Heart failure overview

Heart failure happens when your heart is damaged and not able to effectively pump blood around your body. While it is a serious condition, it doesn’t mean your heart is about to stop or fail completely. Depending on your age, general health and the cause of your heart failure, you can live with the condition for many years.

Heart failure is common in Australia, especially among older people. There are many different causes, but it often develops when the heart is damaged as a result of a heart attack or from health problems such as having untreated high blood pressure for a long time.

There are treatments available for heart failure, including medicines and surgery.

Symptoms of heart failure

Many symptoms of heart failure arise because fluid tends to build up when the heart is not pumping as well as it should.

Shortness of breath may be caused by fluid gathering in the lungs. This is one of the most common symptoms. Feeling breathless may be more obvious when you exert yourself, such as when climbing stairs. It might also happen more often when lying flat or several hours after lying down, making you wake up breathless or coughing. A dry cough can be another sign that there is fluid in the lungs.

Swollen ankles and legs can also result from fluid build-up, and fluid can accumulate in the abdomen, causing swelling and pain.

Other symptoms of heart failure can include:

  • tiredness;
  • weakness;
  • dizziness;
  • palpitations (an awareness of your heart beating or pounding in your chest); and
  • poor appetite.

What causes heart failure?

Heart failure can arise when there is damage to the heart that results in the heart stiffening (so that it doesn’t fill with blood as well) or weakening (so that it doesn’t pump as well).

Conditions that can lead to heart failure include:

There are also factors that can worsen pre-existing heart failure. Examples include:

  • anaemia;
  • abnormal heart rhythms;
  • angina;
  • having a high salt intake;
  • certain medicines; and
  • infection.

What happens to the heart in heart failure?

The right side of your heart pumps blood to the lungs to get oxygen, and the left side pumps this oxygenated blood to the rest of the body. Heart failure can be mostly left-sided or right-sided, but it usually affects both sides of the heart.

blood flow through heart

When the heart doesn’t pump efficiently, it tries to compensate by beating faster. The kidneys also try to help by retaining salt and water to increase the amount of blood in the circulation.

While these changes may help to start with, over time they can actually make things worse. The increased heart rate can eventually result in enlargement of the heart (hypertrophy). Stress on the walls of the heart can lead to fibrosis, making the heart stiffer and less able to fill and pump. And fluid retention can stretch (dilate) the heart muscle.

High pressure in the heart or enlargement of the heart can lead to problems with the heart valves. Arrhythmias (abnormal heart rhythms) can also develop.

Other complications

Heart failure can also affect the function of other organs in the body. Your kidneys and liver may start to stop working properly due to poor blood flow and fluid build-up in the body.

Heart failure can sometimes stop you from doing your usual activities. You may experience feelings of helplessness, depression, anger and loss of confidence because of forced changes to 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.

Tests and diagnosis

After finding out about your symptoms, your doctor will examine you, looking for signs of heart failure, including listening to your heart and breathing with a stethoscope and examining your legs and abdomen for excess fluid.

Your doctor will also want to weigh you, as excess fluid in your body can cause a weight increase. Monitoring your weight over time can help indicate the amount of fluid building up.

Several tests can be used to help diagnose heart failure and its cause.

An electrocardiogram (ECG) records the electrical activity in the heart and can detect signs of heart failure such as heart enlargement.

A chest X-ray can show the size of the heart and show fluid in the lungs associated with heart failure. Your doctor may also recommend several blood tests to help determine the cause and severity of heart failure and check for complications.

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. It can also show if there are problems with the heart valves.

An echocardiogram is usually recommended to confirm the diagnosis and determine the severity of heart failure, which helps doctors work out what treatments will work best for you.

Your doctor may refer you to a cardiologist (heart specialist) for further tests and treatment.

Types of heart failure

During an echocardiogram the left ventricular ejection fraction (LVEF) is measured. LVEF gives an indication of how well the heart is functioning, and can be used to classify heart failure. It is expressed as a percentage of normal, with the lower limit of normal being 50-55 per cent.

According to heart failure guidelines released in 2018 by the Australian Heart Foundation and Cardiac Society of Australia and New Zealand, heart failure can be classified as follows.

  • Heart failure with reduced ejection fraction is when your LVEF is less than 50 per cent and you have symptoms of heart failure. (If your LVEF is between 40 and 50 per cent, there needs to be additional signs of heart failure for the diagnosis to be made.) This type of heart failure used to be called systolic heart failure.
  • Heart failure with preserved ejection fraction is when your LVEF is normal or near-normal (50 per cent or more) but you have symptoms of heart failure and test results showing your heart is stiff and/or not filling properly. This type of heart failure used to be called diastolic heart failure and is most common in older women with high blood pressure.

Heart failure treatment

There are several treatments available in Australia that can help people with heart failure. Your doctor will want to treat the underlying cause of your heart failure, as well as try to improve the pumping ability of your heart.

Medicines can help relieve the symptoms and prevent heart failure worsening. There are also implantable devices and surgical treatments that can help improve heart function. In cases of severe heart failure, your best treatment option may be having a heart transplant.

Your doctor may recommend you attend a special heart failure management programme. This involves seeing a heart failure nurse, who will help you with lifestyle adjustments, treatment and staying active. You’ll also have regular check-ups to make sure your symptoms are well controlled. If you live in a remote area, you can also receive this type of care through a telephone support programme.

Self-care for heart failure

Standard lifestyle advice includes not smoking and maintaining a healthy weight.

Watch your diet and fluid intake

People with heart failure are at increased risk of nutritional deficiencies and imbalances, so your doctor may refer you to a dietitian for dietary advice. In general, you should eat a low-salt diet, because salt encourages the body to store fluid. Avoid foods that are high in salt and use herbs, spices and other flavours to replace salt in cooking. Don’t add salt at the table.

Some people with heart failure may need to restrict their fluid intake. This may be recommended if you have symptoms and signs of fluid build-up in your body. If fluid restriction is needed, intake is usually restricted to 1.5 L of fluid per day.

Alcohol can further damage your heart. You should limit your alcohol 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 alcohol altogether.

A limit of one to 2 caffeinated drinks per day is also recommended. That’s because caffeine can raise your blood pressure and increase your heart rate, making it more difficult for your heart to pump.

Find a balance between activity and rest

Staying active is important when your heart failure is stable. Your doctor, exercise physiologist or physiotherapist can help tailor a physical activity programme to suit you.

Regular activity within the limits of your comfort and symptoms is encouraged - you will be the best judge of how much you can do. You should aim to exercise enough that you breathe faster than usual but are still able to carry out a normal conversation. Don’t work beyond this point. Try to accumulate 30 minutes of mild to moderate physical activity most days.

But remember that while exercise is beneficial when heart failure is stable, bed rest is necessary when symptoms are severe.

Monitor your symptoms

People with heart failure should see their doctor regularly for a review of their symptoms and medication.

Your doctor may recommend that you 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 fluid build-up. A loss of this amount of weight over 2 days may indicate dehydration. Your medication and fluid intake may need to be adjusted in these circumstances.

If you get short of breath when lying down, support yourself with pillows or sleep on a recliner chair, so that your head and chest are elevated. If you notice yourself being more short of breath than usual, that your appetite is reduced or your stomach is bloated, see your doctor as soon as possible.

If you become suddenly short of breath, experience faintness or collapse, or have chest pain, call 000 for an ambulance immediately.

Medicines for heart failure

Medicines can treat the symptoms of heart failure and stop it from worsening. Most people with heart failure need to take 2 or more different types of medication. Your doctor may recommend the following.

  • Angiotensin-converting enzyme (ACE) inhibitors reduce salt and water retention and relax blood vessels, so that the heart doesn’t have to work as hard to push blood through the vessels. ACE inhibitors lower blood pressure, prevent progression of heart failure, and may reduce the risk of heart attack.
  • In people who cannot tolerate ACE inhibitors, angiotensin receptor blockers (ARBs) can be used instead. A newer type of medicine - an angiotensin-receptor neprilysin inhibitor (ARNI) - is available in combination with an ARB, and can be used as an alternative to ACE inhibitors if your symptoms are not well controlled.
  • Beta-blockers can relax blood vessels, reduce the heart’s demand for oxygen and protect the heart from dangerous rhythms. Examples of beta-blockers used to treat heart failure include bisoprolol, carvedilol and extended-release or controlled-release metoprolol. Nebivolol can be used in people older than 70 years.
  • Diuretics (‘water pills’) reduce the amount of fluid the heart has to push by stopping salt and water retention. Diuretics reduce symptoms of heart failure. Aldosterone antagonists (e.g. spironolactone, eplerenone) are a specific type of diuretic that can improve symptoms, reduce complications and improve survival.
  • Digoxin can help the heart work harder and may be used if other medicines are not controlling heart failure.

Medicines have been shown to improve outcomes in people with heart failure with reduced LVEF, but not in those with heart failure with preserved LVEF.

Taking your medicine

Medicines for heart failure are often started at a low dose and then the dose is gradually increased.

Your doctor will let you know about the side effects of these medicines and whether or not they are suitable for you. Many side effects get better over time.

You may need to have your blood potassium levels checked regularly, as several heart failure medicines can cause increased potassium levels. If the amount of potassium in your body is too high it can cause dangerous heart rhythms.

Medicines to avoid

Certain medicines (or certain medicines in combination) can make heart failure worse and need to be avoided. Examples of medicines to avoid include nonsteroidal anti-inflammatory drugs (NSAIDs), some calcium channel blockers (verapamil and diltiazem), corticosteroid medicines and tricyclic antidepressants. Always check with your doctor and pharmacist before taking any medicines.

The complementary medicines St John’s wort and black cohosh should also be avoided because they commonly interact with medicines used to treat heart failure. Grapefruit juice should also be avoided for this reason.

Implantable devices and surgery

Devices such as pacemakers can be an important part of treatment for some people with heart failure. Surgery may also sometimes be used to treat the underlying cause of heart failure.

Cardiac resynchronisation therapy (CRT) 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 (ICDs) can correct irregular heart rhythms and have been shown to reduce the risk of sudden death in certain people with heart failure.

A ventricular-assist device (VAD) can help the heart to pump more effectively in people with severe heart failure. It is a mechanical pump that is implanted in your chest or abdomen and attached to your heart to help it pump blood.

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. However, you may need to make some adjustments.

Work

If you are getting tired at work more easily, you should first see your doctor in case an adjustment or change of treatment may help. However, it may be that you need to reduce your working hours or stop some strenuous activities. If this is the case, talk to your employer to see what can be arranged.

Driving

Austroads, the peak organisation of Australasian road transport and traffic agencies, publishes Assessing Fitness to Drive, national guidelines and medical standards for assessing a person’s fitness to drive.

Austroads’ guideline for heart failure advises that you may drive as long as you don’t have obvious signs or symptoms on moderate exertion. You’ll need to have regular check-ups with your doctor, who needs to confirm that you have minimal symptoms relating to driving and that you are responding to treatment.

There are more stringent criteria for drivers of commercial vehicles.

Sexual activity

As with other activities, sexual activity should be within the limits of your symptoms. Sex should be okay 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. Ask your doctor or nurse if you are unsure.

Heart failure prevention

Not all types of heart failure can be prevented. However, quitting smoking, avoiding excess alcohol and keeping to a healthy weight can help prevent some common causes of heart failure. Keep moving too, as regular physical activity also helps reduce your risk.

Early treatment of conditions that can lead to heart failure (such as high blood pressure) can prevent or delay its development. So, it’s a good idea to have regular heart health and blood pressure checks with your doctor.

Support for people with heart failure

Having heart failure can be scary, and having to constantly be careful about what you eat and drink and the activities you can and can’t do can be frustrating and distressing. Joining a support group, where you can discuss the challenges of living with heart failure with people who really understand, can make you feel less alone. Sharing coping tips and ways of looking at things in a different light may be just what you need to help you get on top of things. Search the internet for a local support group or ask your doctor where to start.

References

1. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Guidelines for the prevention, detection and management of chronic heart failure in Australia 2018. https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext (accessed Aug 2018).
2. Heart failure (published March 2018). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2018 Jul. https://tgldcdp.tg.org.au/ (accessed Aug 2018).
3. Hopper I, Easton K. Chronic heart failure. Australian Prescriber 2017;40:128-36. https://www.nps.org.au/australian-prescriber/articles/chronic-heart-failure (accessed Aug 2018).
4. Austroads; National Transport Commission Australia. Assessing fitness to drive for commercial and private vehicle drivers. Medical standards for licensing and clinical management guidelines (2016; as amended up to August 2017). http://www.austroads.com.au/drivers-vehicles/assessing-fitness-to-drive (accessed Aug 2018).
5. Heart Foundation. Heart failure - the facts. https://www.heartfoundation.org.au/your-heart/heart-conditions/heart-failure-the-facts (accessed Aug 2018).
6. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Australian clinical guidelines for the management of heart failure 2018. Med J Aust || doi: 10.5694/mja18.00647. https://www.mja.com.au/journal/2018/209/10/national-heart-foundation-australia-and-cardiac-society-australia-and-new-0 (accessed Aug 2018).
7. Mayo Clinic. Heart failure (updated 23 Dec 2017). https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142 (accessed Aug 2018).
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