Heart Failure
Causes, Symptoms, and Treatment Options
Contents
What is heart failure?
Heart failure is a broad term used to describe the “failure” of the heart to pump sufficient blood to meet the body’s needs. Heart failure is a constellation of symptoms, not a specific abnormality of the structure or function of the heart. Heart failure symptoms fall into 2 basic categories: low output symptoms and volume overload symptoms.
Low output symptoms occur when the heart is unable to deliver adequate blood flow. These include fatigue, exercise intolerance, reduced cognition, and cold hands and feet.
Volume overload symptoms arise when the body retains too much fluid due to poor heart function. These symptoms include shortness of breath, cough, orthopnea (difficulty breathing while lying down), abdominal bloating, early satiety (feeling full quickly), and leg edema (swelling).
What causes heart failure?
There are many potential causes of heart failure, including heart muscle dysfunction, heart valve dysfunction and abnormal rhythm disturbances.
Heart muscle dysfunction, known as cardiomyopathy, can refer to abnormalities in the strength of the heart contraction or the relaxation of the heart muscle.
Heart valve dysfunction may involve stenosis (narrowing of a valve), which restricts blood flow, or regurgitation (leaking of a valve), where blood flows backward in the wrong direction.
Rhythm disturbances are abnormal electrical signals that can disrupt the synchrony of heart contraction.
What causes cardiomyopathy?
Cardiomyopathy, a condition involving abnormal function of the heart muscle, can result from a wide range of causes. Common contributors include coronary artery disease (blocked heart arteries), hypertension (high blood pressure), and tachycardia (a persistently fast heart rate). It may also develop after a viral illness such as COVID-19 or influenza, during pregnancy, or due to toxic exposures like excessive alcohol, amphetamines, or certain chemotherapy drugs.
Other medical conditions, such as thyroid disorders, diabetes, and connective tissue diseases, can also impact the heart muscle and lead to cardiomyopathy. When the condition is inherited, it is referred to as familial cardiomyopathy, indicating a genetic origin that runs in families.
Identifying the underlying cause of cardiomyopathy is important, as it may influence treatment choices. When no specific cause can be found, the condition is called idiopathic cardiomyopathy.
What is ejection fraction (EF)?
To measure how strong the heart is, we look at something called left ventricular ejection fraction (LVEF), which tells us how well the heart is pumping. The left ventricle is the heart’s main pumping chamber, and a normal LVEF is between 50-70%. When the heart muscle weakens, the ejection fraction drops
Patients with moderate-severe weakness of the heart muscle (LVEF <40%) are described as having heart failure with reduced ejection fraction (HFrEF).
Patients with mild weakness (LVEF 40-49%) are described as having heart failure with mildly reduced ejection fraction (HFmrEF).
Patients with an ejection fraction of 50% or higher and symptoms of heart failure have heart failure with preserved ejection fraction (HFpEF).
Note: Heart failure symptoms can also be caused by right ventricular (RV) failure and pulmonary hypertension. We won’t address RV failure or PH in this discussion.
How is heart failure treated?
Lifestyle modifications
Regardless of the type or cause of your heart failure, several lifestyle changes can help improve symptoms and slow disease progression.
Avoid or limit alcohol:
If alcohol has contributed to your cardiomyopathy, abstinence can help the heart muscle heal and improve symptoms.
Otherwise, moderate consumption (up to 1 drink per day for women; up to 1-2 drinks per day for men) may be acceptable. Be sure to discuss your alcohol intake with your healthcare provider to determine what's best for you.
Avoid stimulants:
Stimulants (e.g., amphetamines, excessive caffeine) can damage the heart and worsen heart failure by increasing stress on the heart muscle.
Get enough sleep:
Sleep deprivation increases stress hormones that negatively affect heart function. Prioritize rest to support heart health.
Get regular physical activity:
The heart is a muscle. Regular exercise such as cycling, swimming and walking strengthens the heart and can help improve symptoms of heart failure.
Lower sodium intake.
Limiting sodium can reduce excess fluid retention, which helps with managing volume overload symptoms (like swelling and shortness of breath).
Maintain a healthy weight:
Being underweight or obese can negatively impact your heart.
If you are underweight, proper nutrition to improve healthy body mass (not water weight) can improve survival.
If you are obese, weight loss can reduce the strain on your heart and improve heart failure symptoms.
Manage stress:
Chronic stress can elevate hormones like adrenaline that are harmful to the heart. Consider practicing stress-reduction techniques such as practicing breath awareness.
Monitor blood pressure, heart rate, and weight:
Tracking these parameters at home helps you understand how your heart is responding to treatment and aids your healthcare team in managing your condition.
Quit smoking (if applicable):
Smoking causes blood vessels to constrict (narrow), which can worsen heart failure symptoms.
Medications
Medications for heart failure depend on the type and severity of the condition. There are six main categories of medications frequently used in the management of heart failure. Of these, guideline-directed medical therapy (GDMT) refers specifically to a group of medications shown to improve survival and reduce hospitalizations in patients with heart failure. GDMT is tailored to the type of heart failure a patient has.
For HFrEF (heart failure with reduced ejection fraction), a 4-drug GDMT regimen is typically recommended.
For HFpEF (heart failure with preserved ejection fraction), a 2- or 3-drug GDMT regimen is usually ideal.
Guideline-directed medical therapy (GDMT)
Beta blockers:
Beta blockers slow the heart rate and reduce the heart’s oxygen demand. In patients with HFrEF, they have been shown to improve survival.
These medications are best started once a patient's volume overload (e.g., leg swelling, shortness of breath) has been controlled. They are typically started at low doses and slowly increased (usually every 2 weeks) to reach target doses.
Common beta-blockers include carvedilol (Coreg), metoprolol succinate (Toprol XL), and bisoprolol (Zebeta).
Mineralacorticoid Receptor Antagonists (MRAs):
MRAs block the effects of aldosterone, a hormone that can worsen heart failure over time.
In patients with HFrEF, MRAs have been shown to improve survival. In those with HFpEF, they help improve quality of life and reduce hospitalizations related to heart failure.
Common MRAs for heart failure include spironolactone (Aldactone) and eplerenone (Inspra).
Renin-Angiotensin-Aldosterone System (RAAS) Inhibitors:
RAAS inhibitors dilate blood vessels, which reduces the workload of the heart muscle. RAAS inhibition not only helps relieve the symptoms of heart failure, but also improves survival. This is a broad category that includes 3 groups of medications: ACE-inhibitors, ARBs, and ARNis:
Angiotensin Receptor-Neprilysin Inhibitor (ARNi) is a combination medication that includes an angiotensin receptor blocker (ARB) and sacubitril which blocks the hormone neprilysin.
The first ARNi medication approved for treatment of heart failure is Entresto (valsartan/sacubitril).
Entresto has been shown to reduce hospitalization for heart failure and improve heart failure survival in patients with HFrEF, HFmrEF, and HFpEF.
Compared to other RAAS inhibitors, Entresto provides an incremental improvement in heart failure survival.
Angiotensin Receptor Blocker (ARB)
There are several ARBs approved for the treatment of heart failure. Some of the most commonly prescribed are losartan (Cozaar), valsartan (Diovan) and candesartan (Atacand).
In addition to improving symptoms and survival for patients with HFrEF, ARBs are used to prevent worsening kidney function in patients with chronic kidney disease (CKD).
Angiotensin-Converting Enzyme (ACE) inhibitors
There are several ACE inhibitors approved for the treatment of heart failure. Some of the most commonly used are lisinopril (Prinivil), fosinopril (Monopril), ramipril (Altace), enalapril (Vasotec) and captapril (Capoten).
As with all RAAS inhibitors, there is strong evidence that ACE inhibitors improve survival in patients with HFrEF.
Some patients (particularly Asian people) develop a cough with an ACE inhibitor. This side effect is mitigated by switching to ARB or ARNi therapy.
Sodium-Glucose Co-Transporter 2 (SGLT2) inhibitors:
Originally developed for diabetes management, SGLT2 inhibitors are now a key part of heart failure treatment.
SGLT2 inhibitors are shown to improve survival in patients with HFrEF, HFmrEF, and HFpEF.
Common SGLT2 inhibitors for heart failure are empagliflozin (Jardiance) and dapagliflozin (Farxiga).
Hydralazine + nitrates:
For some patients (particularly African Americans) with HFrEF, the addition of hydralazine and nitrates to standard medical therapy has been shown to provide a specific survival benefit.
For other HFrEF patients, this combo can be used as an alternative to RAAS inhibitors (like ACE inhibitors or ARBs) if they can’t tolerate those medications due to side effects or other issues.
This combo can also be added if blood pressure remains high despite other treatments.
Diuretics
Diuretics are medications that help the kidneys remove excess fluid from the body by increasing urination. They’re especially helpful for patients experiencing symptoms of fluid overload, such as swelling in the legs or shortness of breath.
Unlike guideline-directed medical therapy (GDMT) medications, diuretics do not improve survival. Their primary role is symptom relief. For that reason, they’re generally reduced or stopped when fluid retention is no longer an issue. If you think your diuretic may no longer be needed, talk with your provider before making changes.
There are two main types of diuretics:
Loop diuretics: are the primary agents for symptom relief in heart failure, particularly for reducing edema and pulmonary congestion. Commonly used loop diuretics include furosemide, bumetanide, and torsemide.
Thiazide and thiazide-like diuretics: are not first-line agents for volume overload in heart failure. They are typically used in combination with a loop diuretic in patients with diuretic resistance or when additional blood pressure control is needed. Commonly used thiazide diuretics include hydrochlorothiazide (HCTZ) and chlorthalidone.
Comorbidity management
Comorbidities refer to the presence of two or more medical conditions in the same patient. Several comorbidities are commonly seen in people with heart failure, and effectively managing the comorbidities can significantly improve symptoms, quality of life, and long-term outcomes.
Depression is common in people with heart failure and is associated with elevated stress hormones that can worsen heart function. Treating depression not only improves emotional well-being and quality of life, but also helps reduce hospitalizations related to heart failure.
Diabetes, especially when poorly controlled, can lead to a form of heart muscle weakness known as diabetic cardiomyopathy. Improving blood glucose control is important for improving cardiac function as well as protecting kidney function and vision. Hemoglobin A1c (HbA1c) is a blood test used to measure average blood glucose over time. Most patients with heart failure should aim to keep their HbA1c below 8%.
Sleep apnea is a condition characterized by brief pauses or reductions in breathing during sleep. These interruptions cause frequent “microarousals,” where the patient briefly shifts from deep to lighter sleep, often without being aware of it. Although they may be subtle, these disruptions prevent restorative sleep and trigger elevated stress hormone levels that can harm the heart. Sleep apnea affects about half of all patients with HFrEF, and treating this condition not only improves symptoms but also improves survival.
Procedures and surgeries
Coronary Revascularization
For patients with coronary artery disease (CAD) causing their heart failure, procedures like catheter-based angioplasty and stenting or bypass surgery can be used to improve blood flow to the heart muscle. Catheter procedures open blocked arteries by inflating a balloon or placing a stent to push plaque aside. Bypass surgery reroutes blood flow around blocked arteries.
The recommended type of revascularization depends on the location, number, and severity of blockages. If the heart muscle is alive but ischemic (not receiving enough blood), improving blood flow may help the muscle function better. However, if the heart muscle is permanently damaged or scarred, revascularization may not be beneficial.
Valve Repair/Replacement
Heart valve problems, such as stenosis (narrowing) or regurgitation (leaking), can affect blood flow through the heart. Repairing or replacing a diseased valve may help improve how blood moves through the heart and relieve symptoms.
Depending on the valve issue, this can be done through open-heart surgery or less invasive transcatheter procedures.
Device Implantation
A pacemaker is a small device implanted under the skin and connected to the heart with leads (conductive wires). These leads may attach to the atrium (upper chamber), ventricle (lower chamber), or both (dual-chamber). The device is programmed to monitor the heart’s electrical activity and deliver electrical impulses when it detects a pause or delay in the heart’s natural conduction. Pacemakers are typically used for patients with abnormally slow heart rates.
A biventricular pacemaker is a specialized device with two ventricular leads: one attached to the right ventricle and the other to the left ventricle. It delivers electrical stimulation to both sides of the heart simultaneously to improve the coordination of contractions, a process known as “cardiac resynchronization therapy.” This therapy is commonly used in patients with heart failure with reduced ejection fraction (HFrEF) who also have left bundle branch block (LBBB), which causes dyssynchronous (uncoordinated) heart contractions.
An implantable cardioverter defibrillator (ICD) is similar to a pacemaker in that it is implanted with leads attached to or near the heart. The ICD continuously monitors the heart’s electrical activity and, if it detects dangerously fast rhythms such as ventricular tachycardia or ventricular fibrillation, it delivers an electrical shock to restore a normal rhythm. While defibrillators don’t prevent these life-threatening arrhythmias, they can quickly resuscitate patients when they occur. ICDs are recommended for patients who have survived a sudden cardiac arrest (secondary prevention) and for those at high risk of sudden cardiac death (primary prevention). The most common use for primary prevention ICDs is in patients with HFrEF whose left ventricular ejection fraction remains below 35% despite receiving optimal guideline-directed medical therapy (GDMT).
A Left Ventricular Assist Device (LVAD) is a mechanical pump surgically implanted for select patients with stage D (end-stage) heart failure due to severely reduced left ventricular function (HFrEF). The LVAD helps improve blood flow and can significantly enhance quality of life and survival for those appropriately selected. It’s important to understand that the LVAD does not replace the heart but rather supports its pumping function. Because LVADs are designed to assist the left ventricle, they may not be suitable for patients with right ventricular failure. Patients considering LVAD therapy, much like those being evaluated for heart transplantation, work closely with specialized Advanced Heart Failure clinics to determine if this treatment is appropriate.
Heart Transplant
For carefully selected patients with end-stage heart failure, a heart transplant may be an option. Typically, candidates are younger than 65 and otherwise healthy aside from severe heart disease.
Transplant surgery involves removing the diseased heart and replacing it with a donor heart. This can significantly improve quality of life, relieve symptoms, and prolong survival. However, it carries risks and requires lifelong immunosuppression and close monitoring. Patients considering transplant work closely with Advanced Heart Failure clinics to evaluate their candidacy.
What are the risks of heart failure?
Heart failure (HF) is more common than you might think. As of 2025, around 7 million people in the U.S. are living with it. Without treatment, heart failure can cause symptoms like fatigue, shortness of breath, exercise intolerance, bloating, and swelling. Over time, it can lead to a decrease in quality of life, repeated hospital stays, and, in severe cases, death.
There are two primary causes of death among heart failure patients: cardiogenic shock and sudden cardiac death (SCD).
Cardiogenic Shock is the more common cause of death in heart failure patients. It happens when the heart is unable to pump enough blood to the body, leading to inadequate perfusion of vital organs. This can develop acutely, but more often it progresses slowly over time, causing worsening symptoms, recurrent hospitalizations, and dysfunction in other organ systems (such as the kidneys, liver, or malnutrition). Ultimately, it leads to death.
Sudden Cardiac Death (SCD) occurs due to an acute electrical event in the heart, such as ventricular tachycardia or ventricular fibrillation. This leads to a dangerously fast heart rate, preventing the heart from pumping blood effectively. SCD can often be reversed with immediate CPR and defibrillation (an electrical shock to restore normal heart rhythm). Since SCD is unpredictable, some patients may have an implantable defibrillator, which can automatically deliver a life-saving shock if necessary.
The primary goal of heart failure treatment is to help patients live as long and as well as possible. However, we must also acknowledge that death of our physical bodies is an inevitable part of life. When heart failure progresses beyond what can be managed through medical or surgical interventions, the focus shifts to enhancing quality of life. This means managing symptoms in a way that aligns with the patient’s personal values and goals.
When it becomes clear that both quality and quantity of life cannot be preserved, it is important to help patients reflect on what matters most to them. With these goals in mind, healthcare providers can support patients in making decisions that allow them to live as well as possible according to their own wishes.
What are the potential side effects of heart failure medications?
Beta-blockers:
Common: low blood pressure, slow heart rate
Rare: diarrhea
Mineralocorticoid Receptor Antagonists (MRAs):
Common: elevated potassium levels
Rare: breast tenderness (spironolactone)
Renin-Angiotensin-Aldosterone System (RAAS) Inhibitors:
Common: cough (with ACE inhibitors), elevated potassium levels, low blood pressure
Rare: angioedema (swelling of the lips or tongue) – requires immediate medical attention
Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors:
Common: dehydration, low blood pressure, urinary tract infection (UTI)
Rare: non-diabetic ketoacidosis – requires immediate medical attention
Diuretics:
Common: dehydration, low blood pressure
Rare: allergic reaction, rash
Note: This is a general overview and is not an exhaustive list of potential side effects.
This content is for general informational purposes only and is not medical advice. Talk with your healthcare provider before making any decisions about your health.
