins in the neck due to excess buildup of fluid in body tissues (edema)
• Persistent coughing or wheezing due to fluid buildup in the lungs
• Abdominal bloating or chest discomfort due to fluid build up
• Dizziness or lightheadedness
• Loss of appetite, early fullness, nausea

Diagnosing Heart Failure

To diagnose heart failure, your doctor will review your medical and family history and will perform a physical exam. Your doctor may also order diagnostic tests. No single test can diagnose heart failure, so more than one may be ordered. These tests include:

Echocardiogram

An echocardiogram (also called an echo) is a cardiac test that uses high frequency sound waves to produce an image of the heart. Pictures are generated as sound waves reflect off certain areas of the heart, allowing cardiologists to see images of the heart on a monitor. It allows different chambers of your heart and valves in between to be assessed.

Cardiac MRI

Cardiac magnetic resonance (CMR) imaging provides sophisticated images of the heart without any radiation. Using a powerful magnetic field and radio signals, the CMR gives the highest definition of heart structures and function that give details about how the blood is flowing throughout the body.

Nuclear Study

This is a simplified term for different types of stress tests performed using a nuclear camera. It involves either exercising on a treadmill or stationary bike or receiving a chemical through an intravenous (IV) line followed by pictures being taken on a nuclear camera.

Heart Catheterization

There are two forms of heart catheterization:

1. Left heart catheterization – Performed to look for blocked heart arteries. It involves threading a thin catheter through blood vessels and into the heart. Using X-rays, doctors look for signs of heart disease.

2. Right heart catheterization – Performed to obtain the pressures in the heart as well as lungs. It enables doctors to very precisely measure the amount of blood being pumped by the heart.

Cardiopulmonary Stress Test

A cardiopulmonary stress test involves a patient exercising on a treadmill or bike while breathing into a tube. The purpose of the test is to measure the amount of oxygen being taken in by the body. This enables the cardiologist to help identify patients with heart failure who are particularly at high risk of having poor outcomes.

Six-Minute Walk Test

This involves a patient walking for six minutes in a hallway. Blood pressure and other symptoms are monitored before and after the test. This helps doctors identify patients who are at risk of poor outcomes and to monitor response to treatments.

Pulmonary Function Test

A pulmonary function test is a breathing test performed by the lung specialist. It is used when there is concern that some of the patient's symptoms may be related to underlying problems.

Sleep Study

A sleep study is used to evaluate patients for sleep apnea. There is a connection between heart failure and sleep apnea, so diagnosing sleep apnea and starting patients on appropriate therapy may help them better manage their heart failure symptoms.

Ankle-Brachial Testing

Ankle-brachial testing is a test performed to measure blood supply in the lower limbs. Some people may have blockages in the legs which cause pain in the leg during activity.

Treatments

A wide range of options are used for treating heart failure. Early diagnosis and treatment can help people who have heart failure live longer, more active lives. Treatment for heart failure depends on the type and severity of the heart failure.

Treatments usually include heart-healthy lifestyle changes, medicines, and ongoing care. If you have severe heart failure, you also may need medical procedures or surgery.

Heart-Healthy Lifestyle Changes

Your doctor may recommend heart-healthy lifestyle changes if you have heart failure. These include:

• Heart-healthy eating
• Aiming for a healthy weight
• Physical activity
• Quitting smoking

Medications

Your doctor will prescribe medications based on the type of heart failure you have, how severe it is, and your response to certain medicines. Some of these medications help make the heart stronger and assist in recovery. The following medications are commonly used to treat heart failure: 

• Beta blockers (Metoprolol succinate, Carvedilol, Bisoprolol) to lower heart rate and blood pressure, which reduces how hard your heart works
• ACE inhibitors and angiotensin receptor blockers (Lisinopril, Enalapril, Captopril, Valsartan, Losartan) to lower blood pressure and reduce strain on the heart
• Diuretics (water pills such as Furosemide, Bumetanide, Torsemide) to increase fluid and sodium excretion from the body and reduce congestion and swelling
• Aldosterone antagonists (Spironolactone, Eplerenone) to remove excess sodium through your urine, which lowers the volume of blood the heart must pump
• Neprilysin inhibitors (Sacubitril/Valsartan, brand name Entresto) to reduce blood pressure, increase urine output and help the heart get stronger
• Arrhythmia medications (Amiodarone, Mexilitine, Sotalol) to control atrial fibrillation or ventricular tachycardia
• Anticoagulation medications (blood thinners such as Apixaban, Rivoraxoban, Dabigatran) to help keep existing blood clots from getting larger
• Intravenous medications (Milrinone, Dobutamine) to temporarily boost the pumping capacity of the heart
• Other medications such as Ivabradine which may be used in select cases to reduce your heart rate, and medications to lower pressure inside your lungs

Devices and Surgical Procedures

There are several devices and surgical procedures used to treat heart failure:

• Barostim™ Baroreflex Activation Therapy is the world’s first FDA-approved heart failure device to use neuromodulation – the power of the brain and nervous system – to improve the symptoms of patients with systolic heart failure. Unlike other HF treatment options, Barostim does not touch the heart and utilizes an electrode that lies on the patient's carotid artery. The electrical impulses that are sent from the neuromodulation device inform the brain of the heart's condition, enabling the brain to improve the function of the heart. GW Hospital was the first in the region to successfully implant the Barostim Baroreflex Activation Therapy.
• Pacemakers are large battery-sized devices which are inserted under the muscle in the chest. They are connected to the heart with wires which are inside the body and not visible outside. Pacemakers are used to maintain the heart rate in conditions where the heart may not be beating at a certain minimum rate.
• Implantable cardioverter defibrillators (ICDs) are similar to pacemakers but their primary function is to shock the heart when the heart goes into arrhythmia (rapid heart rate). People with heart failure, specifically with low ejection fraction, have an increased risk of dying from arrhythmias. An ICD is intended to help prevent that from happening.​ Biventricular ICDs are recommended for patients with certain characteristics. Not all patients will benefit from using them.
• CardioMEMS HF System is indicated for wirelessly measuring and monitoring pressure in the arteries in the lung to enable healthcare professionals to manage symptoms better.
• A left ventricular assist device (LVAD) is an artificial heart pump with a motor. It is used to help the heart pump oxygenated blood to the rest of the body when it cannot pump efficiently enough to meet the body's needs. It takes blood from the heart and pushes it into the main artery (aorta) which supplies the rest of the body. This is usually limited to a very few patients in advanced stages of heart failure.
• A heart transplant involves replacing the patient’s heart with a heart from another person who has died. This procedure is limited to patients who are in an advanced stage of heart failure. This option is chosen when all other treatment options have been exhausted.

Monitoring

It's important to monitor your condition, during and after treatment. Things to monitor include:

• Weight. Patients are encouraged to weigh themselves every day. As extra fluid starts building up, body weight is one of the earliest signs of heart failure.
• Fluid intake. Drinking an excessive amount of fluid may be harmful for most patients with heart failure. However, the exact amount of fluid intake per day varies based on the patient and their underlying type of heart failure.
• Use of other medications. NSAIDS (ibuprofen, Aleve®, Motrin®, and others) are pain relievers that can lead to retention of fluid in the body and blunt the effect of diuretics. Ephedrine is a medication commonly available as part of sinus medications and can cause worsening heart failure
• Alcohol consumption. While a small amount of alcohol may be okay, larger amounts can lead to fluid overload and result in worsening heart function.
• Oral contraceptives. These may result in fluid build-up. Some women get swelling around their ankles while using oral contraceptives.
• Steroids. Can cause swelling and fluid retention if continued for a long period of time.