Heart failure

Heart failure occurs when the heart does not pump blood properly as it should. Symptoms typically include shortness of breath, excessive fatigue, and leg swelling. The shortness of breath may occur with exertion or while lying down, and may wake people up during the night. Chest pain and angina from heart failure is uncommon. It usually occurs when the heart failure is caused by a heart attack.

Common causes of heart failure include coronary artery disease, heart attack, high blood pressure, diabetes, atrial fibrillation, valvular heart disease, excessive alcohol consumption, smoking, obesity, infection, and cardiomyopathy. These cause heart failure by altering the structure or the function of the heart or in some cases both.

The 2 types of heart failure include right-sided heart failure and left-sided heart failure.

Heart failure is common and deadly. It is the leading cause of hospitalization in older people.

## Symptoms

The symptoms of heart failure include:

* Difficulty breathing or shortness of breath
* Fatigue and weakness
* Tiredness
* Swollen legs
* irregular heartbeat
* Chest pain
* Dizziness, lightheadedness, or vertigo
* Nausea and vomiting
* Loss of appetite
* Sweating
* Fainting
* Loss of consciousness

## Causes and risk factors

Common causes of heart failure include coronary artery disease, including a previous myocardial infarction (heart attack), high blood pressure, diabetes, atrial fibrillation, valvular heart disease, excess alcohol use, infection, and cardiomyopathy.

Heart damage can predispose a person to develop heart failure later in life and has many causes including systemic viral infections (e.g., HIV), chemotherapeutic agents such as daunorubicin, cyclophosphamide, trastuzumab and substance use disorders of substances such as alcohol, cocaine, and methamphetamine. An uncommon cause is exposure to certain toxins such as lead and cobalt. Additionally, infiltrative disorders such as amyloidosis and connective tissue diseases such as systemic lupus erythematosus can also cause heart failure. Obstructive sleep apnea (a condition of sleep wherein disordered breathing overlaps with obesity, hypertension, and/or diabetes) is regarded as an independent cause of heart failure.

Smoking, obesity, and drinking alcohol can also cause heart failure.

## Treatment

There are many treatment options for heart failure. The treatment options for heart failure are divided into 2, which are medications and surgery.

### Medications to treat heart failure

A combination of medicines may be used to treat heart failure. The specific medicines used depend on the cause of heart failure and the symptoms. Medicines to treat heart failure include:

* **Angiotensin-converting enzyme (ACE) inhibitors.** These drugs relax blood vessels to lower blood pressure, improve blood flow and decrease the strain on the heart. Examples include enalapril (Vasotec, Epaned), lisinopril (Zestril, Qbrelis) and captopril.
* **Angiotensin II receptor blockers (ARBs).** These drugs have many of the same benefits as ACE inhibitors. They may be an option for people who can't tolerate ACE inhibitors. They include losartan (Cozaar), valsartan (Diovan) and candesartan (Atacand).
* **Angiotensin receptor plus neprilysin inhibitors (ARNIs).** This medicine uses two blood pressure drugs to treat heart failure. The combination medicine is sacubitril-valsartan (Entresto). It's used to treat some people with heart failure with reduced ejection fraction. It may help prevent the need for a hospital stay in those people.
* **Beta blockers.** These medicines slow the heart rate and lower blood pressure. They reduce the symptoms of heart failure and help the heart work better. If you have heart failure, beta blockers may help you live longer. Examples include carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL, Kapspargo Sprinkle) and bisoprolol.
* **Diuretics.** Often called water pills, these medicines make you urinate more frequently. This helps prevent fluid buildup in your body. Diuretics, such as furosemide (Lasix, Furoscix), also decrease fluid in the lungs, so it's easier to breathe. Some diuretics make the body lose potassium and magnesium. Your health care provider may recommend supplements to treat this. If you're taking a diuretic, you may have regular blood tests to check your potassium and magnesium levels.
* **Potassium-sparing diuretics.** Also called aldosterone antagonists, these drugs include spironolactone (Aldactone, Carospir) and eplerenone (Inspra). They may help people with severe heart failure with reduced ejection fraction (HFrEF) live longer. Unlike some other diuretics, these medicines can raise the level of potassium in the blood to dangerous levels. Talk to your health care provider about your diet and potassium intake.
* **Sodium-glucose cotransporter-2 (SGLT2) inhibitors.** These medicines help lower blood sugar. They are often prescribed with diet and exercise to treat type 2 diabetes. But they're also one of the first treatments for heart failure. That's because several studies showed that the medicine lowered the risk of hospital stays and death in people with certain types of heart failure — even if they didn't have diabetes. These medicines include canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance).
* **Digoxin (Lanoxin).** This drug, also called digitalis, helps the heart squeeze better to pump blood. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in people with HFrEF. It may be more likely to be given to someone with a heart rhythm problem, such as atrial fibrillation.
* **Hydralazine and isosorbide dinitrate (BiDil).** This drug combination helps relax blood vessels. It may be added to your treatment plan if you have severe heart failure symptoms and ACE inhibitors or beta blockers haven't helped.
* **Vericiguat (Verquvo).** This medicine for chronic heart failure is taken once a day by mouth. It's a type of drug called an oral soluble guanylate cyclase (sGC) stimulator. In studies, people with high-risk heart failure who took this medicine had fewer hospital stays for heart failure and heart disease-related deaths compared with those who got a dummy pill.
* **Positive inotropes.** These medicines may be given by IV to people with certain types of severe heart failure who are in the hospital. Positive inotropes can help the heart pump blood better and maintain blood pressure. Long-term use of these medicines has been linked to an increased risk of death in some people. Talk to your health care provider about the benefits and risks of these drugs.
* **Other medicines.** Your health care provider may prescribe other medicines to treat specific symptoms. For example, some people may receive nitrates for chest pain, statins to lower cholesterol or blood thinners to help prevent blood clots.

### Surgery for heart failure

Surgery or other treatment to place a heart device may be recommended to treat the problem that led to heart failure.

Surgery or other procedures for heart failure may include:

* **Coronary bypass surgery.** You may need this surgery if severely blocked arteries are causing your heart failure. The surgery involves taking a healthy blood vessel from the leg, arm or chest and connecting it below and above the blocked arteries in the heart. The new pathway improves blood flow to the heart muscle.
* **Heart valve repair or replacement.** If a damaged heart valve causes heart failure, your provider may recommend repairing or replacing the valve. There are many different types of heart valve repair. The type needed depends on the cause of the heart valve problem. Heart valve repair or replacement may be done as open-heart or minimally invasive surgery.
* **Implantable cardioverter-defibrillator (ICD).** An ICD is used to prevent complications of heart failure. It isn't a treatment for heart failure itself. An ICD is a device similar to a pacemaker. It's implanted under the skin in the chest with wires leading through the veins and into the heart. The ICD monitors the heartbeat. If the heart starts beating at a dangerous rhythm, the ICD tries to correct the beat. If the heart stops, the device shocks it back into regular rhythm. An ICD can also work as a pacemaker and speed up a slow heartbeat.
* **Cardiac resynchronization therapy (CRT).** Also called biventricular pacing, CRT is a treatment for heart failure in people whose lower heart chambers aren't pumping in sync with each other. A device sends electrical signals to the lower heart chambers. The signals tell the chambers to squeeze in a more coordinated way. This improves the pumping of blood out of the heart. CRT may be used with an ICD.
* **Ventricular assist device (VAD).** A VAD helps pump blood from the lower chambers of the heart to the rest of the body. It's also called a mechanical circulatory support device. Although a VAD can be placed in one or both lower chambers of the heart, it's usually placed in the lower left one. Your health care provider may recommend a VAD if you're waiting for a heart transplant. Sometimes, a VAD is used as a permanent treatment for people who have heart failure but who aren't good candidates for a heart transplant.
* **Heart transplant.** Some people have such severe heart failure that surgery or medicines don't help. These people may need to have their hearts replaced with a healthy donor heart. A heart transplant isn't the right treatment for everyone. A team of health care providers at a transplant center helps determine whether the procedure may be safe and beneficial for you.