Heart failure

Diagnosis

To diagnose heart failure, your health care provider examines you and asks questions about your symptoms and medical history. Your provider checks to see if you have risk factors for heart failure, such as high blood pressure, coronary artery disease or diabetes.

Your care provider listens to your lungs and heart with a device called a stethoscope. A whooshing sound called a murmur may be heard when listening to your heart. Your provider may look at the veins in your neck and check for swelling in your legs and belly.

Tests

Tests that may be done to diagnose heart failure may include:

• Blood tests. Blood tests can help diagnose diseases that can affect the heart. Blood tests also can look for a specific protein made by the heart and blood vessels. In heart failure, the level of this protein goes up.
• Chest X-ray. X-ray images can show the condition of the lungs and heart.
• Electrocardiogram (ECG or EKG). This quick and painless test records the electrical signals in the heart. It can show how fast or how slowly the heart is beating.
• Echocardiogram. Sound waves create images of the beating heart. This test shows the size and structure of the heart and heart valves and blood flow through the heart.
• Ejection fraction. Ejection fraction is a measurement of the percentage of blood leaving your heart each time it squeezes. This measurement is taken during an echocardiogram. The result helps classify heart failure and guides treatment. An ejection fraction of 50% or higher is considered ideal. But you can still have heart failure even if the number is considered ideal.
• Exercise tests or stress tests. These tests often involve walking on a treadmill or riding a stationary bike while the heart is monitored. Exercise tests can show how the heart responds to physical activity. If you can't exercise, you might be given medicines.
• CT scan of the heart. Also called a cardiac CT scan, this test uses X-rays to create cross-sectional images of the heart.
• Heart MRI scan, also called a cardiac MRI. This test uses magnetic fields and radio waves to create detailed images of the heart.
• Coronary angiogram. This test helps spot blockages in the heart arteries. The health care provider inserts a long, thin flexible tube called a catheter into a blood vessel, usually in the groin or wrist. It's then guided to the heart. Dye flows through the catheter to arteries in the heart. The dye helps the arteries show up more clearly on X-ray images and video.
• Myocardial biopsy. In this test, a health care provider removes very small pieces of the heart muscle for examination. This test may be done to diagnose certain types of heart muscle diseases that cause heart failure.

During or after testing for heart failure, your health care provider may tell you the stage of disease. Staging helps determine the most appropriate treatment. There are two main ways to determine the stage of heart failure:

New York Heart Association (NYHA) classification

This system groups heart failure into four categories by number. You may see Roman numerals used for these category names.

• Class 1 heart failure. There are no heart failure symptoms.
• Class 2 heart failure. Everyday activities can be done without difficulty. But exertion causes shortness of breath or fatigue.
• Class 3 heart failure. It's difficult to complete everyday activities.
• Class 4 heart failure. Shortness of breath occurs even at rest. This category includes the most severe heart failure.

American College of Cardiology/American Heart Association classification

This stage-based classification system uses letters A to D. It includes a category for people who are at risk of developing heart failure.

• Stage A. There are several risk factors for heart failure but no signs or symptoms.
• Stage B. There is heart disease but no signs or symptoms of heart failure.
• Stage C. There is heart disease and signs or symptoms of heart failure.
• Stage D. Advanced heart failure requires specialized treatments.

Health care providers often use the classification systems together to help decide the most appropriate treatment options. Your provider can help you interpret your stage.

Treatment

Treatment of heart failure may depend on the cause. Treatment often includes lifestyle changes and medicines. If another health condition is causing the heart to fail, treating it may reverse heart failure.

Some people with heart failure need surgery to open blocked arteries or to place a device to help the heart work better.

With treatment, symptoms of heart failure may improve.

Medications

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.

Your health care provider may need to change your medicine doses frequently. This is more common when you've just started a new medicine or when your condition is getting worse.

You may be admitted to the hospital if you have a flare-up of heart failure symptoms. While in the hospital, you may receive:

• Medicines to relieve your symptoms.
• More medicines to help your heart pump better.
• Oxygen through a mask or small tubes placed in your nose.

If you have severe heart failure, you may need to use supplemental oxygen for a long time.

Surgery or other procedures

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.

Symptom care and end-of-life care

Your health care provider may recommend special medical care to reduce symptoms and improve quality of life. This is called palliative care. Anyone who has a serious or life-threatening illness can benefit from this type of care. It can be used to treat symptoms of the disease or to ease the side effects of treatment.

In some people with heart failure, medicines no longer work and a heart transplant or device isn't an option. If this occurs, special end-of-life care may be recommended. This is called hospice care.

Hospice care allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one. Hospice care is available in your home or in nursing homes and assisted living centers.

Hospice care provides the following for those who are sick and their loved ones:

• Emotional support.
• Psychological support.
• Spiritual support.

Although it can be difficult, discussing end-of-life issues with your family and medical team is important. Part of this discussion will likely involve an advance care directive. This is a general term for spoken and written instructions you give concerning your medical care, should you become unable to speak for yourself.

If you have an ICD, one important consideration to discuss with your family and health care team is whether the ICD should be turned off so that it can't deliver shocks to make your heart continue beating.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

Some people with heart failure may be told to take omega-3 fatty acid supplements. Some research shows that the supplements may help reduce the need for hospital stays.

Making certain lifestyle changes often improve heart failure symptoms. They may even stop the condition from getting worse.

The following changes are recommended to improve heart health:

• Don't smoke. Smoking damages the blood vessels and raises blood pressure. It lowers blood oxygen levels and speeds up the heartbeat. Quitting is the best way to reduce the risk of heart problems. If you need help quitting, talk to your provider. You can't be considered for a heart transplant if you continue to smoke. Also avoid secondhand smoke.
• Check your legs, ankles and feet for swelling. Do this every day. Call your health care provider if the swelling worsens.
• Weigh yourself. Ask your health care provider how often you should do this. Weight gain may mean your body is holding onto fluid. You may need a change in treatment. Call your provider if you gain 5 pounds (2.3 kilograms) or more within a few days.
• Manage weight. Being overweight increases the risk of heart problems. Ask your health care provider what weight is best for you. Even losing a small amount of weight can help improve heart health.
• Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains, fat-free or low-fat dairy products, and lean proteins. Limit saturated or trans fats.

• Limit salt. Too much salt, also called sodium, can make the body hold onto water. This is called water retention. It makes the heart work harder. Symptoms include shortness of breath and swollen legs, ankles and feet.

  Ask your health care provider if you should follow a no-salt or low-salt diet. Remember that salt is already added to prepared foods.

• Limit alcohol. Alcohol can interfere with certain medicines. It also weakens the heart and increases the risk of irregular heartbeats. If you have heart failure, your health care provider may recommend that you don't drink alcohol.
• Ask how much fluids you can drink. If you have severe heart failure, your provider may suggest that you limit the amount of fluids you drink.
• Stay as active as possible. Moderate exercise helps keep the heart and body healthy. But be sure to talk to your health care provider about an exercise program that's right for you. If you have heart failure, your provider may suggest a walking program or a cardiac rehabilitation program at your local hospital.

• Reduce stress. Strong emotions such as anxiety or anger can make the heart beat faster. Breathing becomes heavier and blood pressure goes up. These changes can make heart failure worse.

  Find ways to reduce emotional stress. Practicing mindfulness and connecting with others in support groups are some ways to reduce and manage stress.

• Get better sleep. Heart failure can cause shortness of breath, especially when lying down. Try sleeping with your head propped up using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea.
• Get recommended vaccinations. Ask your health care provider about getting influenza, pneumonia and COVID-19 vaccinations.

Coping and support

Managing heart failure requires open communication between you and your health care provider. Be honest about any challenges concerning your diet, lifestyle and medicine use. Pay attention to your body and how you feel. Tell your provider when you're feeling better or worse. This helps your health care provider know what treatment works best for you.

These steps may help you manage heart failure:

• Take medicines as directed. If side effects or costs cause problems, ask your provider about other options. Don't stop taking your medicines without first talking to a care provider. Also, go to all scheduled health appointments. If you miss one, ask your health care provider how and when to reschedule.
• Use caution with other medicines and supplements. Some medicines available without a prescription to treat pain and swelling can make heart failure worse. They include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some diet pills and supplements also may be unsafe if you take medicines for heart failure. Always tell your health care provider about all the medicines you take, including those bought without a prescription.
• Weigh yourself daily. Do this when you first wake up, after breakfast and after peeing. Write your weight down in a notebook. Bring the notes to your medical checkups. An increase in weight can be a sign of fluid buildup.
• Check your blood pressure at home. Write down your numbers and bring them with you to your health checkups. Doing so helps your care providers know if treatment is working or if your condition is getting worse. Home blood pressure monitors are available at local stores and pharmacies.
• Know how to contact your health care provider. Keep your provider's phone number, the hospital's phone number, and directions to the hospital or clinic on hand. You'll want easy access to this information if you have health questions or if you need to go to the hospital.
• Ask for help. Sticking to treatment and lifestyle changes may be challenging. It may help to ask your friends and family to help you meet your goals.

Preparing for your appointment

If are worried about your heart failure risk, make an appointment with your health care provider. You may be referred to a doctor trained in heart diseases. This type of provider is called a cardiologist. If heart failure is found early, treatment may be easier and more effective.

Appointments can be brief. Because there's often a lot to discuss, it's a good idea to be prepared for your appointment. Here's some information to help you get ready.

What you can do

• Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet. You may need to avoid food and certain drinks before some tests.
• Write down any symptoms you're having, including any that may seem unrelated to heart failure.
• Write down important personal information, including a family history of heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes. Find out if anyone in your family has had heart failure. Some heart conditions that cause heart failure run in families. Knowing as much as you can about your family history can be helpful.
• Make a list of all medicines, vitamins or supplements that you're taking. Include doses. Bring this list with you to all health checkups.
• Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information given to you during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your health care provider. For example, if you have heart failure you might ask if it's safe for you and your partner to have sex. Most people with heart failure can continue having sex once symptoms are under control. If you have questions, talk to your health care provider.

Your time with your provider is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For heart failure, some basic questions to ask your health care provider include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests will I need? Do these tests require any special preparation?
• What treatments are available? Which do you recommend for me?
• What foods should I eat or avoid?
• What's an appropriate level of physical activity?
• Do I have any activity restrictions?
• How often should I be screened for changes in my condition?
• I have other health conditions. How can I best manage these conditions together?
• Is there a generic available for the medicine you're prescribing for me?
• Do my family members need to be screened for conditions that may cause heart failure?
• Are there brochures or other materials that I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your health care provider is likely to ask many questions. Being ready to answer them may save time to go over any details you want to spend more time on. Your provider may ask:

• When did you first notice your symptoms?
• Do your symptoms occur all the time, or do they come and go?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• Does anything make your symptoms worse?

What you can do in the meantime

It's never too early to make healthy lifestyle changes, such as quitting smoking, cutting down on salt and eating healthy foods. These changes can help prevent heart failure from starting or worsening.