Congestive heart failure

Page last reviewed: 13/07/2011

Heart failure is a serious condition but it does not mean your heart is about to stop working. It describes what happens when the heart is having trouble pumping enough blood around the body and usually occurs because the heart muscle has become too weak or stiff to work properly.

Heart failure affects about 90,000 people in Ireland. It tends to affect older people, and the average age at diagnosis is 76. It is more common in men than women and can be caused by a number of other conditions, such as high blood pressure or a heart attack.

Symptoms of heart failure can happen quickly and this is known as acute heart failure. More often, the symptoms develop slowly over time, which is known as chronic heart failure.

Heart failure can be treated, allowing you to control the effects of the condition and continue to live a normal life.

Types of heart failure

There are two main types of heart failure and the symptoms and effects on your body will depend on which type you have.

  • heart failure due to left ventricular systolic dysfunction (LVSD): when the part of the heart that pumps the blood around the body (left ventricle) doesn't work as well as it should
  • heart failure with preserved ejection fraction (HFPEF): when the heart has difficulty filling with blood

It is important that your healthcare team find out what type of heart failure you have, as it will affect what treatments you will be offered.

Page last reviewed: 13/07/2011

The main symptoms of heart failure are:

  • breathlessness (dyspnoea) when you're more active than usual or sometimes when you're resting
  • extreme tiredness and weakness
  • swelling in the legs, ankles and feet (oedema)

These symptoms are often caused by other conditions but they are signs that you might have heart failure. Your doctor may suggest doing some tests to see if you have got heart failure or to rule it out as a cause for your symptoms.

Other symptoms that might be associated with heart failure include:

  • being woken up in the middle of the night gasping for breath (paroxysmal nocturnal dyspnoea)
  • a cough that will not go away
  • nausea (feeling sick)
  • lack of appetite
  • weight loss
  • confusion or difficulties in concentrating 

Page last reviewed: 13/07/2011

Often there is not one single cause of heart failure. There are a number of conditions that make it more likely that you will develop heart failure. These include:

  • Coronary heart disease, when the arteries supplying blood to the heart become furred up and narrow due to atherosclerosis. This is the most common cause of both heart attack and heart failure.
  • High blood pressure puts extra strain on the heart and over time can lead to heart failure.
  • Damage to the heart muscle (cardiomyopathy) can lead to heart failure. Damage can be caused by infections but also by alcohol misuse, drug abuse or sometimes as a side effect of prescribed drugs. Heart attacks can also damage the heart muscle.
  • Heart rhythm disturbance (atrial fibrillation).
  • Heart valve disease, damage or problems with the valves in the heart due to infection, atherosclerosis or ageing can lead to heart failure. 
  • Anaemia.
  • An overactive thyroid gland.

Many of these factors can be managed either by making lifestyle changes or by taking medicines.

Risk factors you can't change

There are other conditions that you can't change that can also increase the risk of developing heart failure. These include those mentioned below.

Heart rhythm abnormalities (arrhythmias)

If the heart beats too fast, it may not have enough time to fill and empty properly, which causes the heart muscle to weaken. A slow heartbeat may reduce the heart output and cause symptoms of heart failure.

An irregular heart rhythm increases the risk of a blood clot (thrombosis), causing a heart attack or stroke. In some patients it may cause heart failure, especially if the heart rate is too fast.

Myocarditis

This is inflammation of the heart muscle and most commonly caused by infection with a virus. This inflammation can lead to heart failure.

Damaged heart valves

The heart contains four valves that make sure the blood flows one way through the heart. A leaking valve means the heart has to work harder and stretches to deal with the extra volume of blood. A narrowed valve can obstruct blood flow and reduce the amount of blood the heart can pump. Over time both a leaking valve or a narrowed valve can weaken the heart muscle.

Heart valves can be damaged during a heart attack, and some children are born with faulty valves (congenital heart disease). Valves can be repaired with a surgical operation if the damage is detected in time.

Other heart diseases present at birth

Some babies are born with a 'hole in the heart' which is an abnormal connection between the left and right sides of the heart. Blood can flow from one side to the other (usually left to right) causing strain on the right side of the heart, which in turn may cause heart failure to develop.

Glossary

High blood pressure
High blood pressure (hypertension) is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHg.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Heart valve
Heart valves are four sets of flaps that control the direction that blood pumps around the heart.
Thyroid gland
The thyroid gland in the throat makes hormones to help control growth and metabolism (the process that turns the food we eat into energy).
Heart attack,
A heart attack happens when there is a blockage in one of the arteries in the heart.
Artery
Arteries are blood vessels that carry blood from the heart to the rest of the body.

Page last reviewed: 13/07/2011

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

If your doctor thinks you may have heart failure, you will probably need to have tests to find out more. These will include:

  • blood tests, to check if there is anything in your blood that might indicate heart failure or some other illness 
  • an echocardiogram (an 'echo'), which checks how well your heart is pumping

 

Blood tests

Blood tests can show whether you have another condition that may be causing your symptoms, such as anaemia, diabetes, thyroid problems or kidney disease. A blood test can also check whether the level of cholesterol in your blood is too high, as this is associated with coronary heart disease, which may lead to heart failure.

Natriuretic peptide test

Your blood sample will be tested for a substance called natriuretic peptide (also called BNP or NTproBNP). If your heart is damaged or overworked, it will secrete BNP into the blood and the test can detect these higher levels.

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

Echocardiogram (or echo)

An echocardiogram (ECG) is used to look in detail at the structure of your heart. A pulse of harmless, high-frequency sound waves is passed through the chest wall and produce a picture by 'bouncing back' from the structures in the heart (in a similar way to an ultrasound scan in pregnancy).

For the test, you will be asked to lie on your left side with your left arm behind your head. Lubricating jelly is put on your chest and the ultrasound probe (recorder) is placed at various points on the chest between the ribs. The probe picks up echoes from the heart and shows them on the screen as a detailed picture (echocardiogram) of the structures of the heart.

The test allows the operator to find out a lot of information about the heart, including:

  • how well the valves are working and whether any of them are damaged
  • how well the heart is working as a pump (when the contraction of your heart forces blood to circulate around the body, called systolic function)
  • how well the heart relaxes after pumping (when the heart relaxes after each contraction, allowing it to fill with blood, called diastolic function)
  • whether there are holes in the walls between the chambers of the heart, disrupting the one-way system of blood flow and allowing 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 chambers of your heart - the left ventricle - is pumping. The left ventricle pumps the blood around the body. This 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 gets pumped out when the heart muscle contracts. A value of less than 40% would indicate that the heart is not pumping well.

Sometimes different types of echocardiogram are performed. These include:

Stress echocardiogram

A stress echocardiogram is carried out to see how the heart functions when it has to work hard. It is performed by increasing the person's heart rate, either by exercise on a treadmill or exercise bike or by the infusion of a medication.

Transoesophageal echocardiography

This test is carried out when doctors need to look at your heart structure in more detail. Pictures of your heart are taken from inside your body by passing a small probe mounted at the end of a thin flexible tube down your oesophagus (the tube that connects your mouth to your stomach).

Before the test, you may be given a mild sedative to help you relax and an anaesthetic will be sprayed on the back of your throat to make it easier to swallow the tube. While the probe is in your oesophagus, pictures of your heart are taken. The probe is then gently withdrawn.

Other tests

You may also have other tests to help rule out any other causes of your symptoms. These may include:

  • an electrocardiogram (ECG), which records the natural electrical activity in your heart
  • a chest X-ray to check whether your heart is bigger than it should be and whether there is fluid in your lungs, which might indicate heart failure
  • breathing tests to rule out any problems with your lungs
  • blood and urine tests

Page last reviewed: 13/07/2011

Lifestyle changes

If you've been diagnosed with heart failure, you can reduce your risk of further episodes by making simple lifestyle changes. Stopping smoking will quickly reduce your risk of a future heart attack to near that of a non-smoker.

Other lifestyle changes, such as eating more healthily and being more physically active, will also improve your symptoms and reduce the pressure on your heart.

Rehabilitation programmes

You may be offered an opportunity to attend a heart failure rehabilitation programme. Heart failure rehabilitation programmes vary widely throughout the country but most will cover the following basic areas:

  • exercise
  • education
  • relaxation and emotional support

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

Medicines for heart failure

Most patients with heart failure are treated with medicines. Depending on your symptoms, you may need to take several medicines. The usual combination of medicines for heart failure includes:

  • a diuretic
  • an angiotension-converting enzyme (ACE) inhibitor
  • a beta blocker
  • an aldosterone antagonist

Your doctor will discuss the treatments available. The first drug or drugs you try may not work properly or suit you, so expect some changes until you and your GP find a combination that works well for you. You may be offered other medicines if these don't work, or if you have another condition or other symptoms that also need treatment.

Diuretics

Diuretics help to relieve ankle swelling and breathlessness caused by heart failure. They work by helping to remove water and salt from the kidneys in the urine. There are many different types of diuretic, but some of the most widely used for heart failure are bendroflumethiazide, bumetanide and furosemide (also called frusemide).

ACE inhibitors

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

They often have a positive impact on the performance of the heart, and may improve your quality of life. However, they are not suitable for everyone. Examples of ACE inhibitors include ramipril, captopril, enalapril, lisinopril and perindopril. The most common side effect is a dry, irritating cough.

Beta-blockers

Research has shown that beta-blockers can help some people with heart failure. However, they are not suitable for people with asthma. They work by slowing your heart rate and perhaps by protecting your heart from the effects of adrenaline and a related chemical, 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 are bisoprolol, carvedilol and nebivolol.

Aldosterone antagonists

These drugs are suitable for some people with heart failure. They work in a similar way to diuretics, but can also help heal any scarring of the heart muscle.

The most widely used - aldosterone antagonist - is spironolactone. The main side effect of is high levels of potassium in the blood, which can cause problems. Your doctor will do regular blood tests to monitor your potassium level.

Angiotensin receptor blockers (ARBs)

ARBs have been shown to extend life and reduce symptoms in patients with heart failure. They work in a similar way to ACE inhibitors, by widening blood vessels and reducing blood pressure, and tend to be used as an alternative as they do not usually cause cough.

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

Hydralazine with nitrite

This combination of drugs open up (dilate) blood vessels, and are sometimes prescribed by heart specialists for people who are unable to take an ACE inhibitor or ARB.

Digoxin

Digoxin, related to a medicine derived from the foxglove plant, increases the strength of heart muscle contractions and can also slow down heart rate. 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 is beating irregularly).

Anticoagulants

Anticoagulants help to make it more difficult for your blood to clot. This helps 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 medicine

Antiplatelet medicine, for example aspirin, is used to stop blood platelets from forming clots in your blood. Aspirin is not usually taken with warfarin. Speak with your GP if you are concerned.

Devices for heart failure

Pacemakers

If your heart beats too slowly either or all or some of the time, you may need to have a pacemaker fitted. A pacemaker monitors the heart rate continuously, and if the rate drops too low, sends a signal down a wire to the heart muscle to tell it when to beat. There are several different types of pacemaker. The best one for you will depend on what type of heart rhythm or beat problem you have.

The pacemaker is be implanted in your chest by a cardiologist, normally under local anaesthetic. You will usually need to stay in hospital overnight to check that 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.

Cardiac re-synchronisation therapy

In some people with heart failure, the walls of the left ventricle (the main pumping chamber) don't all contract simultaneously, but out of phase with each other. Cardiac resynchronisation therapy (CRT) is a treatment that tries to correct the problem by making the walls of the left ventricle all contract at the same time. The heart then works better.

A pacemaker generator buried under the chest wall is connected to three leads that are manipulated into the correct position in the heart. By sending a a small electrical current to leads connected to the different walls of the left ventricle, the heart is made to beat in a more coordinated way.

CRT tends to be 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

Implantable cardioverter defibrillators (ICDs)

People who have (or are at particularly high risk of having) an abnormal heart rhythm, called VT (ventricular tachycardia) or VF (ventricular fibrillation), may need to have a device fitted called an ICD. With ventricular tachycardia, the heart beats too fast and there is not enough time for the heart to fill with blood properly between beats (contractions), so not enough blood is pumped round the body.

In ventricular fibrillation, 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 ventricular tachycardia 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 ventricular fibrillation, it will defibrillate the heart immediately.

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

CRT-D

Devices that combine cardiac resynchronisation and the ICD function are implanted into patients needing both: two separate devices are not necessary. Such a device is usually called a CRT-D.

Surgery

Medicines are the main treatment for heart failure but for some people, surgery is possible. For example, if you have a damaged heart valve, it is possible to repair it or replace it with an artificial one. If your heart failure is caused by a problem with the left ventricle of your heart, there are a few surgical options for treatment.

Heart valve surgery

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

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

Revascularisation

If your heart failure is related to coronary heart disease your doctor may suggest coronary angioplasty or a coronary artery bypass graft (CABG) to help get the blood flowing to your coronary arteries (the blood vessels leading up to the heart). If this is the right approach for you, your doctor will discuss it with you.

Heart transplantation

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.

It is a big decision to make. Heart transplants are complex surgical operations with risks. They have dramatically improved the survival rates and quality of life among people with severe heart failure but there is a shortage of hearts for transplantation and people may have to wait years for a suitable organ to become available because the donor heart must closely match their own.

Page last reviewed: 13/07/2011

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

Although there is limited evidence to prove that lifestyle changes make a big difference to the risk of heart failure, the following is generally good advice to help you lead a long and healthy life.

In particular, high blood pressure and smoking are risks for heart health and tackling these could help reduce symptoms and improve quality of life.

Stop smoking

For smokers, giving up is likely to be the single biggest way to cut the risk of developing coronary heart disease and heart failure. Tobacco smoke can damage your heart in a number of ways, forcing it to work harder. visit www.quit.ie

Smoking also tends to make the blood thicker and slows down blood flow, increasing the risk of blood clots (thrombosis). It damages the linings of the arteries, causing them to fur up. This furring up of the arteries (atherosclerosis) is a main cause of coronary heart disease, stroke and some forms of dementia.

Research has shown that you are up to four times more likely to give up smoking successfully if you use NHS support, together with stop-smoking medicines. Ask your doctor about this or go to www.quit.ie

Keep your blood pressure down

When your blood pressure is too high, your heart has to work harder to pump blood around the body. To cope with the extra effort the heart muscle becomes thicker over time, but eventually it becomes too stiff or weak to work properly. Keeping blood pressure down can stop this happening so it may be useful to have your blood pressure checked regularly.

It may be necessary to take blood pressure medicines (usually more than one) to get your blood pressure down to a healthy level. It is important you and your doctor choose the medicine or combination of medicines that will suit you.

Reduce your cholesterol level

High levels of cholesterol (fat) in your blood can cause furring and narrowing of the arteries (atherosclerosis), heart attacks and strokes. The risk of coronary heart disease - and therefore heart failure - increases as the level of cholesterol in the blood increases. If you have other risk factors, such as high blood pressure or you smoke, the risk is even bigger.

If your cholesterol level has been found to be too high, your doctor will usually first advise making some changes to your diet (switching to a low-fat diet) and taking plenty of regular exercise. If, after a few months, your cholesterol level has not dropped, you will usually need to take cholesterol-lowering medicines called statins.

Lose weight

Being overweight puts added pressure on your heart and increases your risk of coronary heart disease and a heart attack, both of which make heart failure more likely.

Eat a healthy diet

A healthy diet can help reduce your risk of getting coronary heart disease and therefore heart failure. If you already have heart problems, eating a good diet can help protect your heart from getting worse, as well as protecting you from other diseases such as diabetes and some cancers.

Keep active

Regular physical activity can keep your heart healthy and help you maintain a healthy weight. You do not need to join a gym or start running marathons, but including exercise in your daily routine will help. People who aren't easily mobile can do chair-based exercises.

Drink within safe limits

Drinking above recommended levels can increase blood pressure, which can lead to heart failure. Heavy drinking over a number of years can damage the heart muscle and lead directly to heart failure, as well as having many other harmful effects on your health.

Men who regularly drink more than three to four units of alcohol a day, and women who regularly drink more than two to three units a day are likely to be damaging their health.

Cut your salt intake

Too much salt can raise your blood pressure. Reducing the amount of salt you eat will help keep your blood pressure down and help reduce your risk of getting heart failure. People of African Caribbean descent appear to be more at risk of the harmful effects of salt compared with people from other ethnic groups.

Page last reviewed: 13/07/2011

Cardiac rehabilitation

While taking regular exercise will improve the general health of your heart, exercise programmes led by a health professional can help people with heart failure breathe more easily and improve the quality of their life. If these programmes are available in your area, they are likely to be part of a service called cardiac rehabilitation.

Most people on these programmes will either have had heart surgery or a heart attack but the programmes are also good for people with heart failure. They are usually run in hospitals by a cardiac rehabilitation team, which involves various health professionals, including nurses, physiotherapists, occupational therapists and exercise specialists.

The exercise programmes vary widely across the country but most cover one or more of the following:

  • exercise
  • education
  • relaxation and emotional support

Before you start, you will have an assessment to find out how much exercise you can do safely. The programme worker will then tailor a programme of exercises especially for you. You will be encouraged to start slowly and gently and to increase the amount of exercise you do gradually over the week. Work within your limits and follow the advice you are given.

The sessions will begin with warm-up exercises. The main part of the session will be aerobic exercises that help your heart and circulation. Some programmes will use special equipment, such as exercise bikes, and others will include exercises you can do in a chair.

You may be asked to watch your heart rate while you exercise by using a small machine called a heart rate monitor that you can hold or strap to your wrist. This is to ensure your heart does not work too hard.

At the end of each session, there will be a cool-down phase that will involve stretching your muscles to help stop them aching the next day.

The education part of the programme will give you information on healthy eating, recognising and avoiding stress, and practical ways to reduce your risk of further damage to your heart. Many programmes also focus on different ways to relax and can find a technique that suits you.

Feelings and relationships

Being diagnosed with heart failure can be a great shock. Naturally, some people will feel scared, anxious, depressed, angry, unable to enjoy things any more or to cope with everyday life. It is estimated that around one in five people with heart failure suffer from depression.

Seek help if you think you are depressed. Not only does depression reduce your ability to enjoy life, but it can make your heart failure symptoms worse.

Understandably, heart failure can  make you worry about your health and how it affects your family. Many people also find that their physical relationship with their partner changes after they have been diagnosed, due to worries about having a heart attack, or losing interest in sex, or being unable to get an erection (which can sometimes be caused by your medication).

It is important to discuss any worries or problems you have with your doctor or nurse if you don't feel able to talk to your family. Many people do not want to burden those closest to them with their worries. Your doctor or nurse will be able to provide you with guidance and arrange support. You may also find it helpful to join a heart support group where you can talk to other people with heart conditions whose circumstances are similar to yours.

Travelling

Being diagnosed with heart failure should not prevent you from travelling or going on holiday, as long as you feel well enough and your condition is well controlled. If you have heart failure, check with your doctor before you travel.

Anyone travelling and sitting still for a long time either in a car, coach or on a plane, should do simple exercises to reduce the risk of deep vein thrombosis (DVT). When flying, you should wear flight socks or compression stockings to keep blood flowing through the legs and reduce the risk of DVT.

Also, be aware that your legs and ankles may swell when flying and if you have severe heart failure, breathing may become more difficult.

It may be a good idea to take two sets of medication with you when you travel. Carry them in different places in case you lose one, and make a list of the medication you take, and what it is for.

Travel insurance

Having heart failure should not stop you from getting travel insurance but you may have to find a specialist company that will insure you.

What will happen towards the end?

If their heart failure gets more severe, a person may find themselves becoming more and more immobile. The breathlessness can get worse and this can be a distressing symptom if not managed properly.

Your doctor can prescribe painkillers called opioids which, when used carefully, have been shown to ease the feeling of breathlessness. Some patients find that pain becomes more of a problem as their heart failure worsens. Opioids can also help relieve pain.

What is palliative care?

Palliative care describes the support and care of symptoms when no cure for the disease is possible, often when the person is dying. Your doctor or nurse may suggest you see a specialist or nurse in palliative care, or a counsellor.

A palliative care team will focus on controlling your symptoms, keeping you as comfortable and as pain-free as possible, as well as offering physical, psychological, spiritual and social support for you and your family.

What decisions do I need to make?

The things that you will need to consider are:

  • Making a will if you haven't made one already.
  • An advance statement lets those close to you know about the sort of care you would like, and where you want it (e.g. home, hospital or hospice) if you are not able to decide for yourself, perhaps because you are unconscious. While you can write down your wishes about what sort of future treatment you do and do not want, doctors can override your decision if they think it is in your best interests.
  • Whether you want to make a living will (this is called an advance directive). This allows mentally competent people to refuse some or all forms of medical care in the future when they are unable to make their own decisions or tell doctors what they want (for example, if they are in a coma). This is legally binding, so doctors must comply with your wishes.
  • If your heart stops, do you want to be resuscitated?
  • If you have a defibrillator, would you want it turned off?

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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