Heart failure overview
What is heart failure?
Heart failure refers to the reduced ability of the heart to pump blood efficiently around the body. The term congestive heart failure is also used and refers to the typical symptoms that occur in heart failure from excess fluid accumulation in the body.
Symptoms of heart failure
Heart failure symptoms include:
- Shortness of breath, which may be caused by fluid gathering in the lungs. This is one of the most common symptoms. Shortness of breath may be more obvious on physical exertion, such as climbing stairs. It can also occur when lying flat or several hours after lying down, causing you to wake up breathless or coughing. Sleeping well-supported with pillows may help relieve shortness of breath.
- A dry cough can also indicate fluid on the lungs.
- Swollen ankles and legs resulting from fluid accumulation.
- Abdominal swelling: fluid can also accumulate in the abdomen, causing swelling and pain.
- Weight gain: the fluid retention that occurs with heart failure can cause unusual weight gain.
- Weakness and fatigue.
- Poor appetite.
- Palpitations (an awareness of your heart beating or pounding in your chest).
You may experience feelings of helplessness, depression, anger and loss of confidence because of changes in your lifestyle. These feelings are very real and it's important to discuss them with your family, friends, your doctor, and if necessary, a counsellor.
What causes heart failure?
The most common cause of heart failure is damage to the heart muscle, often due to:
- coronary artery disease; or
- high blood pressure.
Other causes of heart failure include:
- cardiomyopathy (disease of the heart muscle);
- myocarditis (inflammation of the heart muscle, usually resulting from an infection);
- chronic (long-term) lung disease;
- overactive or underactive thyroid gland;
- alcohol misuse;
- valve problems;
- heart abnormalities present at birth (congenital heart disease);
- obstructive sleep apnoea; and
- drug side effects.
When the heart stops pumping efficiently, it compensates by beating faster, eventually resulting in enlargement of the heart (hypertrophy) to cope with the extra workload. The body also tries to increase the volume of blood in the circulation by retaining water and it also gets the kidneys to retain salt (sodium). Because of the fluid retention, the heart muscle becomes stretched (dilated) and eventually loses its ability to contract efficiently, so the amount of blood pumped to the body is reduced.
Your doctor will ask about your symptoms and perform a physical examination. In addition, several tests can be used to help diagnose heart failure, including the following.
- Electrocardiogram (ECG). An ECG records the electrical activity in the heart and can detect signs of heart failure such as heart muscle enlargement.
- Chest X-ray. A chest X-ray can show the size of the heart and show fluid in the lungs associated with heart failure.
- Blood tests. Your doctor may recommend several blood tests to help determine the cause and severity of heart failure and check for complications.
- Echocardiogram. An echocardiogram is an ultrasound of the heart that can show the size of the heart chambers, how the heart is pumping and how effectively it is pumping blood.
- self-care measures and lifestyle adjustments;
- treating any underlying cause of the heart failure;
- medicines to treat symptoms and prevent heart failure worsening;
- implantable devices to help the heart function; and
- surgical treatments.
Self-care and lifestyle
Monitor your symptoms
- Weigh yourself daily. If your weight increases by more than 2 kg in 48 hours, especially if associated with other symptoms, contact your doctor. A rapid gain in weight may indicate a fluid build-up and an increase in your diuretic tablets may be needed. Also, loss of this amount of weight over 2 days may indicate dehydration.
- See your doctor regularly for a review of your symptoms and medication.
If you become suddenly short of breath, experience faintness or collapse, or have chest pain or other acute symptoms, call an ambulance immediately.
Find a balance between rest and activity
Although rest may be a part of the initial treatment, staying active is very important. You will be the best judge of how much you can do.
Your doctor can help tailor a physical activity programme to suit you. Regular walking within the limits of your comfort and symptoms is also strongly encouraged. You should be able to carry out a normal conversation when you exercise. Do not work beyond this point. Try to accumulate 30 minutes of physical activity most days.
While exercise is beneficial when symptoms are mild, bed rest is necessary when symptoms are severe.
Watch your diet and fluid intake
- Eat a no-added-salt diet, because salt encourages the body to store fluid. Foods high in salt include salted nuts, dips, snacks, luncheon sausage, ham, corned beef, cheese, soy sauce, Marmite, Vegemite, canned or packaged soups, and some processed and canned foods. Use herbs, spices and other flavours to replace salt in cooking and avoid adding salt at the table.
- Eat a wide variety of foods.
- Eat foods low in fat, especially saturated fat and high in fibre.
- Eat plenty of fresh fruit and vegetables to provide extra potassium for the body to balance any potential loss of potassium caused by some types of diuretics (water tablets). However, check with your doctor first, as some medicines used to treat heart failure actually increase potassium levels.
Some people with heart failure may need to restrict their fluid intake – your doctor can advise you but in general it’s recommended you consume no more than 2 L of fluid per day.
If you are a smoker, quit. Smoking causes continuing damage to your lungs, heart and blood vessels. It's never too late to give up and there is help available.
Phone the Quitline on 13 7848 or see your GP.
If you are overweight it’s recommended that you lose weight to help improve your ability to be physically active and your quality of life.
Alcohol and caffeine
It’s generally recommended for people with heart failure to avoid alcohol or to only drink in small amounts. Limit your intake to no more than one or 2 standard drinks a day, unless otherwise stated by your doctor.
People with alcohol-related heart failure should avoid drinking alcohol.
A limit of one to 2 caffeinated drinks per day is recommended.
Medicines are used to treat the symptoms of heart failure and to prevent heart failure from worsening. Most people need treatment with 2 or more different types of medicines.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) relax blood vessels so that the heart doesn’t have to work as hard to push blood through. ACE inhibitors lower blood pressure, prevent progression of heart failure, and may reduce the risk of heart attack. Angiotensin receptor blockers (ARBs) are generally used in people who cannot tolerate ACE inhibitors.
- Beta-blockers relax blood vessels and/or slow the heart down, depending on the type used.
- Diuretics (‘water pills’) reduce the amount of fluid the heart has to push. Diuretics reduce symptoms of heart failure.
- Aldosterone antagonists are a specific type of diuretic that have been shown to improve symptoms, reduce complications and improve survival.
- Digoxin has many actions, including helping the heart work harder.
- Vasodilators, such as hydralazine and isosorbide dinitrate, are sometimes used to relax blood vessels.
- Fish oil may be an option for people whose symptoms are not controlled with standard therapy.
Implantable devices and surgery
Other treatments that may be used in people with heart failure include the following.
- Cardiac resynchronisation therapy (CRT), which involves insertion of a type of pacemaker (a device that is implanted under the skin of the chest) to keep the heart beating in a regular, synchronised way. CRT has been shown to improve heart function and symptoms.
- Implantable cardioverter defibrillators (which can correct irregular heart rhythms) have been shown to reduce the risk of sudden death in certain people with heart failure.
- Left ventricular-assist devices (LVAD) can help the heart to pump more effectively.
- Revascularisation procedures. In some people with blocked coronary arteries, reopening the arteries with either angioplasty or coronary artery bypass grafting surgery can be helpful.
- Valvular heart surgery may be indicated if leaking or blocked heart valves are present and contributing to the heart failure.
- Heart transplant surgery is an option for eligible people when other treatments have failed.
Living with heart failure
Heart failure can often be adequately treated and controlled, allowing you to continue with many normal daily activities. You may need to adjust your working hours or drop off some strenuous activities if you tire more easily. If this is happening to you, discuss it with your doctor in case a change of medication is necessary, or with your employer to see if other work can be arranged.
Austroads, the association of Australasian road transport and traffic agencies, publishes Assessing Fitness to Drive, the latest national guidelines and standards for assessing a person’s fitness to drive.
Austroads’ guideline for heart failure advises that you may drive if asymptomatic (without obvious signs or symptoms of disease) on moderate exertion. However, if you have severe symptoms, consult your doctor. There are more stringent criteria for drivers of commercial vehicles.
As with other activities, it should be within the limits of your symptoms. Sexual intercourse should be OK if you can climb 2 flights of stairs without stopping due to angina, dizziness or shortness of breath. Less strenuous positions, for example, side-by-side or having the healthier person on top, may be best.
2. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Guidelines for the prevention, detection and management of chronic heart failure in Australia (updated July 2011). http://www.csanz.edu.au/documents/guidelines/clinical_practice/2011_HF_CSANZ_Chronic_Heart_Failure.pdf (accessed Feb 2015).
3. Austroads; National Transport Commission Australia. Assessing fitness to drive for commercial and private vehicle drivers. Medical standards for licensing and clinical management guidelines (March 2012; as amended up to 30 June 2014). http://www.austroads.com.au/drivers-vehicles/assessing-fitness-to-drive (accessed Feb 2015).
4. National Heart, Lung and Blood Institute. Heart failure (updated 27 Mar 2014). http://www.nhlbi.nih.gov/health/health-topics/topics/hf (accessed Feb 2015).