If you have received a diagnosis of heart failure, you may worry that your heart is about to give out. In reality, the term means your heart is not functioning normally. While heart failure is very serious, it is treatable. Heart failure symptoms you experience reveal what is wrong with your heart, so by working closely with your physician, you may be able to stabilize your heart’s condition or even reverse it.
“It’s an exciting time for the treatment of heart failure, since new medications and innovative technologies are helping many individuals with heart failure live longer and experience fewer symptoms,” says Cleveland Clinic heart failure cardiologist Arianne Agdamag, MD.
What Is Heart Failure?
There are two, possibly three, types of heart failure.
Heart failure is typically classified by ejection fraction, or the percentage of blood the heart ejects with each contraction (heartbeat). A normal ejection fraction is between 52% for men or 53% for women and 65%.
When the ejection fraction is less than normal, an individual is said to have heart failure with reduced ejection fraction (HFrEF). In HFrEF, the heart’s left ventricle is unable to contract with sufficient force to meet the body’s needs for oxygenated blood.
Sometimes, the heart contacts well enough to eject a normal amount of blood with each beat but is too stiff to expand properly between beats. Because the ventricles cannot adequately refill with blood, less blood is pumped into the body. These people are diagnosed with heart failure with preserved ejection fraction (HFpEF).
Thanks to advances in treatment, some people previously diagnosed with HFrEF find their ejection fraction has increased or normalized. These individuals are said to have heart failure with improved ejection fraction (HFimpEF).
Damage to the heart muscle from a heart attack causes heart failure in more than half of individuals in the United States and other Western countries with the syndrome. While the terms “heart failure” and “heart attack” are not synonymous, Dr. Agdamag says they are often confused.
“I like to explain that the heart has muscle, electrical, and plumbing components,” she explains. “A heart attack is a plumbing issue: The flow of blood through the pipes that feed the heart muscle is interrupted. Heart failure is a muscle issue: The pump is weakened or otherwise compromised by a heart attack, an electrical disturbance, or one of many diverse conditions.”
Common Symptoms of Heart Failure
Heart failure isn’t a disease, but rather a collection of symptoms—what, in medical terms, is known as a syndrome. Because heart failure is a progressive condition, it may cause no symptoms or very mild symptoms in its early stages. The most common symptoms include:
- Shortness of breath. Fluid accumulation in the lungs makes breathing difficult. “People with heart failure often find they cannot walk very far without becoming winded, or they wake up often at night because they can’t breathe,” Dr. Agdamag says.
- When the heart does not work effectively, muscles throughout the body do not receive enough oxygen. This phenomenon causes a lack of energy.
- Rapid weight gain. Fluid retention may cause a weight gain of several pounds in a day or two.
- Swelling (edema) in the legs, ankles, feet or abdomen caused by a high volume of fluid in the blood vessels.
- Persistent cough caused by fluid backup in the lungs.
- Difficulty breathing when lying down (orthopnea). When you lie flat, blood in the lower half of your body flows back to your heart. If a weakened left ventricle cannot handle the increased volume, blood will back up in the lungs, producing congestion and coughing.
- Difficulty sleeping. Fluid in the lungs may cause individuals with heart failure to awaken feeling short of breath.
Other Warning Signs to Watch For
As heart failure advances, the severity of symptoms increases, and new symptoms may appear. Heart failure complications include:
- Poor appetite. When blood flow is insufficient, the body diverts oxygenated blood to the heart and brain. Decreased blood flow to the stomach and intestines makes digestion difficult, and appetite decreases.
- Nausea and vomiting. Fluid accumulation in the liver, stomach, and intestines causes bloating, nausea, and feelings of fullness after eating very little.
- Irregular heart rhythm. Heart failure may cause a change in the pattern or efficiency of electrical signals in the heart.
- Difficulty concentrating or confusion. Insufficient oxygen in blood to the brain may cause poor memory, drowsiness, and confusion.
- Difficulty carrying out daily activities. As oxygen delivery to the muscles drops, carrying out basic activities becomes increasingly difficult.
- Difficulty breathing when leaning over. Shortness of breath that occurs within 30 seconds of bending over is a sign of worsening heart failure.
- Decreased urination. When the kidneys do not receive enough blood to make urine, urine production decreases.
- Insufficient blood flow to the body interferes with digestion and the absorption of nutrients, causing malnutrition. The result can be an extreme loss of body weight, fat, and muscle, leading to a skeletal appearance.
Types and Stages of Heart Failure
Whether the right or the left side of the heart is affected by heart failure determines which symptoms will occur.
The left side of the heart receives blood from the lungs, so when the left side of the heart fails, blood backs up in the lungs and can leak into the air spaces. This process makes it hard to breathe.
The right side of the heart receives blood returned through the veins. When the right side of the heart is affected, blood backs up in the body, pooling in the legs and ankles, abdomen, and gastrointestinal tract.
Once heart failure is diagnosed, several systems are used for classifying its severity. The most widely used are the American College of Cardiology/American Heart Association (ACC/AHA) system and the New York Heart Association (NYHA) classification system.
The ACC/AHA system classifies heart failure into four stages based on its progression. Individuals with symptoms fall into stages C and D:
- Stage A: At risk for heart failure, but without symptoms, structural abnormalities (detrimental physical changes in the heart) or elevated biomarkers of stretch or injury.
- Stage B: Pre-heart failure. No signs or symptoms of heart failure, but evidence of structural abnormalities, abnormal heart function, or elevated biomarkers.
- Stage C: Heart failure. Symptoms of heart failure caused by structural or functional abnormality.
- Stage D: Advanced heart failure. Severe symptoms at rest or with minimal exertion, recurrent hospitalizations despite guideline-directed medical therapy or need for advanced therapies or palliative care.
The NYHA classification system divides people with heart failure into four groups according to the degree of difficulty they have in carrying out physical activity. It is a subjective assessment made by the physician and represents the individual’s condition at the time of evaluation. A person’s NYHA class may change between visits as treatments cause improvement or the disease progresses.
- Class I: No impairment. No limitation in physical activity. Ordinary physical activity does not cause symptoms of heart failure.
- Class II: Mild to moderate. Some limitation in physical activity. Comfortable at rest, but ordinary physical activity results in heart failure symptoms.
- Class III: Marked limitation in physical activity. Comfortable at rest, but minimal physical activity causes heart failure symptoms.
- Class IV: Unable to perform any physical activity without heart failure symptoms, or symptoms are present at rest.
What Causes Heart Failure Symptoms?
Heart failure has multiple underlying causes that result in symptoms. A recent study found that 85% of heart failure can be attributed to risk factors that are preventable, including coronary artery disease, valve disease, hypertension, chronic kidney disease, diabetes, and obesity.
In addition, heart failure can be caused by arrhythmias; toxicity from alcohol or substance abuse or prior chemotherapy or radiation; obstructive sleep apnea; lung diseases; infections; and multiple familial, genetic, and acquired diseases of the heart muscle, to name a few.
The complexity of heart failure makes it impossible to diagnose the condition based on symptoms alone.
“Ejection fraction, evidence from imaging tests, and blood biomarkers must be considered along with symptoms to reveal the type of heart failure an individual has and its severity. This information is necessary to begin appropriate treatment,” Dr. Agdamag says. “The prognosis for any individual depends on the specific cause of their heart failure and the number of underlying risk factors they have.”
When to Seek Medical Help
Many heart failure symptoms are not unique to that condition but should be promptly evaluated.
“Any time you have shortness of breath, leg swelling, rapid weight gain, or difficulty carrying out activities as usual, see your healthcare provider,” Dr. Agdamag says. “These can be symptoms of heart failure, but they can represent other diseases, as well.”
If you experience chest pain or symptoms consistent with heart attack or stroke, call 911. Don’t wait to see what happens. “These symptoms should always be treated as an emergency,” she adds.
Living with Heart Failure: Managing Symptoms
Once you have been diagnosed with heart failure, you and your doctor will need to work as a team to minimize your symptoms and prevent your heart failure from progressing.
“Because the treatment for heart failure relies on trends in blood pressure, body weight, and heart rate, we encourage patients to weigh themselves and take their blood pressure and heart rate every day,” Dr. Agdamag says. “This information helps us guide treatment and know when medications need to be adjusted.
“By identifying early fluid buildup and increasing heart rate or blood pressure early, we can keep you more comfortable and prevent unnecessary hospitalizations for advanced treatments.”
In addition to tackling heart failure, you may need to address one or more underlying risk factors. For about half of individuals with heart failure, this process may involve making lifestyle changes and taking medications to bring your blood pressure, cholesterol, blood sugar, or body weight under control.
You probably will need to make substantial changes in your daily habits. However, the results should pay off in terms of improved quality of life and, hopefully, length of life.
“Keeping tight control of the risk factors for heart failure in their early stages is key to preventing the condition from progressing and may even reverse it,” Dr. Agdamag says.
