What is Heart Failure?

The heart pumps oxygen and nutrient-rich blood throughout the body and receives it back. Heart failure (HF) is a condition in which the heart is not able to pump blood as well as it should, so the body’s cells do not receive sufficient oxygen and nutrients. The term HF can be confusing; as it suggests the heart has failed or stopped working; but that is not the case.

Types of Heart Failure

The heart has two atria and two ventricles (heart chambers). The left ventricle is larger than the right and pumps blood to the body, while the right side pumps blood to the lungs. Usually, HF starts on the left side and but can involve the right side as well, particularly in later stages. HF is usually a long term condition (chronic) and can have flare ups or acute worsening. One of the measures of the pumping capability of the heart is ejection fraction (EF), which indicates how much of the blood the heart receives is being pumped out with each beat. Based on the EF, heart failure can broadly be categorised as:

Heart failure with reduced ejection fraction (also called systolic heart failure): In this, the heart muscle becomes weak and is unable to pump blood effectively.

Heart failure with preserved ejection fraction (also called diastolic heart failure): In this, the heart muscle becomes stiff and is unable to relax sufficiently because of which enough blood is not able to fill in the heart.

Congestive heart failure is a commonly used term, to describe a condition in which the heart fails to pump enough blood, because of which blood backs up in the veins, resulting in swelling all over the body. The swelling can be observed in the ankles, legs and belly, but it can also be observed in the lungs, resulting in breathing problems and cough.

Causes of Heart Failure

Some of the common causes of heart failure are as follows:

Coronary artery disease:

The heart receives oxygen and nutrients through blood vessels called arteries. Cholesterol build up the arteries can reduce the flow of blood to the heart muscle. As the blood flow reduces, the heart muscle can become weak, leading to heart failure.

Heart attack:

Heart attack is generally a sudden condition, in which a cholesterol plaque in an artery of the heart breaks forming a blood clot, causing complete obstruction of the blood flow to a part of the heart muscle. This leads to a part of the heart muscle dying, which weakens the heart, and can cause heart failure.

High blood pressure:

High blood pressure increases the workload on the heart. Over time, if the heart can no longer cope up with the increased stress, it starts becoming weaker, leading to heart failure.

Diabetes:

Over time, high blood sugar levels from diabetes can damage blood vessels and nerves in the heart. This can lead to fatty deposits in the blood vessels, which can block blood flow to the heart, causing it to become weak. People with diabetes are more likely to have other conditions that increase the risk of heart failure, such as high blood pressure, high cholesterol, and being overweight.

Obesity:

Obesity increases the workload on the heart, leading to heart failure. Obesity may also cause other conditions like high blood pressure and sleep apnoea, which increase the risk of developing heart failure.

Genetic or familial:

An abnormality in any of the genes responsible for the structure and functioning of the heart muscle can lead to heart failure. This can run in families or can be a new development.

Toxins:

There are substances that are directly toxic to the heart muscle which can lead to heart failure like alcohol in large amounts for a long time, certain drugs like amphetamines, high doses of certain chemotherapy medications. Excessive alcohol consumptions can also cause other conditions like increased blood pressure and obesity, which are linked with heart failure.

Viral infections:

Certain viral infections can involve the heart and make it weak.

Heart valve problems:

The blood flow that goes in and out of the heart is managed by a set of valves acting as gateways. If a heart valve becomes dysfunctional, it can increase the load on the heart, which if left untreated, can lead to heart failure.

Arrhythmia (Abnormal heart rhythm):

Some types of fast irregular heart rhythms, if left untreated, can ultimately cause heart failure.

Congenital heart disease

These are defects in the heart present since birth, in which the heart and its chambers or valves haven't formed correctly, so the other parts of the heart have to work harder to pump blood. This may lead to heart failure, even years after corrective surgery has been performed.

Risk Factors for Heart Failure

The chance of having heart failure increases with the following:

Elevated blood pressure
Diabetes
Having a heart attack
Being overweight
Excessive alcohol consumption
Smoking
Family history
Older age

Symptoms of Heart Failure

Symptoms may develop slowly, or start suddenly. Heart failure symptoms may include:

Shortness of breath with activity or when lying down
Fatigue and weakness
Reduced ability to exercise or even do daily activities
Swelling in the legs, ankles and feet
Rapid or irregular heartbeat
Wheezing
A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood
Swelling of the belly area
Very rapid weight gain from fluid buildup
Nausea and lack of appetite
Difficulty concentrating or decreased alertness
Chest pain if heart failure is caused by a heart attack

Diagnosis of Heart Failure

The diagnosis of heart failure is based on a combination of medical history, physical examination, diagnostic tests, and imaging studies. Here's an outline of the key steps involved:

Medical History:

Your doctor will take a detailed history to see if you have risk factors for HF and symptoms of HF as described above.

Physical Examination:

Vital Signs: Elevated heart rate, high or low blood pressure.
Signs of Fluid Overload
Heart Examination: Heart murmurs or abnormal heart sounds may suggest heart failure
Diagnostic Tests:
Blood Tests:
BNP or NT-proBNP: These are proteins that are markers of heart failure.
Complete Blood Count (CBC): To check for anaemia or infection.
Electrolytes, Renal Function, and Liver Function Tests: To assess the effects of heart failure on organs and diagnose associated medical conditions.
Diabetes screening
Thyroid Function Tests: Since thyroid dysfunction can mimic or worsen heart failure.

Imaging:

Echocardiogram (Echo): This is the most important imaging tool. It provides detailed information about the structure and function of the heart, including ejection fraction (EF).
Chest X-ray: Used to assess heart size and look for signs of fluid in the lungs
Cardiac MRI: In some cases, to assess heart structure or function in more detail.

Electrocardiogram (ECG):

Can show evidence of prior heart attacks, arrhythmias, strain on the heart, all of which can contribute to heart failure.

Stress Testing:

Exercise stress tests or stress test with medications may be done to assess the functional capacity of the heart and detect underlying coronary artery disease.

Cardiac Catheterization:

In some cases, especially if coronary artery disease or heart attack is suspected, cardiac catheterization may be used to assess the arteries of the heart and measure pressures in the heart.

Other Specialized Tests:

Right heart catheterization: To measure the pressures within the heart in cases of advanced heart failure or when pulmonary hypertension (high pressure in the lungs which can cause right heart failure) is suspected.

A combination of these approaches helps confirm the diagnosis of heart failure, understand its severity, and guide treatment options.

Stages and Prognosis

There are four stages of heart failure, ranging from the high risk of developing heart failure to advanced heart failure. The first stage is if you have a strong family history or some other factors that increase your risk of developing HF in the future. In stage B, there are changes in the structure of the heart or elevated BNP/ NT-proBNP, suggesting that conditions like hypertension, are negatively affecting the heart. Stage C is if you develop symptoms or signs of HF. Stage D is the final stage with advanced symptoms.

Treatment of Heart failure

Appropriate and timely treatment of HF can improve symptoms, slow the progression of the disease, reduce hospitalizations and prolong survival. Treatment approach depends on the type of heart failure (reduced ejection fraction vs. preserved ejection fraction), its severity, and any underlying causes. Generally, your doctor will recommend the following:

Lifestyle Modifications:

Dietary Changes:

Avoid excess salt intake
Avoid excess fluid intake, if you have fluid build-up.

Weight Monitoring: Regular weight monitoring to detect fluid retention early.
Exercise: Tailored exercise programs like cardiac rehabilitation help improve functional capacity and quality of life.
Avoid Smoking and Alcohol: Both are important for preventing worsening heart failure.

Medications:

A. For Heart Failure with Reduced Ejection Fraction (HFrEF):

Angiotensin-converting enzyme inhibitors (ACE inhibitors) or Angiotensin II receptor blockers (ARBs):

Examples: Lisinopril, Losartan.
These decrease strain on the heart, reverse some of the damage of the heart muscle, and help the heart work more effectively, slowing the progression of heart failure.

Angiotensin receptor-neprilysin inhibitors (ARNIs):

Example: Sacubitril/valsartan
Improves outcomes in patients with HFrEF and is often preferred over ACE inhibitors/ARBs.

Beta-blockers:

Examples: Carvedilol, Metoprolol succinate, Bisoprolol.
They reduce heart rate and lower the heart's oxygen demand, improving heart function over time.

Mineralocorticoid receptor antagonists (MRAs):

Examples: Spironolactone, Eplerenone.
These help reduce sodium retention, and reverse some of the damage of the heart muscle.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors:

Examples: Empagliflozin, Dapagliflozin.
Originally developed for diabetes, these are now used to improve outcomes in heart failure.

Diuretics:

Example: Furosemide, Torsemide
Help control fluid build-up, reducing symptoms of breathlessness and swelling. Used mainly for symptom relief.

Hydralazine and Nitrates:

Example: Hydralazine/Isosorbide dinitrate.
Can be used in those intolerant of ACE inhibitors/ARBs/ARNI.

Ivabradine:

Used in patients with HFrEF and high heart rates despite beta-blockers to reduce hospitalization risk.

B. For Heart Failure with Preserved Ejection Fraction (HFpEF):

Diuretics: For managing fluid overload, as most other therapies that reduce mortality inHFrEF have not shown the same benefits in HFpEF.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors:

Examples: Empagliflozin, Dapagliflozin.
These have also been shown to beneficial in HFpEF

Treating Underlying Conditions:

This is perhaps the most important if you have HFpEF
Effective management of associated conditions like hypertension, atrial fibrillation, diabetes, coronary artery disease, obesity, sleep apnoea, anaemia, etc is essential to manage HFpEF.

Device Therapy:

Implantable Cardioverter-Defibrillator (ICD):

For patients with HFrEF and high risk of sudden cardiac death due to arrhythmias.

Cardiac Resynchronization Therapy (CRT):

For patients with HFrEF and left bundle branch block ( an electric conduction issue that causes dyssynchronous contraction of the left ventricle) this device helps improve the efficiency of heart contractions.

Surgical Treatments:

Coronary Artery Bypass Grafting (CABG) or Percutaneous Coronary Intervention (PCI):

If coronary artery disease (blockage of coronary arteries) is a major contributor to heart failure.

Valve Repair or Replacement:

If valvular heart disease (like mitral or aortic valve problems) is causing or worsening heart failure.

Left Ventricular Assist Device (LVAD):

A mechanical pump used in patients with end-stage heart failure, either as a bridge to heart transplant or as long-term therapy.

Heart Transplant:

For patients with severe heart failure unresponsive to medical and device therapy.

Palliative Care:

In advanced cases for whom LVAD or heart transplant is not an option, palliative care focuses on symptom management, quality of life, and end-of-life care.

Managing Comorbidities:

Diabetes: SGLT2 inhibitors (like dapagliflozin) have both glucose-lowering and heart failure benefits.
Hypertension: Aggressive blood pressure control to prevent worsening of heart failure.
Atrial Fibrillation: Managing arrhythmias with medications, ablation procedures, and/or anticoagulation to reduce the risk of stroke.

Treatment plans should be individualized based on the patient's heart failure type, severity, and other medical conditions. Regular follow-up and monitoring of symptoms, heart function, and treatment adherence are crucial for managing heart failure effectively.

Complications

If you have health failure, it's important to have regular health checkups, even if symptoms improve. Your health care provider can examine you and run tests to check for complications.

Complications of heart failure depend on your age, overall health and the severity of heart disease. They may include:

Other heart problems: Heart failure can cause changes in the heart's size and function. These changes may damage heart valves and cause irregular heartbeats.
Infections: . Having heart failure can increase your risk of catching infections, particularly viral respiratory infections. Therefore, it is important to get influenza (flu) and pneumococcal (bacterial pneumonia) vaccines.
Kidney damage or failure:Heart failure can reduce the blood flow to the kidneys. Untreated, this can cause kidney failure. Kidney damage from heart failure can require dialysis for treatment.
Liver damage: Heart failure can cause fluid build-up that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for the liver to work properly.
Sudden cardiac death: . If the heart is extremely weak, there is a risk of dying suddenly due to a dangerous irregular heart rhythm.

Prevention

One way to prevent heart failure is to treat and control the conditions that can cause it. These conditions include coronary artery disease, high blood pressure, diabetes and obesity.

Some of the same lifestyle changes used to manage heart failure also may help prevent it. Try these heart-healthy tips:

Don't smoke.
Get plenty of exercise.
Eat healthy foods.
Maintain a healthy weight.
Reduce and manage stress.
See a general physician regularly and get your blood pressure, sugar, cholesterol and weight checked. If you have hypertension, diabetes, or high cholesterol, these conditions should be adequately treated.
Take medicines as directed.

FAQs regarding Heart Failure: All your concerns addressed

Q. What are the four stages of heart failure?
A. Heart failure is a chronic, long-term condition that tends to progress with time, unless treated adequately.

Stage A: This is when you have a high chance of developing heart failure because of family history or you have more than one of the following medical conditions:

Diabetes
Hypertension
Coronary artery disease
Metabolic syndrome
History of substance abuse like excessive alcohol consumption

Stage B:

This stage is considered pre-heart failure, and it means that you have been diagnosed with a structural change in your heart like left ventricular systolic dysfunction, a heart attack, increased left ventricular size, etc or elevated BNP/ NT-proBNP levels, but you have NEVER had any symptoms of heart failure.

Stage C:

This stage is when you have a structural change in the heart, like those described above in stage B, elevated BNP/ NT-proBNP levels AND you develop symptoms of heart failure like

Fatigue
Swollen feet and ankles
Breathlessness with activity, or even at rest

Stage D:

Patients who reach this stage are suffering from advanced heart failure that is not responding to the usual medications, or devices. Advanced treatments like heart transplant or LVAD is indicated at this stage.

Q. What is the difference between heart failure and congestive heart failure?
A. Heart failure occurs when the heart muscle fails to pump enough blood for normal body functions. Over time in heart failure, since the heart is unable to pump blood forward, it starts backing up, leading to fluid overload in the organs like the legs and lungs. This is referred to as congestive heart failure. This leads to symptoms like breathlessness, cough, leg swelling and frequent urination.

Q. Can an infection cause heart failure?
A. It is infrequent and can be difficult to prove at times, but a viral infection can affect the heart directly or indirectly, causing inflammation of the heart muscle called as myocarditis. This is an acute condition, can be mild or severe requiring intensive care. There is usually no specific treatment for this, but with good supportive care, the heart function may be recoverable. Sometimes, over time, the heart muscle can become permanently scarred after myocarditis, leading the heart to become enlarged and weak with thin walls. This can lead to heart failure.

Q. Can blood tests detect heart failure?
A. Yes, there is a blood test for a protein called B-type natriuretic peptide (BNP) and a related protein called, NT-proBNP that can identify heart failure and even risk of heart failure. It is important to understand that BNP may be elevated in conditions other than heart failure too, like kidney disease. There are also other types of tests that your doctor will perform to diagnose heart failure, assess its severity, coexisting medical conditions and decide treatment, like, tests for anaemia, thyroid, high cholesterol, etc.

Q. Can chest X-rays show heart failure?
A. Yes, but not always. A chest X-ray may show signs of heart failure like an enlarged heart size, or fluid in the lungs. A chest X-ray may also be normal in heart failure.

Q. Does heart failure mean that it does not function anymore?
A. Heart failure does not mean there is a complete failure of the heart. This condition means that the heart has become weak and struggles to pump enough blood to the rest of the body.

Q. Does heart failure need immediate medical attention?
A. Yes, it is a serious and progressive condition that needs immediate medical attention. If timely treatment is not provided, this condition may get worse, and be more difficult to manage.

Q. Is there any treatment for heart failure?
A. Yes, there are several treatment options available, with which you can have long, healthy life, even with heart failure. The usual line of treatment involves lifestyle changes along with medicines. In some cases, a device, or surgery may be appropriate. If there is an underlying condition causing or worsening heart failure, that may need treatment as well. Treatment differs for different people. You should seek medical treatment to discuss your treatment options.

Q. What is a BNP test?
A. BNP a protein secreted by the heart. It stands for B-type natriuretic peptide. N-terminal-pro-BNP is a breakdown product of BNP. The levels of these proteins increase in patients with heart failure. Nowadays, NT-proBNP is checked more often that BNP, as it is more sensitive. This test will guide your doctor in making a diagnosis of heart failure. It can also show how your condition is progressing, if there is improvement and response to treatment or not. This can help your doctor modify treatment. You will be required to provide a small amount of blood to be placed in a machine that measures the level of these proteins. Your doctor will discuss the results and recommend treatment accordingly with you.