Heart Failure

Heart failure has numerous causes. As we previously noted, the heart’s chronic inability to pump blood efficiently is often the result of weakness or damage caused by another cardiovascular health issue, like high blood pressure (which forces your heart to work harder) or a previous heart attack.

“Substances that are toxic to the heart such as alcohol and certain drugs, as well as chemotherapy medications, can also cause heart muscle weakness,” Dina Katz, M.D., a cardiologist at Phelps Hospital, Northwell Health, in Sleepy Hollow, New York, tells SELF.

According to the U.S. National Library of Medicine, hypertension, coronary artery disease, and diabetes are some of the most common causes of heart failure:

• Hypertension, or high blood pressure, refers to the force of your blood against your artery walls. Hypertension is one of the most common causes of heart failure, especially in people assigned female at birth and in Black individuals.
• Coronary artery disease is caused by plaque build-up of cholesterol and other substances in your artery walls, which prevents blood from flowing through your arteries.
• Diabetes is when your blood glucose, or sugar, is too high either because you don’t have enough insulin (a hormone that regulates your blood sugar) or because your body doesn’t use insulin well. Over time, high blood sugar can also lead to high blood pressure and eventually heart disease.

Other conditions and risk factors that can lead to heart failure include the following:

• Metabolic syndrome is a group of risk factors that develop in tandem and can increase your risk for heart disease, according to the NHLBI. These factors include high blood pressure, having high body fat around your waist, high blood sugar, high triglycerides (a type of fat in the blood), and low HDL (“good”) cholesterol levels.
• Heart valve disease means at least one of your heart’s valves—there are four that guide the direction of blood flow—don’t fully open or close, according to the Mayo Clinic. You can be born with heart valve disease or it can be caused by another health condition.
• Congenital heart defects happen when your heart chambers or valves don’t form properly before you’re even born. When this happens, your heart is forced to work harder than it should.
• Peripartum cardiomyopathy is a rare type of heart failure that makes your heart weaker and larger during pregnancy, according to the Cleveland Clinic. Generally, people with high blood pressure, people who are overweight, and Black people have a higher risk of developing this form of heart failure while pregnant. Most often, people with peripartum cardiomyopathy will recover some or even all of their heart function after they give birth.
• Heartbeat irregularities, or arrhythmias, occur when your heart beats too fast, too slow, or in an abnormal rhythm.
• Severe viral infections, including the flu and COVID-19, can lead to inflammation of the heart muscle (medically known as myocarditis), potentially impacting its ability to pump blood⁵.

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Heart failure can be categorized in a number of ways, depending on the portion of your heart that is affected and its ability to pump blood. Most commonly, heart failure is diagnosed based on a measure called ejection fraction (E.F.), which is how much blood the heart pumps each time it contracts⁶. A normal ejection fraction falls somewhere between 50% and 70%.

“If the ejection fraction is normal and the patient has heart failure symptoms, they have heart failure with preserved ejection fraction,” Dr. Weisshaar explains. “If the ejection fraction is low, they have heart failure with reduced ejection fraction.”

Here’s a bit more about how heart failure may be classified based on the amount of blood that’s pumped with each contraction:

Left-sided heart failure

As the name suggests, left-sided heart failure develops when there are problems with the left side of your heart—the left ventricle in particular can’t pump enough blood throughout the body, for example. This is the most common type of heart failure and can be broken down further into subcategories, HFrEF and HFpEF.

Heart failure with reduced ejection fraction (HFrEF)

Heart failure with reduced ejection fraction, or systolic heart failure, means your heart muscle is weak and has trouble pumping at its normal capacity. In this type of heart failure, the heart’s left ventricle (one of its two large chambers) increases in size and cannot contract enough to pump blood throughout the body. Coronary artery disease, a prior heart attack, and dilated cardiomyopathy, in which the heart becomes enlarged and weak, are a few things that can lead to HFrEF⁷.

Heart failure with preserved ejection fraction (HFpEF)

Heart failure with preserved ejection fraction, or diastolic heart failure, happens when the heart is still strong but it becomes stiff and can’t relax between beats or properly fill with blood⁸. The heart has a hard time pumping enough blood to the body, especially during intense physical activity. Having risk factors like high blood pressure, coronary artery disease, and high cholesterol increases your risk of HFpEF. People assigned female at birth are more likely to develop HFpEF, although the reasons for this are not known. 

Right-sided heart failure

“In right-sided heart failure, the right ventricle cannot supply blood to the lungs, leading to shortness of breath, fatigue, abdominal distension, and leg swelling,” Dr. Katz says. Right-sided heart failure is generally caused by having left-sided heart failure, but it can also happen if you have a lung disease, according to experts at University of Michigan Health.

Congestive heart failure

If you have heart failure and it causes a buildup of fluid throughout your body, this is known as congestive heart failure⁹. This happens when blood backs up in your veins, causing swelling in the tissues, and you may notice that certain body parts, such as your ankles, become swollen, according to the American Heart Association. 

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The American College of Cardiology and the American Heart Association¹⁰ classify heart failure into four stages based on its progression over time:

• Stage A includes people who have a high risk of developing heart failure because they have a family history of the condition or certain risk factors, such as hypertension, diabetes, or metabolic syndrome. In this stage there are no structural issues with the heart, and heart failure symptoms have not developed yet.
• Stage B includes people who are diagnosed with a weak left ventricle that affects their heart’s ability to pump blood. This stage also includes individuals who have had a heart attack in the past but do not yet have any signs or symptoms of heart failure.
• Stage C includes people who have been diagnosed with heart failure and have had or currently have symptoms.
• Stage D includes people with serious heart failure, meaning they are experiencing heart failure symptoms at rest even after taking medication or trying other interventions like surgery. At this stage, you may need more advanced treatments, like a device that helps your heart and lungs function more efficiently.

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If you have any of the heart failure symptoms mentioned above, it’s worth scheduling an appointment with a primary care doctor if you have one. If necessary, your doctor can refer you to a cardiologist. During your appointment, the doctor will do a physical exam to listen to your heart and discuss your symptoms, your personal health history history, whether you have a family history of cardiovascular disease, and any lifestyle habits that may contribute to your symptoms, such as smoking. According to the Cleveland Clinic, your doctor may then run some tests, including:

• Blood tests, which look for markers that reflect cardiovascular health, like your cholesterol levels as well as a hormone called B-type natriuretic peptide (BNP), which people with heart failure have. Blood tests can also identify other conditions such as anemia, which might cause symptoms like fatigue that are similar to heart failure.
• X-rays of your chest, which show the size of your heart and whether you have fluid buildup around your heart or lungs—an indicator that your heart isn’t pumping blood efficiently.
• An echocardiogram, which produces images of your heart using sound waves. This allows your doctor to see how your blood flows and to measure your ejection fraction.
• An electrocardiogram (EKG), which measures your heart’s electrical activity to determine if your heartbeat is irregular or weak.
• Coronary angiography, which is a test that uses X-rays and a dye called contrast material to show blockages in your blood flow, according to the U.S. National Library of Medicine. During the procedure, your cardiologist moves a catheter (a thin tube) through one of your arteries and into your heart. The contrast material is injected into the catheter, so your doctor can see how it moves in your body in the X-ray photos.
• A stress test, which shows how your heart responds to activities such as exercise. Looking at how your heart pumps blood when it’s pushed harder can help your doctor see if it’s working properly.

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Every part of your body relies on proper blood flow to function, so that means heart failure can cause complications when things are off. (You’ll notice that some of the complications can also be contributors to heart failure, so developing these can make your heart failure worse.) Some common complications include:

• Irregular heart rhythms, which can cause a rapid heartbeat, make you faint, and increase your risk of having a stroke. A stroke is a very serious condition that happens when your brain doesn’t get the blood it needs.
• Kidney failure, which can make you feel very tired, lower your appetite, and cause you to urinate less often.
• Anemia, which is characterized by a lack of healthy red blood cells—the oxygen transporters in your body. This can make you feel really tired and weak. You could also develop irregular heartbeats, experience chest pain, and feel really cold.
• Heart valve problems, which can lead to other complications such as atrial fibrillation, leading to blood clots in your heart.
• Unintended weight loss, which can happen if your blood backs up and causes your liver and intestines to swell, making it hard for you to absorb nutrients. This is understandably uncomfortable and can also make it challenging for you to eat.
• Skin and hair changes; for example, your skin might become really thick or develop ulcers, and your hair could start to fall out.

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Heart failure treatment really depends on the type of heart failure you have and what stage it is in, as well as the underlying cause of your condition. Once heart failure has progressed enough to be diagnosed, it can’t be reversed, but the right treatment plan can help you greatly reduce your condition to the point where you have very few symptoms, according to the NHLBI. Although treatment plans are individual, here’s what you can generally expect when creating a plan with your cardiologist:

Lifestyle changes

In the earliest stages, you’ll start with learning more about how to prevent the progression of heart damage in the first place. “Treatment of heart failure starts with education,” Dr. Katz says. For instance, if you are in stage A with a high risk of developing heart failure, then it’s important to understand how you can lower that risk with lifestyle modifications, including:

• Stop smoking cigarettes if you do smoke.
• Address your blood pressure or cholesterol if they are too high.
• Exercise for at least 150 minutes per week if you can.
• Stop using illegal drugs if you do so.
• Have no more than two alcoholic drinks a day (for people assigned male at birth) or no more than one drink a day (for people assigned female at birth).
• Follow a lower sodium diet if recommended by your doctor.

Heart failure medication

If your heart failure has progressed, your treatment plan will likely include medication. Here are some drugs that are commonly prescribed and how they work.

• Diuretics are prescribed to get rid of extra fluid, which helps your heart pump more easily and treats symptoms like fluid fluid retention, according to the Cleveland Clinic. Diuretics help you breathe more easily and decreases swelling in your body.
• Aldosterone antagonists, such as spironolactone, help remove extra fluid and sodium in your body and decrease the amount of blood your heart has to pump, according to the NHLBI. These medications are shown to reduce the risk of being hospitalized with heart failure.
• Angiotensin-converting enzyme (ACE) inhibitors are prescribed to open your blood vessels so your heart can pump blood more easily, per the Cleveland Clinic. These medications can help lower your blood pressure and reduce your risk of having a heart attack.
• Angiotensin II receptor blockers (ARB) work similarly to ACE inhibitors and are sometimes prescribed to people who cannot tolerate ACE inhibitors, according to the Mayo Clinic.
• Beta blockers slow your heart rate, lower blood pressure, reduce your heart failure symptoms, and can help you live longer, according to the Mayo Clinic.
• Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide (GLP) agonists are two new groups of medications used to lower blood sugar in people with diabetes that can also reduce heart failure hospitalizations, according to NHLBI. For example, one class of medications called empagliflozin (an SGLT-2 inhibitor) is FDA-approved to reduce the risk of hospitalizations and death for people with diabetes and cardiovascular disease or people with HFrEF, according to the U.S. Food and Drug Administration. SGLT-2 inhibitors and GLP agonists medications are currently being researched for heart failure and may be used more commonly in the future.
• Hydralazine and isosorbide dinitrate (BiDil) is sometimes prescribed to people with severe heart failure when other medications are not effective. It helps relax blood vessels, which can help improve blood flow and reduce strain on your heart, according to the Mayo Clinic.

Surgery

Sometimes patients may need surgery to address problems with the heart valves or improve blood supply to the heart. There are numerous types of surgery, and the exact procedure depends on the extent of your heart damage. For example, coronary bypass surgery creates a new pathway for blood flow, which can be helpful if your heart failure is caused by blocked arteries. Or if your heart failure is caused by a heart valve that isn’t working properly, then you might have surgery to repair that valve. Working with a board-certified cardiologist who can assess your particular situation can help you decide if the benefits of surgery outweigh any risks.

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If you believe you’re experiencing symptoms related to your heart, it’s important to see a doctor as soon as you can for further evaluation. However, if you experience any of the following symptoms, it’s important to head to the emergency room or call 911 right away:

• Severe or unexpected chest pain that’s accompanied by shortness of breath, nausea, weakness, or sweating
• Pressure, heaviness, tightness, or a squeezing sensation in your chest that lasts more than 15 minutes
• A rapid heart rate of more than 120 to 150 beats per minute, particularly if you also feel dizzy or have trouble breathing
• Feeling faint or actually fainting

Even though a heart failure diagnosis can feel overwhelming, it’s important to remember that the right treatment plan—thanks to “all the amazing advances in heart failure therapy,” Dr. Katz notes—can make a huge difference in your health and quality of life.

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Sources:

1. Circulation, Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association
2. Current Heart Failure Reports, Acute Heart Failure: Definition, Classification, and Epidemiology
3. Exercise and Sport Sciences Review, Exercise Intolerance in Heart Failure: Central Role for the Pulmonary System
4. Progress in Cardiovascular Nursing, Correlates of Fatigue in Patients With Heart Failure
5. Postgraduate Medical Journal, Viral Myocarditis and Dilated Cardiomyopathy: Mechanisms, Manifestations, and Management
6. Institute for Quality and Efficiency in Health Care, Types of Heart Failure
7. The Practice of Clinical Echocardiography, Systolic Heart Failure
8. American Family Physician, Diastolic Heart Failure: Challenges of Diagnosis, and Treatment
9. StatPearls, Congestive Heart Failure
10. Circulation, ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.