Cardiac Failure Chronic

Heart failure, Congestive heart failure, CHF, Chronic heart failure

Chronic heart failure is a long-term condition where the heart cannot pump blood well enough to meet the body’s needs. While the heart is still working, it becomes too weak or stiff over time, causing blood and fluids to build up in the lungs, legs, and other parts of the body.

Table of contents

• What is chronic heart failure?
• Types of chronic heart failure
• Symptoms
• Causes and risk factors
• How is it diagnosed?
• Treatment
• Living with chronic heart failure
• Outlook

What is chronic heart failure?

Chronic heart failure, also called congestive heart failure or simply heart failure, happens when your heart muscle cannot pump blood as well as it should^[1]. The term “heart failure” does not mean that your heart has stopped working or is about to fail completely. Instead, it means your heart needs support to work better^[6].

When your heart cannot handle the amount of blood it should, blood builds up in other parts of your body. Most often, this buildup collects in your lungs, legs, and feet^[2]. Blood often backs up and causes fluid to build up in these areas, which leads to various symptoms^[1].

More than 6 million people in the United States have congestive heart failure, making it the leading cause of hospitalization in people older than 65^[2]. Nearly 6.7 million adults aged 20 years or older in the United States live with this condition^[9].

Chronic heart failure is a long-term condition that typically gets gradually worse over time^[3]. This ongoing, progressive nature is what makes it “chronic,” setting it apart from acute heart failure, which develops very suddenly^[3]. While it usually cannot be cured, symptoms can often be controlled and managed effectively for many years^[6].

Types of chronic heart failure

The condition affects the lower chambers of the heart, called the right and left ventricles. The left ventricle pumps blood around the body, supplying it with oxygen^[3]. Types of chronic heart failure include left-sided heart failure, right-sided heart failure, and high-output heart failure, which is a rare type^[2].

Chronic heart failure is classified according to how the heart reacts when it pumps. The two main types are^[3]:

• Heart failure with reduced ejection fraction (also called systolic heart failure or HFrEF): This type occurs when the heart is too weak and does not squeeze normally.
• Heart failure with preserved ejection fraction (also called diastolic heart failure or HFpEF): This type occurs when the heart is too stiff and does not fill with blood normally.

It is also possible to be affected by a combination of these two types. Moreover, each type of chronic heart failure can affect the left ventricle, right ventricle, or both at the same time^[3].

Left-sided heart failure is the most common cause of right-sided heart failure. When your left ventricle is not working correctly, it allows blood to back up. At some point, this backup affects your right ventricle^[2].

Symptoms

If you have heart failure, your heart cannot supply enough blood to meet your body’s needs. Symptoms may develop slowly. Sometimes, heart failure symptoms start suddenly^[1]. The symptoms of chronic heart failure generally depend on the type of the condition being experienced and its location, meaning which ventricle is involved^[3].

Heart failure symptoms may include^[1]:

• Shortness of breath with activity or when lying down
• Fatigue and weakness
• Swelling in the legs, ankles, and feet
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Wheezing
• A dry, hacking cough
• A full (bloated) or hard stomach
• Weight gain
• Loss of appetite or upset stomach (nausea)
• Need to urinate while resting at night
• Chest pain
• Dizziness or lightheadedness

The main symptom of left-sided chronic heart failure is shortness of breath, which generally becomes worse with activity or when lying flat. A cough may also be present. If the condition is affecting the right side of the heart, edema, a buildup of fluid causing swelling of the legs and ankles, is the most commonly experienced symptom^[3].

Sometimes, you may have mild symptoms of congestive heart failure or none at all. This does not mean you no longer have heart failure. Symptoms of heart failure can range from mild to severe and may come and go^[2]. Unfortunately, congestive heart failure usually gets worse over time. As it worsens, you may have more or different signs or symptoms^[2].

Doctors generally classify a person’s heart failure according to the severity of the symptoms being experienced. The New York Heart Association (NYHA) Functional Classification system is the commonly used grading system. People are sorted into four categories^[3]:

1. Physical activity is not limited by symptoms.
2. Physical activity is slightly limited. Rest is comfortable.
3. Physical activity is markedly limited. Rest is comfortable.
4. Unable to carry out physical activity without discomfort. Symptoms are present while resting.

People experiencing possible symptoms of chronic heart failure should consult a doctor^[3].

Causes and risk factors

Chronic heart failure has no single cause. It is most accurately thought of as a complication of a variety of other conditions, each affecting the ability of the heart to pump blood around the body effectively^[3]. Heart failure is often the result of a number of problems affecting the heart at the same time^[6].

Some heart conditions slowly leave the heart too weak or stiff to fill and pump blood properly. These conditions include narrowed arteries in the heart and high blood pressure^[1]. The most common cause of heart failure is ischemic heart disease^[5].

Causes of congestive heart failure include^[2]:

• Coronary artery disease and/or heart attack
• Cardiomyopathy (genetic or viral) — conditions affecting the heart muscle
• Heart issues present at birth (congenital heart disease)
• Diabetes
• High blood pressure (hypertension)
• Arrhythmia — heart rhythm problems, such as atrial fibrillation
• Kidney disease
• A body mass index (BMI) higher than 30
• Tobacco and recreational drug use
• Alcohol use
• Medications such as cancer drugs (chemotherapy)
• Damage or other problems with the heart valves

Sometimes obesity, anemia, drinking too much alcohol, an overactive thyroid, or high pressure in the lungs (pulmonary hypertension) can also lead to heart failure^[6].

Risk factors for congestive heart failure include^[2]:

• Being older than 65
• Using tobacco products, cocaine, or alcohol
• Having an inactive (sedentary) lifestyle
• Eating foods that have a lot of salt and fat
• Having high blood pressure
• Having coronary artery disease
• Having a heart attack
• Having a family history of congestive heart failure
• Smoking
• Exposure to second-hand smoke

How is it diagnosed?

To diagnose heart failure, your healthcare professional examines you and asks questions about your symptoms and medical history. Your care professional checks to see if you have risk factors for heart failure, such as high blood pressure, coronary artery disease, or diabetes^[10]. Your healthcare provider will ask you about other health conditions you have, a family history of heart disease or sudden death, and your use of tobacco products^[2].

Your care professional listens to your lungs and heart with a device called a stethoscope. A whooshing sound called a murmur may be heard when listening to your heart. Your care professional may look at the veins in your neck and check for swelling in your legs and belly^[10].

Tests that may be done to diagnose heart failure may include^[10]:

• Blood tests: Blood tests can help diagnose diseases that can affect the heart. Blood tests also can look for a specific protein made by the heart and blood vessels. In heart failure, the level of this protein goes up.
• Chest X-ray: X-ray images can show the condition of the lungs and heart.
• Electrocardiogram (ECG or EKG): This quick and painless test records the electrical signals in the heart. It can show how fast or how slowly the heart is beating.
• Echocardiogram: Sound waves create images of the beating heart. This test shows the size and structure of the heart and heart valves and blood flow through the heart.
• Ejection fraction: This measurement is the percentage of blood leaving your heart each time it squeezes. This measurement is taken during an echocardiogram. The result helps classify heart failure and guides treatment.
• Exercise tests or stress tests: These tests often involve walking on a treadmill or riding a stationary bike while the heart is monitored.

A number of tests can be used to help check how well your heart is working, including blood tests, an ECG, and an echocardiogram^[6].

Treatment

Heart failure has no cure. But treatment can help you live a longer, more active life with fewer symptoms^[12]. Treatment for heart failure usually aims to control the symptoms for as long as possible and slow down the progression of the condition^[6]. Treatment usually involves taking medicines, making lifestyle changes, and sometimes using medical devices or having surgery^[1].

How you are treated will depend on what is causing your heart failure. Common treatments include^[6]:

• Lifestyle changes — including eating a healthy diet, exercising regularly, and stopping smoking
• Medicine — a range of medicines can help; many people need to take 2 or 3 different types
• Devices implanted in your chest — these can help control your heart rhythm
• Surgery — such as a bypass operation or a heart transplant

Treatment will usually be needed for life^[6]. A cure may be possible when heart failure has a treatable cause. For example, if your heart valves are damaged, replacing or repairing them may cure the condition^[6].

Lifestyle changes

Your provider may recommend these heart-healthy lifestyle changes alone or as part of a cardiac rehabilitation plan^[12]:

• Lower your sodium (salt) intake. Salt may make fluid buildup worse.
• Aim for a healthy weight since extra weight can make your heart work harder.
• Get regular physical activity. Ask your healthcare provider about how active you should be, including during daily activities, work, leisure time, sex, and exercise. Your level of activity will depend on how serious your heart failure is.
• Quit smoking. Smoking harms your heart.
• Avoid or limit alcohol. Your provider may recommend that you limit or stop drinking alcohol.
• Manage contributing risk factors. Controlling some conditions can help prevent heart failure from getting worse.

Having a healthy lifestyle, including eating a balanced diet, doing exercise, and not smoking, can help with your symptoms and reduce your risk of becoming seriously ill^[6]. A heart-healthy diet includes fruits, vegetables, whole grains, and lean protein^[20].

You may also be given advice about dietary changes that can specifically help with heart failure, such as limiting the amount of fluid you drink^[17]. Rapid weight gain can indicate fluid buildup, a sign of worsening heart failure. Contact your physician if you gain two or three pounds in one day^[20].

Medicines

Most people with heart failure are treated with medication. Often you will need to take 2 or 3 different medicines^[11]. Take your medicine as directed—do not take less or more^[20].

Some of the main medicines for heart failure include^[11]:

• ACE inhibitors
• Angiotensin-2 receptor blockers (ARBs or AIIRAs)
• Beta blockers
• Mineralocorticoid receptor antagonists
• Diuretics
• Ivabradine
• Sacubitril valsartan
• Hydralazine with nitrate
• Digoxin
• SGLT2 inhibitors

You may need to try a few different medicines before you find a combination that controls your symptoms but does not cause unpleasant side effects^[11].

Devices and surgery

Devices implanted in your chest can help control your heart rhythm^[6]. Surgery options include bypass operations, heart transplants, and other procedures^[6]. Some people may need a heart transplant or a device to help the heart pump blood^[1].

Living with chronic heart failure

“Living with congestive heart failure does not mean you have a poor quality of life,” according to medical experts. “With a healthy diet, regular exercise, the right amount of sleep, and daily rest, you can enjoy and live your best life”^[20].

If you have heart failure, it is important to look after your own health and wellbeing, with support from those involved in your care^[17]. Managing symptoms with lifestyle modifications and keeping a daily healthy routine can help to prevent congestive heart failure from worsening^[20].

Important tips for living with heart failure include^[20]:

• Conserve your energy: The more active you are, the harder your heart works to pump blood. Take frequent breaks to rest. Elevating your feet at rest time reduces the risk of swelling in your legs and feet.
• Exercise regularly: Keeping your body active is an essential part of good heart health. Light physical activity, including walking or swimming, strengthens your heart muscle. Stop the activity and call your physician if you develop shortness of breath or chest pain.
• Get the right amount of sleep: When you sleep, your heart does not work as hard to pump blood. To get better sleep, limit or avoid caffeine and alcohol, maintain a regular sleep routine, and talk to your physician about any sleep-related breathing issues.
• Take your prescribed medicine: Discuss potential side effects with your physician and call them immediately if you are concerned you are not feeling well.
• Check your weight daily: You may also notice swelling in your legs and feet.

You will have regular contact with your GP or care team to monitor your condition at least every 6 months^[17]. These appointments may involve talking about your symptoms, such as whether they are affecting your normal activities or are getting worse; a discussion about your medication, including any side effects; and tests to monitor your health^[17].

Contact your GP or care team if your symptoms are getting worse or you develop new symptoms^[17].

Having heart failure should not prevent you from traveling or going on holiday, as long as you feel well enough and your condition is well controlled. But check with your doctor before you travel^[17].

Outlook

Heart failure is a serious long-term condition that will usually continue to get slowly worse over time^[6]. It can severely limit the activities you are able to do and is often eventually fatal^[6].

But it is very difficult to tell how the condition will progress on an individual basis. It is very unpredictable. Lots of people remain stable for many years, while in some cases it may get worse quickly^[6].

Early diagnosis and treatment can improve quality and length of life for people who have heart failure^[9]. People with heart failure may have severe symptoms. Treatment usually involves taking medicines, reducing sodium in the diet, drinking less liquids, using devices that remove excess salt and water from the blood, having heart transplant and other surgeries, and getting daily physical activity^[9].

In 2023, heart failure was mentioned on 452,573 death certificates and was responsible for 14.6% of all causes of death in the United States^[9]. Heart failure cost the nation an estimated $30.7 billion in 2012, including the cost of health care services, medicines to treat heart failure, and missed days of work^[9].