If you are told you have congestive heart failure, it doesn’t mean your heart is failing: It means your heart is not pumping as well as it should. It is a serious condition, but not necessarily fatal.
In fact, about 6.7 million Americans are living with congestive heart failure. Thanks to new medications and devices that can stabilize and, in some cases, improve heart function, many of these individuals live long, healthy lives.
What Is Congestive Heart Failure?
Congestive heart failure is not a disease but rather a collection of symptoms, or a syndrome.
“You must have symptoms before we can say you have congestive heart failure,” says Arianne Clare Agdamag, MD, a Cleveland Clinic heart failure specialist.
The type and extent of symptoms vary widely among individuals. Whether your heart is unable to contract (pump) normally or relax well enough to refill normally between beats, blood can back up in the body, causing congestive heart failure symptoms—most commonly, shortness of breath (dyspnea) fatigue and swelling in the legs, feet and abdomen (edema).
Congestive heart failure gets its name from fluid buildup in the lungs that produces shortness of breath. However, this fluid is not always present, so today, congestive heart failure is more commonly referred to as “heart failure.”
Other symptoms of heart failure include shortness of breath when bending over, difficulty breathing when lying down, difficulty sleeping, rapid weight gain, poor circulation, decreased urination, lightheadedness, dizziness, poor appetite, irregular heart rhythms and impaired mental processes.
Ejection Fraction in Congestive Heart Failure
Ejection fraction (EF) is the percentage of blood the heart ejects with every contraction and is a measure of heart function. A normal EF is 52% to 65%.
Individuals with heart failure with reduced ejection fraction (HFrEF) have an EF of 40% or less. When the EF is 41% to 49%, it is called heart failure with mildly reduced EF (HFmrEF). When treatment reverses declines in EF, HFrEF may become heart failure with improved EF (HFimpEF).
In heart failure with preserved ejection fraction (HFpEF), 50% or more of blood is pumped out with each heartbeat. The heart contracts normally but is too stiff and unable to expand well enough to refill with blood between beats. As a result, the heart pumps insufficient blood out to the body.
What Causes Congestive Heart Failure?
The most common causes of HFrEF are blockages in the coronary arteries leading to damage of the heart muscle—a condition known as ischemic cardiomyopathy.
HFpEF is primarily caused by hypertension, obesity, and atrial fibrillation, which is the most prevalent type of irregular heart rhythm (arrhythmia).
What Are the Four Stages of Congestive Heart Failure?
To emphasize the progressive nature of congestive heart failure, the American Heart Association, American College of Cardiology, and Heart Failure Society of America developed a staging system:
- Stage A: Risk factors but no symptoms and no evidence of structural heart disease or biomarkers of stretch or injury.
- Stage B: No signs or symptoms of heart failure but evidence of structural heart disease, increased filling pressures or risk factors, plus increased levels of cardiac biomarkers such as troponin or natriuretic peptides.
- Stage C: Structural heart disease with symptoms of heart failure.
- Stage D: Advanced heart failure with symptoms that interfere with daily life and require frequent hospitalizations, despite advanced treatments.
Four Classes of Congestive Heart Failure
Individuals with congestive heart failure often find New York Heart Association (NYHA) classification more useful, because it defines their symptoms and ability to function. NYHA class is not fixed and can change with a favorable response to treatment:
- Class 1. No symptoms. Can perform ordinary activities without limitations.
- Class II. Mild symptoms; occasional swelling; no symptoms at rest; somewhat limited in the ability to exercise or do strenuous activities.
- Class III. Comfortable only at rest; noticeable limitations in ability to exercise or participate in mildly strenuous activities.
- Class IV. Symptoms at rest; unable to do any physical activity without discomfort.
“We use both classification systems, because the management of each stage and class is different,” Dr. Agdamag explains.
How Long Can You Live with Congestive Heart Failure?
The answer depends on how your symptoms progress.
“There is no quick fix for congestive heart failure, but when it is caught early, it is often possible to prevent its progression,” Dr. Agdamag says.
Guidelines recommend that within one month of being diagnosed, all people with symptomatic HFrEF should start taking the following guideline-directed medical therapy:
- An angiotensin receptor/neprilysin inhibitor (sacubitril/valsartan [Entresto]), angiotensin-converting enzyme (ACE) inhibitor (e.g., captopril [Capoten], enalapril [Vasotec], fosinopril [Monopril] and others), or an angiotensin receptor blocker (e.g., valsartan [Diovan] and candesartan [Atacand])
- A beta-blocker: carvedilol (Coreg) or metoprolol succinate (Toprol).
- A mineralocorticoid receptor antagonist (sometimes called an aldosterone antagonist): spironolactone (Aldactone) or eplerenone (Inspra).
- A sodium-glucose cotransporter 2 (SGLT2) inhibitor: dapagliflozin (Farxiga), empagliflozin (Jardiance), and sotagliflozin (Inpefa); studies have shown these drugs can add up to 6.3 years to the life of individuals with HFrEF.
Other medications may be added to manage specific symptoms that may occur, including water retention, anemia, and arrhythmias.
The situation is different for individuals with HFpEF, who have fewer choices and whose condition simply does not respond to most medications that work well in HFrEF. Fortunately, SGLT2 inhibitors have been shown to reduce the risk of heart-failure hospitalization and cardiovascular death in individuals with all forms of congestive heart failure.
Treating Advanced Congestive Heart Failure
As HFrEF progresses, guideline-directed medical therapy may not be sufficient.
“Red flags that tell me things are not heading in the right direction include recurrent hospitalizations for fluid retention requiring intravenous diuretics, worsening kidney function, worsening blood pressure and sodium levels, poor tolerance to medications and elevated levels of the protein NT-proBNP,” Dr. Agdamag says.
People with advanced congestive heart failure may benefit from seeking care in a center with special expertise in heart failure. Such centers offer the full range of sophisticated devices and surgical procedures designed to improve symptoms and extend life. The complex, ever-changing condition is best managed by a physician familiar with the full range of medications, devices and advanced treatments for heart failure, including left-ventricular assist devices and heart transplantation.
“It is important to stay alert to small changes and take immediate action to help prevent your condition from deteriorating,” Dr. Agdamag advises. “Devices such as pulmonary artery monitors allow for early detection of increasing fluid levels so that symptoms can be treated early.”
Be an Active Partner in Your Care
Congestive heart failure is a chronic condition, but you can prevent it from worsening by complying with your medication regimen and taking an active role in your care.
“Even when heart failure is advanced and the ejection fraction is low, there are things you can do to prevent your condition from declining and your symptoms from worsening,” Dr. Agdamag says. “We recommend you see your cardiologist regularly to make sure your blood pressure is controlled and that you are taking the right doses of the right medications. When you start feeling good, don’t stop taking your medications.
“The benefits of your medication regimen will be optimized by living a heart-healthy lifestyle,” she continues. “This means maintaining a normal weight, exercising regularly—we recommend participating in a cardiac rehab program—eating a healthy diet, stopping smoking and quitting alcohol.”
