Heart Failure: Symptoms & Therapy

Brief overview

• Causes: first and foremost narrowing of the coronary arteries (coronary heart disease), high blood pressure, heart muscle diseases (cardiomyopathies), inflammation of the heart muscle (myocarditis), valvular heart disease, cardiac arrhythmias, chronic lung disease, valvular heart disease, heart attack, cirrhosis of the liver, side effects of medications, elevated blood lipids, diabetes
• Symptoms: depending on the stage, shortness of breath (dyspnea) on exertion or at rest, reduced performance, fatigue, pale or blue discoloration of the lips and nail beds, edema, especially of the ankles and lower legs, thickened neck vessels, rapid weight gain, nocturnal urge to urinate, palpitations, cardiac arrhythmias, low blood pressure
• Treatment: drugs to lower blood pressure (antihypertensives), to flush it out (diuretics), to slow the heartbeat (e.g., beta blockers), to reduce the effect of certain hormones (aldosterone antagonists), and to strengthen the heart (e.g., digitalis). Depending on the cause, surgery (e.g., of the heart valves, bypass, pacemaker), sometimes heart transplantation

Heart failure: causes and risk factors

In heart failure (cardiac insufficiency), the heart is no longer as efficient as a healthy heart. It can no longer supply the body’s tissues with enough blood (and therefore oxygen). This can be life-threatening. Heart failure can be due to various causes:

The second main cause is high blood pressure (hypertension). With high blood pressure, the heart has to pump harder on a permanent basis, for example against narrowed vessels in the bloodstream. Over time, the heart muscle thickens to be able to build up more pressure (hypertrophy). In the long term, however, it cannot withstand this strain – and the pumping capacity decreases.

Other causes of heart failure are cardiac arrhythmias and inflammation of the heart muscle. Defects of the cardiac septum and heart valve defects (congenital or acquired) can also lead to heart failure. The same applies to fluid accumulation in the pericardium (pericardial effusion, especially in pericarditis).

Heart failure can also be caused by heart muscle diseases (cardiomyopathies). These in turn can be caused, for example, by inflammation or excessive alcohol, drug or medication abuse.

Metabolic diseases can also play a role in the development of heart failure. Examples are diabetes mellitus (diabetes) and thyroid function disorders (such as hyperthyroidism).

Diseases of the lungs such as emphysema or COPD (chronic obstructive pulmonary disease) are other possible causes of heart failure.

In particular, the less common right heart failure (functional weakness of the right side of the heart) can be caused by lung disease. This is because the vessels in the diseased lungs are usually also damaged. Blood can no longer flow through them properly (pulmonary hypertension). It backs up into the right heart and puts a strain on it.

Sometimes medications also cause heart failure. This risk exists, for example, with certain drugs for cardiac arrhythmias, certain cancer drugs (antineoplastic drugs), appetite suppressants and migraine drugs (such as ergotamine). However, tumors of the heart or cancer metastases may also cause heart failure.

Systolic and diastolic heart failure

Heart failure is generally composed of two parameters: systolic and diastolic heart failure.

The term systolic heart failure (also congestive heart failure) refers to the reduced pumping ability of the heart: The pumping function and ejection output of the left ventricle are reduced.

As a result, the organs are no longer supplied with sufficient blood. In addition, the blood backs up. This causes edema, for example in the arms and legs or in the lungs.

In most cases, the left ventricle is pathologically altered and thus less expandable and can no longer absorb sufficient blood. As a result, less blood is pumped on into the systemic circulation. This leads to an undersupply of oxygen to the body. Diastolic heart failure occurs mainly in old age. Women are affected more often than men.

Heart failure: classification

Heart failure can be classified according to various criteria:

• Depending on the area of the heart affected, a distinction is made between left heart failure, right heart failure and global heart failure (both halves of the heart affected).
• Depending on the course of the disease, a distinction is made between acute heart failure and chronic heart failure.
• A rough classification according to the state of the disease is that of compensated heart failure and decompensated heart failure.

The European Heart Society (ESC) also classifies heart failure according to the ejection capacity of the heart. If the left heart continues to pump enough blood, doctors speak of a preserved ejection fraction (ejection fraction = EF, normal value 60-70 percent). This contrasts with a reduced ejection fraction. This results in the following classification:

• Heart failure with reduced left ventricular EF (HFrEF = heart failure with reduced ejection fraction, EF at 40 percent or less)
• Heart failure with mid-range EF (HFmrEF = heart failure with mildly-reduced ejection fraction, formerly heart failure with mid-range ejection fraction, EF = 41-49 percent)
• Heart failure with preserved EF (HFpEF = heart failure with preserved ejection fraction, EF is at least 50 percent)

Heart failure: left, right, global

In right heart failure, the right atrium and the right ventricle of the heart muscle are primarily affected by the heart failure.

A weak right hemisphere of the heart can no longer provide sufficient power and the blood backs up in the vessels that supply it (veins). This increases the pressure in the veins and fluid is forced out of the veins into the surrounding tissue. Water retention (edema) develops in the body, especially in the legs and abdomen.

Right heart failure usually develops as a result of chronic left heart failure.

In left heart failure, the pumping capacity of the left side of the heart is no longer sufficient. As a result, blood backs up into the pulmonary vessels (congested lung). This is particularly dangerous because water can accumulate in the lungs (pulmonary edema). Coughing and shortness of breath are typical symptoms.

If global heart failure is present, the pumping capacity of both parts of the heart is reduced. Thus, symptoms of both right and left heart failure are seen.

Acute heart failure and chronic heart failure

Compensated and decompensated heart failure

The terms compensated heart failure and decompensated heart failure describe the cases in which symptoms occur. Compensated heart failure usually causes symptoms only during exercise. At rest, on the other hand, the heart can still provide the necessary output, so that no symptoms appear.

Decompensated heart failure, on the other hand, causes symptoms such as water retention (edema) or shortness of breath (dyspnea) even at rest or during low exertion.

Doctors use the terms mainly when heart failure is already known to exist. If the symptoms are under control (for example, through proper medication), the heart failure is compensated. However, if this condition gets out of hand (for example, due to acutely added illnesses or failure to take pills), heart failure is considered decompensated.

Heart failure: NYHA classification

• NYHA I: No physical symptoms at rest or with everyday exertion.
• NYHA II: Slight limitations in exercise capacity (e.g., 2 flights of stairs), but still no symptoms at rest.
• NYHA III: High limitations even with everyday physical exertion. Symptoms such as fatigue, cardiac arrhythmias, shortness of breath and “chest tightness” (angina pectoris) occur rapidly even with low levels of exertion.
• NYHA IV: Symptoms appear with any physical exertion and at rest. Affected persons are usually immobile (bedridden) and dependent on permanent assistance in their daily lives.

Heart failure: symptoms

Heart failure: Symptoms of left heart failure

The left part of the heart is where blood is sent after it has been oxygenated in the lungs. When this half of the heart stops working properly, blood backs up into the lungs. This leads to coughing and shortness of breath (dyspnea).

Heart failure symptoms with “asthma cardiale”.

If left heart failure continues to progress, fluid leaks from the pulmonary capillaries into the alveoli. In addition to shortness of breath, this also leads to increased coughing. At the same time, the bronchi may become tense. This symptom complex is also called “asthma cardiale” (“heart-related asthma”).

If fluid continues to enter the lung tissue, a condition known as pulmonary edema develops. Its hallmarks are severe shortness of breath and “bubbly” breathing sounds (“bubbling”). Due to the undersupply of oxygen, the skin and mucous membranes turn bluish (cyanosis). Some patients cough up foamy, sometimes flesh-colored secretions.

If fluid collects around the lungs in the pleural space, physicians refer to this as a pleural effusion. It is also one of the possible symptoms of heart failure.

Heart failure: symptoms of right heart failure.

The deoxygenated blood from the body flows into the right part of the heart. It is pumped from the right ventricle to the lungs, where it is re-oxygenated. When the right side of the heart is affected by heart failure, the but backs up into the body’s veins.

Typical heart failure symptoms in this case are accumulations of water in the body (edema). They usually first appear in the legs (leg edema) – especially at the ankles or on the back of the feet, then also above the shins. In bedridden patients, the edemas first form usually over the sacrum.

In the advanced stage of right heart failure, water also deposits in the organs. Other typical heart failure symptoms therefore include impaired organ function.

The water retention often causes rapid weight gain, often more than two kilos per week.

These swellings can dry out the skin because the pressure in the tissue becomes too great. Possible consequences are inflammations (eczema), which can develop into open, poorly healing wounds.

Global heart failure: symptoms

If both halves of the heart are affected by organ weakness, the condition is referred to as global heart failure. The symptoms of both forms of the disease (right and left heart failure) then occur together.

Other heart failure symptoms

Heart failure causes water retention (edema) throughout the body. These are released (mobilized) mainly at night when the affected person is lying down.

The body wants to eliminate the released, excess fluid via the kidneys. This is why sufferers have to go to the toilet very frequently at night. This frequent urination at night is known as nocturia.

It occurs when, due to advanced cardiac insufficiency, the central nervous system is no longer supplied with blood properly.

Under stress, the heart beats very fast (palpitations = tachycardia). In addition, cardiac arrhythmias can occur, especially in cases of pronounced cardiac insufficiency. The arrhythmias can become life-threatening and must then be treated immediately.

Another classic heart failure sign in the late stages is low blood pressure.

General and very common heart failure symptoms also include reduced performance, fatigue and exhaustion.

Heart failure: tests and diagnosis

Heart failure diagnosis is based on taking the patient’s medical history (anamnesis) and on physical and instrumental examinations.

During the anamnesis interview, the physician asks the patient, among other things, about his or her symptoms and whether there is a family history of heart disease (genetic predisposition).

Listening to the heart’s activity with a stethoscope provides the doctor with the first indications of a valvular defect or heart muscle weakness. When listening to the lungs, a rattling sound is a sign of heart failure. It indicates water retention in the lungs.

However, rales also occur in pneumonia, for example. The doctor may also hear a third heart sound (this is usually only normal in children and adolescents).

In the case of edema in the legs, visible dents can be pressed into the skin. If the physician measures the pulse, it may change in intensity with each beat (pulsus alternans). Furthermore, the examiner recognizes protruding neck veins – a sign of blood backlog.

The blood flow that passes through the heart can be visualized with the help of color Doppler sonography. This is a special form of ultrasound examination. The doctor also uses an ultrasound scanner to see fluid accumulations, for example in the abdomen (ascites) or chest (pleural effusions). At the same time, he checks the vena cava and organs for signs of congestion.

Cardiac arrhythmias are best detected with a long-term ECG. The patient is given a small portable device to take home. It is connected to electrodes that the doctor places over the patient’s chest and continuously records heart activity.

A long-term ECG usually runs for 24 hours. The examination is painless and does not affect the patient.

Stents (vascular supports) may be inserted to keep the coronary vessel permanently open. Furthermore, stress tests (for example, on a bicycle ergometer) help to assess the extent of the problem. In some cases, the heart is so weak that these tests are no longer possible.

A blood pressure measurement is also performed if heart failure is suspected.

In addition, the physician orders various urine and blood tests in the laboratory. Among other things, the urine status and a blood count are taken. Based on the blood count, the physician detects anemia, for example. In addition, the electrolytes (especially sodium and potassium) and the iron status are determined. The doctor also has various organ parameters determined in the laboratory, such as creatinine, fasting blood sugar and liver enzymes, including coagulation values.

In addition, chest X-rays and a magnetic resonance imaging (MRI) scan can support a heart failure diagnosis.

Heart failure: treatment

Heart failure therapy consists of several components and depends primarily on the severity of the heart failure. Basically, in addition to drug therapy, personal lifestyle is also crucial. In severe cases, a pacemaker or heart transplant may be necessary.

Heart failure: medication

Drug therapy for heart failure aims to prevent complications of the disease and improve patients’ quality of life. Different medications are used depending on the cause of heart failure. Some drugs have been shown to improve prognosis, while others primarily relieve existing symptoms.

Overall, several agents are available for heart failure therapy. The most important of these include:

ACE inhibitors: these block a protein that is responsible for the constriction of blood vessels in the body. As a result, the blood vessels remain permanently dilated and blood pressure drops. This relieves the heart and the remodeling of the heart muscle as a result of the permanent overload is slowed down. The physician usually prescribes ACE inhibitors first (NYHA I).

AT-1 antagonists (= angiotensin receptor blockers, sartans): They block the action of a hormone that increases blood pressure. However, they are only used if the patient cannot tolerate ACE inhibitors or angiotensin receptor neprilysin inhibitors (ARNI).

Mineralocorticoid receptor antagonists (MRA, also called aldosterone antagonists): These are additionally indicated in NYHA stages II-IV, particularly when the heart is no longer pumping adequately (EF < 35 percent). They increase water excretion from the body, which ultimately relieves the heart. As "antifibrotic therapy," this treatment is thought to help reverse harmful myocardial remodeling.

Angiotensin receptor neprilysin inhibitors (ARNI): This is a fixed drug combination of an angiotensin receptor blocker (AR, = AT-1 antagonist, see above) and a neprilysin inhibitor (NI). The latter inhibits the breakdown of various hormones in the body and thus dilates the vessels, promotes excretion and counteracts scar tissue in the heart muscle. Currently available is the combination of the active ingredients sacubitril (NI) and valsartan (AR). Physicians prescribe ARNI as a replacement for ACE inhibitors or sartans.

SGLT2 inhibitors (inhibitors of sodium-glucose cotransporter-2, gliflozines): SGLT2 inhibitors are known from the treatment of diabetes. However, they can also help patients with chronic heart failure – regardless of whether they have diabetes or not. Doctors prescribe them alongside therapy with ACE inhibitors/ARNIs, beta-blockers and aldosterone antagonists, especially if patients still experience symptoms when taking them.

Ivabradine: This medication lowers the heart rate. Doctors prescribe it if the heartbeat is too fast (> 70/min) even under beta-blockers or if they are not tolerated.

Digitalis: Preparations with digitalis improve the pumping power of the heart. It does not prolong life, but increases the quality of life and resilience of those affected. Digitalis (digitoxin, digoxin) is used to control the rate of atrial fibrillation, a common heart rhythm disorder.

Physicians use the above agents primarily in patients who have heart failure with reduced ejection fraction (HFrEF) (and NYHA classes II to IV). Standard therapy here includes ACE inhibitors (or ARNIs, or sartans if intolerant) plus beta blockers plus aldosterone antagonists plus SGLT2 inhibitors (according to the European Society of Cardiology guidelines).

In patients with preserved ejection fraction (HFpEF), there is no such drug recommendation. If affected individuals are “overhydrated,” they receive diuretic medications. The situation is similar for people with slightly reduced ejection fraction (HFmrEF) of the heart. Depending on the case, doctors prescribe preparations that are also used for heart failure with reduced ejection fraction (HFrEF).

Iron administration in anemia and heart failure

More iron in the blood can ultimately facilitate breathing. This is because iron is a basic building block of the blood pigment hemoglobin, which plays a crucial role in oxygen transport. Sooner or later, iron deficiency leads to anemia, which promotes heart failure.

Hawthorn for heart failure

Herbal medicine recommends hawthorn preparations for heart failure. They are said to improve the contractility and oxygen supply of the heart muscle. They also counteract cardiac arrhythmias (antiarrhythmic effect).

From a scientific point of view, no relevant and proven efficacy of hawthorn in cardiac insufficiency has been demonstrated so far. If patients nevertheless want to try such medicinal plant preparations, then in consultation with the physician or pharmacist and in addition to the conventional medical heart failure treatment.

Pacemaker against heart failure

Both together can compensate for the heart failure. In CRT, pacemaker wires are inserted into the heart chambers so that they beat in the same rhythm again.

Patients who have survived a cardiac arrest or suffer from dangerous arrhythmias benefit from an implantable cardioverter-defibrillator (ICD). The device is inserted like a pacemaker. It delivers an electric shock when it detects a dangerous arrhythmia.

Sometimes doctors use a combination device of the two systems, called a CRT-ICD system(also called a CRT-D system).

Surgical measures

If heart failure worsens despite existing therapy, it may be necessary to replace the old heart with a new one (heart transplant). Patients can receive a donor heart or an artificial heart. This can lead to various complications, such as rejection reactions.

If defective heart valves are the cause of heart failure, surgery may also be necessary. Sometimes a “repair” (reconstruction) of the heart valve is possible. In other cases, the defective heart valve is replaced (biological or mechanical valve prosthesis).

Heart failure: What you can do yourself

If you have been diagnosed with heart failure by your doctor, it is important to adopt a healthy lifestyle. This will minimize risk factors and improve your quality of life. You should therefore take the following to heart:

1. Diet: Make sure you eat enough fruits and vegetables. Avoid animal fats as much as possible and eat a low-salt diet. Salt causes water to be stored in the body. The heart then has to work harder.
2. Weighing yourself daily: To help you keep track of your body’s fluid balance, step on the scale daily and write down your weight. Seek medical advice immediately if you have gained more than one kilo overnight, more than two kilos within three days or more than two and a half kilos in one week.
3. Exercise: Effective heart failure therapy always includes exercise and moderate physical activity. In everyday life, for example, you can walk to work and take the stairs instead of the elevator. Walks, light strength and coordination exercises, swimming, cycling and walking are also recommended. You can also join a sports group for heart patients (rehab sports). Be sure to discuss with your doctor which physical activities and sports make sense in your case and to what extent you may exercise.
4. Alcohol: Minimize your alcohol intake because alcohol can damage heart muscle cells. Women are recommended to consume no more than twelve grams of pure alcohol (one standard drink) per day. Men should consume no more than 24 grams of pure alcohol (equivalent to two standard drinks) per day. As a general rule, alcohol should not be consumed on at least two days per week. Patients whose heart failure was caused by excessive alcohol consumption (alcohol toxic cardiomyopathy) should avoid alcohol altogether.
5. Smoking: It’s best to give up smoking completely – and any other form of drugs, too!
6. Vaccination: Get vaccinated against influenza every year and against pneumococcus every six years. Vaccination against Covid-19 and subsequent booster shots are also advisable in heart failure.
7. Diary: Keep a diary of any symptoms you notice. That way, you won’t forget anything the next time you see your doctor.

Patients with heart failure have long been advised to take it easy and avoid physical exertion. However, many scientific studies have found a positive effect of moderate endurance training in heart failure. Physical activity is not only safe, but even an important part of treatment.

Exercise in heart failure improves the physical performance and quality of life of those affected. However, it is still unclear whether activity also has an effect on patients’ life expectancy.

In acute disease states such as acute coronary syndrome, shortness of breath at rest, water retention in the tissues or inflammation of the heart muscle, exercise is taboo. In general, caution is advised with heart failure: Always ask your doctors to what extent you are allowed to exert yourself.

Starting exercise with heart failure

What exercise for heart failure?

There is no one-size-fits-all exercise plan for people with heart failure. It depends on the individual patient, the stage of heart failure and their general health and fitness status. In general, exercise in heart failure includes two main components:

• Moderate, continuous endurance training: three to five times a week (daily, if necessary; in the course of time, combination with interval training also possible)
• dynamic strength training: two to three times a week

If affected persons have no condition at all, pure respiratory muscle training may be useful at first.

Moderate endurance training

A sensible option here is the so-called ÖLI rule (= more often, longer, more intensive). This means that the training frequency is increased first, then the duration and finally the intensity.

So if the endurance training can be completed for 10 minutes, the training frequency is increased from, for example, three to five units per week. The next step is to extend the training sessions: Instead of 10 minutes, the patient then exercises for 15 to 20 minutes. The last step is to increase the intensity: Instead of 40 percent of maximum capacity, he goes to 50 to 60 percent.

In the course, heart failure patients can also do interval training. Here, the units are shorter, but more intense. The intensity is then in the moderate-intensive range at about 60 to 80 percent of maximum capacity. The day after interval training, it is usually a good idea to take a break.

For people with heart failure, moderate endurance training is suitable, for example:

• slow cycling or bicycle ergometer
• climbing stairs (e.g. on the stepper)
• Aqua gymnastics
• Dancing

When trained, other sports such as jogging or endurance swimming are also possible. By the way, during a moderate workout, breathing is accelerated, but you can still talk in full sets.

Dynamic strength training

Strength and resistance training is also important for people with heart failure. This is because many sufferers exhibit what is known as wasting syndrome in the advanced stages. This involves a reduction in muscle mass and loss of strength.

Dynamic strength-endurance training with little weight and many repetitions is recommended. To create a training plan, it makes sense to determine the so-called “one repetition maximum” (1-RM), for example.

Correct breathing is particularly important during this training: despite exertion, press breathing should be avoided.

Patients with heart failure are best off doing dynamic strength training two to three times a week.

By the way, high-intensity interval training (HIIT) is a possible option for low-risk patients with stable heart failure. According to the Federation of European Societies of Sports Medicine (EFSMA), this requires trained personnel to supervise the training.

It is advisable to see your doctor at regular intervals (every three to six months) for check-ups and to discuss new exercise limits with him or her.

Heart failure: course of the disease and prognosis

Heart failure is not curable. Only in a few cases can the symptoms be reduced to such an extent that a completely unimpaired life is possible. However, each patient can influence the extent to which the disease progresses.

In addition to lifestyle, it is above all adherence to therapy (compliance) that patients must observe. By adherence to therapy or compliance, physicians mean the extent to which patients adhere to the prescribed and discussed therapy.

This includes, for example, taking the prescribed medication regularly, even if there are perhaps no symptoms at all at the moment. Complications and deterioration of the general condition can thus be prevented in advance.

Compliance also includes regular check-ups with the family doctor. If blood values (e.g. electrolytes, kidney values) are outside the normal range, more frequent checks are necessary.

Also important in the case of heart failure: If you suspect that your condition has worsened, see your doctor immediately!

Heart failure: life expectancy

Patients now have a better prognosis and a comparatively high life expectancy despite the disease. In individual cases, this depends on the type (genesis) of the disease, the age of the affected person, possible concomitant diseases and the personal lifestyle.

Nevertheless, chronic heart failure is a progressive disease that can cause death. Particularly in the advanced stages, the already shaky condition can suddenly worsen at any time and can also be fatal. Therefore, it is important to think about such acute situations already at the beginning of the disease.

Discuss with your doctor which measures would then make sense and record your wishes in the form of a living will. A health care proxy is just as useful. In it, you specify who should take care of your affairs if you are no longer able to do so due to illness.