Heart failure - Diagnosis and treatment (2023)

Diagnosis

To diagnose heart failure, your doctor will take a careful medical history, review your symptoms and perform a physical examination. Your doctor will also check to see if you have risk factors for heart failure, such as high blood pressure, coronary artery disease or diabetes.

Your doctor can listen to your lungs for signs of fluid buildup (lung congestion) and your heart for whooshing sounds (murmurs) that may suggest heart failure. The doctor may examine the veins in your neck and check for fluid buildup in your abdomen and legs.

After the physical exam, your doctor may also order some of these tests:

• Blood tests. Blood tests are done to look for signs of diseases that can affect the heart.
• Chest X-ray. X-ray images can show the condition of the lungs and heart.
• Electrocardiogram (ECG). This quick and painless test records the electrical signals in the heart. It can show the timing and length of the heartbeats.
• Echocardiogram. Sound waves are used to produce images of the heart in motion. This test shows the size and structure of the heart and heart valves and blood flow through the heart. An echocardiogram can be used to measure ejection fraction, which shows how well the heart is pumping and helps classify heart failure and guides treatment.

• Stress test. Stress tests measure the health of the heart during activity. You may be asked to walk on a treadmill while attached to an ECG machine, or you may receive an IV drug that simulates the effect of exercise on the heart.

  Sometimes a stress test is done while wearing a mask that measures how well the heart and lungs get oxygen and breathe out carbon dioxide.

• Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of the heart and chest. Sometimes, contrast is given. Because the contrast agent could affect kidney function, talk to your doctor if you have kidney problems.

• Magnetic resonance imaging (MRI). In a cardiac MRI, you lie on a table inside a long, tubelike machine. Radio waves create images of the heart.

  A cardiac MRI may be done with a dye (contrast). It's important to tell your doctor about any problems with your kidneys before you receive a cardiac MRI or other MRI because contrast can cause a rare and serious complication in people who have kidney disease.

• Coronary angiogram. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel, usually in the groin, and guided to the heart arteries. A dye (contrast) is injected through the catheter to make the arteries show up more clearly on an X-ray, helping the doctor spot blockages.
• Myocardial biopsy. In this test, a doctor inserts a small, flexible cord into a vein in the neck or groin, and 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.

Results of tests to diagnose heart failure help doctors determine the cause of any signs and symptoms and decide on a treatment plan. To determine the best treatment for heart failure, doctors may classify heart failure using two systems:

New York Heart Association classification

This scale groups heart failure into four categories.

• Class I heart failure. There are no heart failure symptoms.
• Class II heart failure. Everyday activities can be done without difficulty but exertion causes shortness of breath or fatigue.
• Class III heart failure. It's difficult to complete everyday activities.
• Class IV 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 and includes a category for people who are at risk of developing heart failure. Doctors use this classification system to identify risk factors and begin early, more aggressive treatment to help prevent or delay 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.

Your doctor often will use both classification systems together to help decide the most appropriate treatment options. Your doctor can help you interpret your score and plan your treatment based on your condition.

Treatment

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger.

Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, treatment of heart failure involves a balance of the right medications and, sometimes, use of devices that help the heart beat and contract properly.

Medications

Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more medications, including:

• 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, Prinivil) and captopril.
• Angiotensin II receptor blockers. These drugs, which include losartan (Cozaar), valsartan (Diovan) and candesartan (Atacand), have many of the same benefits as ACE inhibitors. They may be an option for people who can't tolerate ACE inhibitors.
• Beta blockers. These drugs slow your heart rate and reduce blood pressure. Beta blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer. Examples include carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL, Kapspargo Sprinkle) and bisoprolol.

• Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs so you can breathe more easily.

  Because diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.

• Aldosterone antagonists. These drugs include spironolactone (Aldactone, Carospir) and eplerenone (Inspra). These are potassium-sparing diuretics that have additional properties that may help people with severe systolic heart failure live longer.

  Unlike some other diuretics, spironolactone and eplerenone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern, and learn if you need to modify your intake of food that's high in potassium.

• Positive inotropes. These medications 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 more effectively and maintain blood pressure. Long-term use of these drugs 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.
• Digoxin (Lanoxin). This drug, also called digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure. 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 newer 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 vericiguat had fewer hospital stays for heart failure and heart disease-related deaths compared with those who received an inactive pill (placebo).
• Other medications. Your doctor may prescribe other medications to treat specific symptoms. For example, some people may receive nitrates for chest pain, statins to lower cholesterol or blood-thinning medications to help prevent blood clots.

Your doctor may need to adjust your doses frequently, especially when you've just started a new medication or when your condition is worsening.

You may be admitted to the hospital if you have a flare-up of heart failure symptoms. While in the hospital, you may receive additional medications to help your heart pump better and relieve your symptoms. You may also receive supplemental 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 procedures to implant cardiac devices may be recommended to treat the underlying problem that led to heart failure. Surgery or other procedures for heart failure may include:

• Coronary bypass surgery. If severely blocked arteries are causing your heart failure, your doctor may recommend coronary artery bypass surgery. The procedure involves taking a healthy blood vessel from your leg, arm or chest and connecting it below and above the blocked arteries in your heart. The new pathway improves blood flow to your heart muscle.

• Heart valve repair or replacement. If a faulty heart valve causes your heart failure, your doctor may recommend repairing or replacing the valve. Surgeons can repair the valve by reconnecting valve flaps or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve.

  Heart valve repair or replacement may be done as open-heart surgery, a minimally invasive surgery or a heart procedure using flexible tubes called catheters (cardiac catheterization).

• Implantable cardioverter-defibrillators (ICDs). 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 your chest with wires leading through your veins and into your heart.

  The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also work as a pacemaker and speed your heart up if it is going too slow.

• Cardiac resynchronization therapy (CRT). Also called biventricular pacing, CRT is a treatment for heart failure in people whose lower heart chambers (ventricles) aren't pumping in sync with each other. A device called a biventricular pacemaker sends electrical signals to the ventricles. The signals trigger your ventricles to contract in a more coordinated way, which improves the pumping of blood out of your heart. CRT may be used with an ICD.

• Ventricular assist devices (VADs). A VAD — also known as a mechanical circulatory support device — is a device that helps pump blood from the lower chambers of your heart (ventricles) to the rest of your body. Although a VAD can be placed in one or both ventricles of your heart, it is most frequently implanted in the left ventricle.

  (Video) Heart failure diagnosis | Circulatory System and Disease | NCLEX-RN | Khan Academy

  Your doctor 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 medications 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 doctors at a transplant center will evaluate you to determine whether the procedure may be safe and beneficial for you.

Palliative care and end-of-life care

Your doctor may recommend including palliative care in your treatment plan. Palliative care is specialized medical care that focuses on easing your symptoms and improving your quality of life. Anyone who has a serious or life-threatening illness can benefit from palliative care, either to treat symptoms of the disease, such as pain or shortness of breath, or to ease the side effects of treatment, such as fatigue or nausea.

It's possible that your heart failure may worsen to the point where medications are no longer working and a heart transplant or device isn't an option. If this occurs, you may need hospice care. Hospice care provides a special course of treatment to terminally ill people.

Hospice care allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in hospice residences. Hospice care provides emotional, psychological, social and spiritual support for people who are ill and those closest to them.

Hospice care is available in your own home or in nursing homes and assisted living centers. For people who stay in a hospital, specialists in end-of-life care can provide comfort, compassionate care and dignity.

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 advance care directives — a general term for oral 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 doctors is whether it 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

Making lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening. These changes may be among the most important and beneficial you can make:

• Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster.

  If you smoke, ask your doctor to recommend a program to help you quit. You can't be considered for a heart transplant if you continue to smoke. Avoid secondhand smoke, too.

  (Video) Heart failure treatment - Early stages | Circulatory System and Disease | NCLEX-RN | Khan Academy

• Check your legs, ankles and feet for swelling daily. Contact your doctor if the swelling worsens.
• Discuss weight monitoring with your doctor. Weight gain may mean that you're retaining fluids and need a change in your treatment plan. Ask your doctor how often you should weigh yourself and when to contact your doctor because of weight gain.
• Maintain a healthy weight. If you're overweight, a dietitian can help you work toward your ideal weight. Even losing a small amount of weight can help improve your 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 salt. Too much salt (sodium) can cause water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet.

  Ask your doctor if you should follow a no-salt or low-salt diet. Keep in mind that salt is already added to prepared foods, and be careful when using salt substitutes.

• Limit saturated or trans fats in your diet. In addition to avoiding salty foods, limit the amount of saturated and trans fats in your diet. These potentially harmful dietary fats increase your risk of heart disease.
• Get vaccinations. Ask your doctor about getting influenza, pneumonia and COVID-19 vaccinations.

• Limit alcohol and fluids. Your doctor may recommend that you don't drink alcohol if you have heart failure, since it can interact with your medication, weaken your heart muscle and increase your risk of abnormal heart rhythms.

  If you have severe heart failure, your doctor may also suggest that you limit the amount of fluids you drink.

• Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. But be sure to talk to your doctor about an exercise program that's right for you. Your doctor may suggest a walking program or a cardiac rehabilitation program at your local hospital.

• Reduce stress. When you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse, since your heart is already having trouble meeting the body's demands.

  Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible. Spend time with friends and family to be social and help keep stress at bay.

• Sleep easy. If you're having shortness of breath, especially at night, sleep 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.

Coping and support

Proper heart failure treatment can sometimes improve symptoms and help you live longer. You and your doctor can work together to help make you most comfortable. Pay attention to your body and how you feel, and tell your doctor when you're feeling better or worse. This way, your doctor will know what treatment works best for you.

These steps may help you manage heart failure:

• Keep track of the medications you take. Make a list of all the medications you take, carry it with you and share it with your doctors. Don't stop taking any medications without first talking to your doctor. If side effects from any medications you take are uncomfortable or concerning, let your doctor know.
• Check your medications. Some medications available without a prescription, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diet pills, may worsen heart failure and lead to fluid buildup. Talk to your doctor about all the medications you take.
• Be careful about supplements. Some dietary supplements may interfere with heart failure medications or could worsen your condition. Talk to your doctor about any supplements you are taking.
• Use a diary to monitor your weight. Bring the notes to visits with your doctor. An increase in weight can be a sign of fluid buildup.
• Keep track of your blood pressure. Consider purchasing a home blood pressure monitor. Write down your blood pressure numbers between doctor appointments and bring the record with you to visits.
• Write down your questions for your doctor. Before a doctor's appointment, prepare a list of any questions or concerns. For example, is it safe for you and your partner to have sex? Most people with heart failure can continue sexual activity once symptoms are under control. Ask for clarification, if necessary. Be sure you understand everything your doctor wants you to do.
• Know your doctor's contact information. Keep your doctor's phone number, the hospital's phone number, and directions to the hospital or clinic on hand. You'll want to have these available in case you have questions for your doctor or you need to go to the hospital.

Managing heart failure requires an open communication between you and your doctor. Be honest about whether you're following recommendations concerning your diet, lifestyle and taking medications. Your doctor often can suggest strategies to help you get and stay on track.

Preparing for your appointment

If you think you may have heart failure or you are worried about your heart failure risk because of other underlying conditions, make an appointment with your family doctor. If heart failure is found early, your treatment may be easier and more effective.

Because appointments can be brief and 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 for your appointment and know what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. For some imaging tests, for example, you may need to fast for a period of time beforehand.
• Write down any symptoms you're experiencing, including any that may seem unrelated to heart failure.
• Write down key 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 important.
• Make a list of all medications, vitamins or supplements that you're taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
• Write down questions to ask your doctor.

Your time with your doctor 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 doctor 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?
• 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 alternative to the medicine you're prescribing for me?
• Do my family members need to be screened for conditions that may cause heart failure?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor 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.