Imagine experiencing shortness of breath during everyday activities, like walking to the kitchen to make a sandwich.
Your legs are swelling.
Then, you notice you’ve had to start propping yourself upright with pillows to sleep at night.
These symptoms on their own can be concerning, but then you get the diagnosis: congestive heart failure.
Those can be scary words to hear. However, most people will develop some form of heart failure as they get older.
But getting on board with being healthy at a young age and understanding the signs of heart failure can pay off down the road.
Here, University of Michigan Health Frankel Cardiovascular Center cardiologist and advanced heart failure specialist Abbas Bitar, M.D., tells you what you need to know.
What is congestive heart failure?
Bitar: The American Heart Association defines heart failure as a complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood.
Simply, heart failure is a condition where the heart doesn’t pump blood as well as it should.
This happens when the heart’s structure or function is damaged, making it harder to fill with blood or push it out to the body.
Congestive refers to fluid buildup in organs which results in symptoms such as shortness of breath and swelling in the legs, ankles or feet, among others.
Heart failure is a broad condition, and patients can have vastly different experiences.
How is congestive heart failure measured?
Bitar: There are multiple ways to measure or classify heart failure.
To start, left ventricular ejection fraction, which is the percentage of blood the left ventricle pumps out with each beat, is most commonly used to classify patients into one of three categories:
- Heart failure with reduced ejection fraction (<40%), or HFrEF: when the heart muscle is too weak to pump enough blood with each beat.
- Heart failure with mid-range ejection fraction (40-49%), or HFmrEF: when the heart pumps out a moderate amount of blood.
- Heart failure with preserved ejection fraction ≥50%, or HFpEF: when the heart pumps normally but is too stiff to fill properly.
Ejection fraction provides vital insight into the strength and function of the heart.
The American College of Cardiology and American Heart Association also determined four main stages of heart failure:
- Stage A: At risk of heart failure – someone who is at risk to develop heart failure but does not have structural heart changes or symptoms of heart failure. This could be someone that has a condition like coronary artery disease, high blood pressure or diabetes.
- Stage B: Pre-heart failure – someone who has structural heart changes but doesn’t have symptoms.
- Stage C: Symptomatic heart failure – someone who has structural heart changes confirmed from imaging, and they also have symptoms.
- Stage D: Advanced heart failure – someone who has structural heart changes and refractory (recurring or resistant-to-treatment) symptoms.
It’s important to remember that heart failure is a clinical diagnosis, so it relies on a patient’s history, a physical examination and an imaging component to fulfill a clinical suspicion of heart failure.
Finally, there are also four classes identified by the AHA to monitor symptoms and clinical course:
- Class I (1): No physical limitations.
- Class II (2): Slight physical limitations but otherwise asymptomatic while at rest.
- Class III (3): Some physical limitations and, for the most part, asymptomatic at rest.
- Class IV (4): Significant physical limitations and many have symptoms at rest. Cannot carry out day-to-day activities without having symptoms.
For the most part, stages don’t change but classes can vary based on the individual clinical course.
What are the signs of congestive heart failure?
Bitar: The most common symptoms are:
- Shortness of breath
- Trouble breathing while sleeping or lying flat
- Loss of appetite or the feeling of being full
- Swelling of the legs, ankles or feet
In clinic, we often ask patients how many pillows they use to prop up their heads at night.
Many are surprised by this question, but it helps us assess fluid levels in the body.
The human body functions similarly to a bottle containing liquid. When a bottle with a small amount of fluid is tipped on its side, the liquid remains at the bottom and doesn’t reach the top.
However, if the bottle contains a large amount of fluid, the liquid rises to the top. In the human body, excess fluid can accumulate in the lungs, leading to breathing difficulties.
Some patients may also have an irregular heartbeat or chest pain.
These aren’t typical heart failure symptoms but result from the main issue.
For example. when excess fluid builds up, it increases pressure in the heart, which can lead to chest pain similar to angina.
What causes congestive heart failure?
Bitar: The most common causes of heart failure are coronary artery disease and hypertension, or high blood pressure.
There are other metabolic causes too, such as thyroid issues, that can affect the heart muscle.
Ultimately, there are two components which can heighten your chances of heart failure:
- Genetics – certain diseases, like cardiomyopathy, autoimmune or connective tissue diseases that affect the heart muscle.
- Environment and behaviors – such as being inactive, smoking or having an unhealthy diet, which increase your risk of developing coronary artery disease.
Age is also a factor: More than 20% of Americans over the age of 40 have some form of heart failure and over 80% of people diagnosed with heart failure are aged 65 years or older.
How long can you live with congestive heart failure?
Bitar: There is no unifying answer for how long someone can live with heart failure.
How well someone responds to treatment and the cause of their heart failure will play a role in their prognosis.
Statistically, patients with advanced heart failure who continue to experience Class 3 or 4 symptoms despite treatment have poor survival rates.
Their risk of mortality can be as high as 50% within one year.
On the other hand, those who respond well to treatment and are not limited with heart failure symptoms can experience survival rates in line with those that do not have heart failure at all.
So, it’s a pretty wide spectrum.
How do you treat congestive heart failure?
Bitar: Treatment often starts with managing blood pressure and reducing the congestion that may cause swelling or shortness of breath.
Patients with symptoms of fluid buildup are put on a diuretic, or “water pill”, to remove excess fluid from the body and prevent symptoms.
The main classes of medicines are:
- Beta blockers, which decrease heart rate and its workload.
- ACE inhibitors, angiotensin receptor blockers, also known as ARBs or angiotensin receptor-neprilysin inhibitors, also known as ARNIs, which relax blood vessels to reduce blood pressure.
- SGLT2 inhibitors, which eliminate excess sugar from the body, helping prevent fluid buildup.
- Mineralocorticoid receptor antagonists, also known as MRAs, or aldosterone antagonists, which block a hormone called aldosterone that is responsible for fluid retention.
Each has been shown to reduce the risk of dying and being hospitalized due to heart failure from anywhere between 15-20%.
None of these medications are risk free, and your health care provider will work with you to manage any side effects, such as sodium retention.
For the smaller subset of patients with advanced heart failure and refractory symptoms, treatments go beyond medication.
Around 10-15% of patients with more advanced symptoms may need other treatments.
This is when you get into heart pumps, like left ventricular assist devices, and heart transplants.
Can heart failure be reversed?
Bitar: It all comes down to the cause of the heart failure.
If someone experiences a heart attack that leads to a scar on their heart muscle, they may not be able to recover from that.
However, if the heart failure is because someone has high blood pressure and then it is controlled by treatment, many of those patients’ heart muscles can recover.
The drugs we mentioned in the last question have been shown to reduce the risk of death and hospitalization.
What I tell patients in clinic is, ‘You do have heart failure. We can put you on treatment, and then time will tell how you respond.
As a doctor, what do you want patients to know most about congestive heart failure?
Bitar: Heart failure is more common than people realize, but, for most, it’s not a terminal condition.
Many patients do well with medical treatment. For those who don’t, there are options to help extend and improve their lives.
While there’s no cure, identifying and managing risk factors, like high blood pressure and coronary artery disease, early on is crucial.
The key is early diagnosis and intervention, as there’s a lot we can do to help to improve patient’s quality of life and longevity.
If you care about heart disease, please read studies about a big cause of heart failure, and common blood test could advance heart failure treatment.
For more information about heart health, please see recent studies about a new way to repair human heart, and results showing drinking coffee may help reduce heart failure risk.
Written by Rachel Zeichman.
Source: Michigan Medicine.
