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Congestive heart failure

Heart failure is a condition caused by the heart failing to pump enough blood around the body at the right pressure.

Heart failure is a condition caused by the heart failing to pump enough blood around the body at the right pressure.

It usually occurs because the heart muscle has become too weak or stiff to work properly.

If you have heart failure, it does not mean your heart is about to stop working. It means your heart needs some support to do its job, usually in the form of medicines.

Breathlessness, feeling very tired and ankle swelling are the main symptoms of heart failure. But all of these symptoms can have other causes, only some of which are serious.

The symptoms of heart failure can develop quickly (acute heart failure). If this happens, you will need to be treated in hospital. But they can also develop gradually (chronic heart failure).

Read more about the symptoms of heart failure.

Types of heart failure

There are three main types of heart failure. They are:

  • heart failure caused by left ventricular systolic dysfunction (LVSD) – this is because the part of the heart that pumps blood around your body (the left ventricle) becomes weak 
  • heart failure with preserved ejection fraction (HFPEF) – usually a result of the left ventricle become stiff, causing difficulty filling with blood
  • heart failure caused by diseased or damaged heart valves

It is important the type of heart failure you have is identified as it will affect the type of treatment you will be offered. A number of tests can be used to help diagnose heart failure.

You should also have blood tests, an electrocardiogram (ECG) and an echocardiogram. These are used to investigate your heart and check how well it is functioning. If you have not had these tests, you should ask your doctor for an explanation.

Read more about how heart failure is diagnosed.

What causes heart failure?

Heart failure does not often have a single cause. A number of problems usually "gang up" on the heart, causing it to fail.

There are a number of health conditions that increase your chances of developing heart failure, including:

  • high blood pressure (hypertension) – this can put extra strain on the heart, which over time can lead to heart failure
  • coronary heart disease (CHD) – where the arteries that supply blood to the heart become clogged up by fatty substances (atherosclerosis), and may cause angina or a heart attack
  • heart muscle weakness (cardiomyopathy) – this can cause heart failure; the reasons for this are often unclear, but it may be genetic in origin, or caused by an infection (usually viral), alcohol misuse, or medication used to treat cancer
  • heart rhythm disturbance (atrial fibrillation)
  • heart valve disease, damage or problems with the heart's valves

Sometimes anaemia, an overactive thyroid gland (hyperthyroidism) or high pressure in the lungs (pulmonary hypertension) can also lead to heart failure.

Read more about the causes of heart failure.

Treating heart failure

In most cases, heart failure is a lifelong condition that cannot be cured. Treatment therefore aims to find a combination of measures, including lifestyle changes, medicines, devices or surgery that will improve heart function or help the body get rid of excess water.

A cure may be possible in cases where heart failure has a specific cause. For example, if your heart valves are damaged, it may be possible to replace them, which can cure the condition.

As treatment will usually be lifelong, you and your doctor will need to find a balance of effective treatments that you can manage in the long term so you have the best symptom control and quality of life possible.

Effective treatment for heart failure can have the following benefits:

  • it helps make the heart stronger
  • it improves your symptoms
  • it reduces the risk of a flare-up
  • it allows people with the condition to live longer and fuller lives

Read more about how heart failure is treated.

Preventing heart failure

Many of the factors that increase your risk of developing heart failure can be managed either by making lifestyle changes or by taking medicines.

For example, in terms of lifestyle factors, you should:

Read more about preventing heart failure.

Living with heart failure

Being diagnosed with heart failure may come as a shock. While the outlook is related to age, the severity of the heart condition, and any other health problems that may exist, such as lung or kidney diseaseanaemia and diabetes, it also depends on what you do to reduce your risk.

Self care means taking responsibility for your own health and wellbeing, with support from the people who are involved in your care.

It is very important that you take any prescribed medication, even after you feel better. Some medicines are designed to protect or heal your heart.

If you do not take them, they cannot help and the underlying problem will get worse. The medicines can prevent or delay your heart problem and stop symptoms getting worse.

Speak to your healthcare team if you have any questions or concerns about the medication you are taking or any potential side effects.

As heart failure is a long-term condition, you will have regular contact with your healthcare team. Developing a good relationship with the members of your team will enable you to discuss your symptoms and any concerns you have. The more the team knows about you, the more they can help you.

Read more about living with heart failure.


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Congestive heart failure

The symptoms of heart failure can vary from one person to the next. The main symptoms are breathlessness, extreme tiredness and ankle swelling, which may extend up the legs.

The symptoms of heart failure can vary from person to person. The main symptoms are breathlessness, extreme tiredness and ankle swelling, which may extend up the legs.

These symptoms may be caused by conditions other than heart failure, and sometimes there may be more than one cause for them.

For example, it is possible for someone to have both emphysema and heart failure, and for both to cause breathlessness. Tiredness and ankle swelling are not usually caused by serious problems.

If you have symptoms such as tiredness and breathlessness, your GP may suggest that you have some tests to see whether you have heart failure, or to rule it out as a cause of your symptoms.

If you have heart failure, you may also get breathless if you lie flat, or you may wake up in the middle of the night with such severe breathlessness that you have to sit or stand up to catch your breath. If you have severe heart failure, you may need to sleep propped up by several pillows.

Ankle swelling related to heart failure is usually better in the morning and gets worse later in the day, although this is the case for most causes of ankle swelling.

If you have ankle swelling in the morning, it may be useful to raise the foot end of your mattress by 15 to 30cm (about 6 to 12 inches) because this will help gravity drain the fluid back into your body.

Other symptoms sometimes associated with heart failure include: 

  • a persistent cough
  • lack of appetite
  • weight loss
  • tachycardia (rapid heart rate)

Some people diagnosed with heart failure may find the diagnosis difficult to cope with and develop depression and anxiety.

Monitoring your health

If you have been diagnosed with heart failure, you should monitor your symptoms closely. Weigh yourself daily (after getting up in the morning, before getting dressed) using a reliable set of scales.

If your weight increases by more than 2kg (4 to 5lb) over a few days, it may be a sign of fluid retention. This could be an indication that you need to watch the amount of salt in your diet, or check with your care team about whether you need to take some more diuretics (water pills).

You should also inform your GP or care team if you develop any new symptoms, or if an existing symptom suddenly gets worse.

 

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Congestive heart failure

If you have symptoms of heart failure, your GP will ask you to describe them in detail. You will also have a physical examination.

If you have symptoms of heart failure, your GP will ask you to describe them in detail. You will also have a physical examination.

If heart failure is suspected, a number of tests may be recommended to find out more. Some of the tests that you may have include:

  • blood tests – to check whether there is anything in your blood that might indicate heart failure or some other illness
  • breathing test – you may be asked to blow into a tube to check whether a lung problem is contributing to breathlessness 
  • an electrocardiogram – this records the electrical activity of your heart 
  • an echocardiogram – where ultrasound waves are used to examine your heart and check how well it is pumping, and whether there are valve problems (the procedure is similar to the one used to look inside the womb during pregnancy)

You should ask your doctor whether you should have these tests if you are not offered them but you are receiving treatment for heart failure.

Blood tests

Blood tests can help identify whether another condition is causing your symptoms, such as anaemia, diabetes, thyroid problems, kidney disease, or liver disease. A high blood cholesterol level is often associated with coronary heart disease, which may lead to heart failure.

Natriuretic peptide test

Your blood will be tested for a substance called natriuretic peptide (also called BNP or NTproBNP). If your heart is under high levels of stress, it will secrete BNP into your blood. The test is able to detect these increased levels.

A natriuretic peptide test can also indicate the severity of your heart failure. Higher levels of BNP/NTproBNP in your blood may indicate that you have more severe heart disease, while lower levels may indicate a milder form.

You can read more about the BNP test on the Lab Tests Online UK website. 

Echocardiogram (echo)

An echocardiogram, or echo, is a procedure that can be used to look at the structure of your heart in detail.

A pulse of harmless high-frequency sound waves is passed through the chest wall and produces a picture by "bouncing back" from the heart's structures (similar to an ultrasound scan used during pregnancy).

During the test, you will be asked to lie on your left side with your left arm behind your head. A gel will be put on your chest and an ultrasound probe (recorder) will be placed at various points on your chest between your ribs.

The probe will pick up echoes from your heart and show them on a screen as a detailed image of the structures of your heart. The image is known as an echocardiogram.

An echocardiogram provides a lot of useful information about the heart, including:

  • how well your heart valves are working and whether any are damaged
  • how well your heart is working as a pump (when your heart contracts, it forces blood to circulate around your body – this is known as the systolic function)
  • how well your heart relaxes after pumping (the heart fills with blood when it relaxes after each contraction – this is known as the diastolic function)
  • whether there are holes in the walls between the chambers of your heart that allow blood to flow from one side to the other (intracardiac shunts)

The most important finding from an echocardiogram is usually a measurement of how well one of the heart's chambers – the left ventricle – is pumping. The left ventricle pumps the blood around the body.

A measurement called the left ventricular ejection fraction (LVEF) is an estimate of how much of the blood that enters the left ventricle is pumped out when the heart muscle contracts.

In a healthy heart, about 60% of the blood entering the left ventricle is pumped out when the heart muscle contracts. A value of less than 40% indicates that your heart is definitely not pumping normally.

Sometimes different types of echocardiogram are carried out. These are outlined below.

Stress echocardiogram

A stress echocardiogram is carried out to see how well your heart functions when it has to work hard. During the test, your heart rate will be increased, either by exercising on a treadmill or exercise bike, or by using injected medication.

Transoesophageal echocardiography

Ultrasound does not travel well through lungs, which can make imaging the heart through the chest wall difficult.

However, the heart lies right in front of the oesophagus (the tube connecting your mouth to your stomach).

This makes it possible for a thin, flexible tube with a small ultrasound probe at the end to be inserted into your oesophagus to examine the structures of your heart in much greater detail. 

Before the procedure, you may be given a mild sedative to help you relax, and an anaesthetic will be sprayed on to the back of your throat.

You can read more about echocardiograms on the British Heart Foundation website.

Chest X-ray

A chest X-ray may sometimes be used to check whether your heart is bigger than it should be and whether there is fluid in your lungs, which might indicate heart failure. It can also pick up lung conditions that may be causing breathlessness.

Read more about tests for heart conditions on the British Heart Foundation website.


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Congestive heart failure

Medicines are the main treatment for heart failure. A number of surgical options are available. Lifestyle factors such as a healthy diet and exercise are also important.

Lifestyle changes

If you have been diagnosed with heart failure, you can reduce your risk of further episodes by making simple lifestyle changes.

Stopping smoking (if you smoke) will quickly reduce your risk of having a heart attack to near that of a non-smoker.

Other lifestyle changes – such as eating healthily, moderating your alcohol and salt intake, and taking regular exercise – will also improve your symptoms and reduce the pressure on your heart.

Read more about lifestyle changes and preventing heart failure.

Rehabilitation programmes

You may be given an opportunity to attend a heart failure rehabilitation programme. These programmes vary widely throughout the country, but most will cover basic areas, including:

  • exercise
  • education
  • relaxation and emotional support

After completing your rehabilitation programme, it is important that you continue to take regular exercise and lead a healthy lifestyle to protect your heart and reduce the risk of further heart-related problems.

You can read more about cardiac rehabilitation on the British Heart Foundation website.

Medicines for heart failure

Most people with heart failure are treated with medicines. Depending on your symptoms, you may need to take several medicines. For people with heart failure and heart failure caused by left ventricular systolic dysfunction, these include:

  • ACE-inhibitors
  • angiotensin receptor blockers (ARBs)
  • beta-blockers
  • aldosterone blockers (spironolactone or eplerenone)
  • diuretics
  • ivabradine
  • digoxin (occasionally)

Many patients with heart failure with preserved ejection fraction will require similar treatment.

The doses of these medications will be adjusted by your doctor. You may occasionally need to have blood tests to monitor your kidney function, especially when doses are altered.

Ask your doctor if you are not sure whether you are on the best dose for you. The first medicine you try may not work properly or suit you, so changes may be needed until you and your GP find a combination that works for you.

You may also be offered other medicines if you have another condition or other symptoms that also need treatment.

Diuretics

Diuretics (water pills) make you pass more urine and help relieve ankle swelling and breathlessness caused by heart failure.

There are many different types of diuretic, but some of the most widely used for heart failure are bumetanide and furosemide (also called frusemide). In some mild cases, a diuretic called bendroflumethiazide may be used.

A diuretic called metolazone may be used together with bumetanide or furosemide in people with severe fluid retention.

ACE inhibitors

Angiotensin-converting enzyme (ACE) inhibitors work by dilating your blood vessels (opening them up), which makes the blood flow more easily and reduces blood pressure. This makes it easier for your heart to pump blood around the body.

ACE inhibitors often have a positive impact on the heart's performance and may improve your quality of life. They reduce the risk of hospitalisation and prolong life.

Examples of ACE inhibitors include ramipril, captopril, enalaprillisinopril and perindopril.

The most common side effect is a dry, irritating cough. If you have a troublesome cough, an ACE inhibitor may be switched to an ARB.

ACE inhibitors can also cause your blood pressure to fall too low, and they may upset kidney function. Your GP will monitor this.

Beta-blockers

Beta-blockers are usually used to treat people with heart failure caused by systolic dysfunction (where the left ventricle that pumps blood around the body doesn't work properly).

These drugs reduce the risk of hospitalisation and prolong life in patients with a low left ventricular ejection fraction (the amount of blood pumped out by the left side of your heart).

However, beta-blockers may not be suitable for people with asthma, although most patients with chronic obstructive pulmonary disease (COPD) will be able to tolerate them.

Beta-blockers work by slowing your heart down and protecting your heart from the effects of chemicals produced by the body called adrenaline and noradrenaline.

Your doctor may start you on a low dose and increase it over a few weeks or months. There are several different beta-blockers, but the ones used to treat heart failure in the UK are bisoprolol, carvedilol and nebivolol.

Ivabradine

As long as the heart is in a normal rhythm (sinus), ivabradine will slow the heart rate. It can be a useful alternative for some people when beta-blockers cannot be used or are not tolerated.

If beta-blockers do not slow the heart enough, the addition of ivabradine can provide added protection, leading to improved heart function and symptoms.

It can also reduce the risk of hospitalisation and prolong life in people with a low left ventricular ejection fraction.

Aldosterone antagonists

Aldosterone antagonists are suitable for some people with heart failure. They work in a similar way to diuretics, but they can stop the diuretics from washing out potassium and may also help reduce scarring of the heart muscle.

They improve symptoms, reduce the risk of hospitalisation, and prolong life in people with a low ventricular ejection fraction.

The most widely used aldosterone antagonists are spironolactone and eplerenone. Spironolactone may cause swelling and pain around the nipples in men and testicular atrophy (shrinking of the testicles). Eplerenone rarely causes such effects.

The most serious side effect of these medicines is that they can cause the level of potassium in your blood to go too high, which can cause problems. Your doctor will carry out regular blood tests to monitor your potassium level.

Angiotensin receptor blockers (ARBs)

Angiotensin receptor blockers (ARBs) work in a similar way to ACE inhibitors by widening blood vessels and reducing blood pressure. They tend to be used as an alternative because they do not usually cause a cough.

Examples of ARBs include candesartan, losartan, telmisartan and valsartan. Side effects include low blood pressure (hypotension) and high levels of potassium in your blood. Your doctor will carry out regular blood tests to monitor your potassium level.

Although ARBs do not cause coughs, they may not be quite as effective as ACE inhibitors.

Hydralazine with nitrate

When hydralazine is combined with nitrate, the blood vessels dilate (open up). These medicines are sometimes prescribed by heart specialists for people who are unable to take an ACE inhibitor or ARB.

Digoxin

Digoxin, derived from the foxglove plant, can increase the strength of your heart muscle contractions and slow down your heart rate. It can improve symptoms and reduce hospitalisation, but it does not appear to prolong life.

It is recommended for people who have symptoms despite treatment with ACE inhibitors, ARBs, beta-blockers and diuretics. It is used earlier in people who have both heart failure and a condition called atrial fibrillation (where the heart beats irregularly).

Anticoagulants

Anticoagulants make it more difficult for your blood to clot, helping to prevent a stroke.

Warfarin is the most commonly used anticoagulant, and requires careful monitoring by your GP or doctor to make sure you get the right amount.

Antiplatelet medicines

Platelets are cell fragments that are part of the clotting system. Aspirin and clopidogrel reduce the stickiness of blood platelets, which may reduce the risk of a heart attack or stroke.

Aspirin is not usually taken with warfarin. Speak with your GP if you are concerned.

Devices for heart failure

Pacemakers

You may need to have a pacemaker fitted if your heart beats too slowly, even if this only occurs occasionally.

A pacemaker monitors your heart rate continuously. If your heart rate drops too low, it sends a signal down a wire to your heart muscle to stimulate it.

There are several different types of pacemaker. The best one for you will depend on the type of heart rhythm or beat problem you have.

The pacemaker is implanted under the skin by a cardiologist (heart specialist), usually under local anaesthetic. You will usually need to stay in hospital overnight to check it is working properly. Serious complications from pacemakers are unusual.

Pacemakers need to be checked regularly by specialist technicians at a pacemaker clinic. You will also need to be careful about things that can affect how your pacemaker works, such as hospital equipment and security systems in shops or at airports.

Read more about pacemaker implantation. You can also find out more about pacemakers on the British Heart Foundation website.

Cardiac resynchronisation therapy

In some people with heart failure, the walls of the left ventricle (the main pumping chamber) do not work together and contract out of phase with each other.

Cardiac resynchronisation therapy (CRT) is a special type of pacemaker that can correct the problem, making the walls of the left ventricle all contract at the same time. This makes the heart more efficient.

Most pacemakers only have one or two wires to the heart, but CRT requires an extra wire that is a bit harder to get into place than the other wires.

CRT is considered for people who:

  • have moderate to severe heart failure symptoms despite medication
  • have a left ventricular ejection fraction (the amount of blood pumped out of the left ventricle) of less than 35%
  • have evidence from an electrocardiogram (ECG) that there is a problem with the electrical activation of the left ventricle (a measurement called QRS width) – if it is longer than 150 milliseconds (ms), there is strong evidence of benefit; if it is 120 to 150ms, the evidence is less strong (a normal QRS is less than 100ms)

Implantable cardioverter defibrillators (ICDs)

People who have (or are at high risk of having) an abnormal heart rhythm, called ventricular tachycardia (VT) or ventricular fibrillation (VF), may need to have a device known as an implantable cardioverter defibrillator (ICD) fitted.

With VT, the heart beats too fast and there is not enough time for the heart to fill with blood between beats. This can lead to a blackout and may cause VF.

In VF, the heart rhythm is so abnormal that the heart no longer contracts, but "quivers" instead. This results in death unless an electrical shock is given to the heart to restart it.

An ICD works by constantly monitoring the heart rhythm. If VT is detected, the ICD will try to correct it. If this does not work, the ICD will try to bring the heart back to normal by giving it a small, controlled electrical shock.

If this fails, the ICD will deliver a larger shock. The electrical shocks are known as defibrillation. If the ICD detects VF, it will defibrillate the heart immediately.

As with pacemakers, ICDs are implanted in hospital, usually under local anaesthetic. Like pacemakers, you will need to avoid things that can interfere with the way the ICD works, such as airport security systems.

Read more about ICDs on the British Heart Foundation website.

CRT-D

Devices that combine cardiac resynchronisation and the ICD function are implanted into patients who need both. Two separate devices are not necessary. These combination devices are usually called CRT-Ds.

Surgery

Medicines are the main treatment for heart failure, but for some people an operation may help.

Heart valve surgery

If the valves of your heart are damaged or diseased, your doctor may suggest valve surgery. There are two types of valve surgery – valve replacement and valve repair.

The type of surgery you have will depend on what is wrong with the valve and how serious the problem is. Your doctor will discuss it with you.

Angioplasty or bypass (revascularisation)

If your heart failure is related to coronary heart disease, your doctor may suggest coronary angioplasty or a coronary artery bypass graft (CABG).

This will help get the blood flowing to your heart muscle and can improve angina, reduce the risk of a heart attack in some cases, and sometimes improve heart muscle function.

Left ventricular assist devices

A great deal of research has been carried out to try to make a mechanical heart that can replace heart function completely. So far attempts have met with limited success.

However, mechanical pumps have been developed to boost, rather than replace, the failing left ventricle. These are quite successful for people with severe heart failure that is difficult to control with medicines.

These pumps are complex and expensive, and are not suitable for everyone. They are usually only implanted into a patient surgically at a heart transplant centre.

Mechanical booster pumps require an external battery, so a wire has to be tunnelled underneath the skin. The wire can cause an infection, which is a major drawback of this type of technology.

In the UK, several hundred people are living at home with fairly active lives after having one of these pumps fitted.

Heart transplantation

In recent years, the survival rates and quality of life among people with severe heart failure has improved substantially.

However, some people have such severe heart failure that treatment with medicines or surgery does not help, and they may need to have their diseased heart replaced with a healthy one from a donor.

Having a heart transplant is a major decision. It is a complex surgical operation with risks. There is also a shortage of hearts for transplantation, and some people have to wait years for a suitable heart closely matching their own.

Read more about heart transplants. You can also find out more about other types of surgical heart treatments on the British Heart Foundation website. 

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