Heart failure


Photo of patient being examined by a doctor

In people with heart failure, the heart isn't able to pump enough blood around their body. As a result, their organs, muscles and other types of tissue do not get enough oxygen. Heart failure is also sometimes referred to as congestive heart failure (CHF) or cardiac insufficiency.

Heart failure can be acute, like after a , or it may develop over time, for example because of permanently high blood pressure or coronary artery disease.

Depending on how severe heart failure is, it may go unnoticed, only cause minor symptoms, or really affect your physical fitness. People who have advanced heart failure find it hard to carry out normal everyday activities. Various treatments can relieve the symptoms and help you live longer.


Heart failure can cause various symptoms. The most common symptoms are:

  • shortness of breath and difficulty breathing
  • tiredness and exhaustion
  • a build-up of fluid in the feet, ankles or legs or – less commonly – in the genital area or abdomen (belly)

Other possible symptoms include a rapid heartbeat, urinating often at night, difficulties concentrating and a dry cough. People may also gain weight due to the build-up of fluid.

But these kinds of symptoms can have a number of other causes. And a lot of people who have heart failure have other medical conditions too. So it can be hard to recognize early signs of heart failure.


Heart failure is usually caused by another health problem that damages the heart muscle or the blood vessels. These are the most common causes:

In coronary artery disease (CAD, also called coronary heart disease, or CHD), the arteries that supply the heart with oxygen-rich blood are too narrow. This can prevent the heart from getting enough blood, resulting in heart failure. In a , one of these blood vessels is blocked so suddenly that no blood can get through to part of the heart, and muscle tissue dies.

Constant high blood pressure can cause the blood vessels to lose their elasticity. The heart then has to work against higher all the time. In order to counteract this problem and make sure that all parts of the body are supplied with blood, various changes occur in the body. For instance, the heart muscle grows larger and thicker, which increases the heart’s ability to pump blood at first. After a while, though, the muscle may harden or the heart chambers may become larger. In the long term, this can reduce the heart's ability to pump blood, eventually leading to heart failure.

Heart failure can also be caused by conditions affecting the heart muscle, the heart valves or the sac around the heart (pericardium). Examples of such conditions include inflammations, congenital heart muscle abnormalities, heart valve defects and abnormal heart rhythms like atrial fibrillation. Heart muscle tissue may also be damaged by alcohol abuse, drug abuse, or certain medications.

Risk factors

The main risk factors for heart failure are:

  • Type 2 diabetes
  • Smoking
  • Drinking a lot of alcohol
  • Being severely overweight (obese)
  • Some medications for the treatment of cancer

People with a genetic predisposition for less common heart diseases, like some types of heart muscle disease, are also at greater risk of developing heart failure.


Heart failure mainly occurs in older people. It usually first arises after the age of 65, and the risk increases with age. More than 10% of people over the age of 70 have heart failure.


There are four stages of heart failure, based on how severe it is:

  • Symptom-free (asymptomatic) heart failure: There are no symptoms, but certain tests can detect that the heart isn't performing as well as it should.
  • Mild heart failure: More strenuous physical exercise like climbing stairs or walking uphill causes symptoms like exhaustion or shortness of breath. But light physical exercise doesn't cause any symptoms.
  • Moderate heart failure: Even everyday activities and light physical exercise, like walking on a level surface, can cause symptoms.
  • Severe heart failure: Symptoms occur at rest or during even the slightest physical exercise. You can only lie down if your upper body is elevated. Some people with severe heart failure are bedridden.

The way in which heart failure continues to develop over time varies from person to person, depending on things like what is causing it and whether they have other medical conditions. In some people the symptoms can be kept under control for many years. But sometimes the heart becomes weaker after a short amount of time. Doctors can help to predict how the condition will go on to develop.

If another medical problem is responsible for the heart failure, and that problem can be treated (e.g. damaged heart valves), it is sometimes possible to stop the heart failure from getting worse. In most people, though, the cause of heart failure can't be treated, and the heart becomes weaker over time.


Advanced heart failure can really affect your quality of life because it is difficult or even impossible to carry out normal activities. It can also cause various problems such as abnormal heart rhythms, and poorly healing wounds on the lower legs.

A sudden build-up of fluid in the lungs (pulmonary edema) can lead to choking fits and coughing up a foamy liquid. Large amounts of fluid trapped between the ribs and the lungs can make it very difficult to breathe. Fluid may also accumulate in the belly or liver, causing bloating, loss of appetite, nausea and digestive problems.

If heart failure suddenly gets a lot worse, it can become life-threatening and hospital treatment may be needed. A sudden turn for the worse is characterized by symptoms like shortness of breath following even light exercise or at rest, especially while lying down.


Possible signs of heart failure include trouble breathing, exhaustion, swelling due to water retention, abnormal heart sounds (murmurs), or crackling sounds when breathing. In order to diagnose heart failure properly, though, doctors have to do various examinations such as:

  • an ECG (electrocardiogram) to measure the electrical activity of your heart and your heartbeat,
  • a blood test to measure the levels of various things in your blood, and
  • an ultrasound scan of the heart (echocardiogram or “echo test”).

Echo tests allow doctors to see how effectively the heart is pumping blood and how well the heart valves are working.

It’s also important to try to find out what is causing the heart failure so that any underlying diseases can be treated.


The treatment of heart failure is made up of several parts:

  • Treating the underlying disease: If – as is usually the case – the heart failure developed because of another type of cardiovascular disease, such as high blood pressure, that underlying disease is treated too.
  • Medication: Medication such as beta blockers, ACE inhibitors and diuretics can reduce the burden on the heart and relieve the symptoms. The exact medication used will depend on the type of heart failure.
  • Physical exercise: There are special heart exercise programs for people with heart failure, with a focus on individually adjusted training to build up their stamina and muscles. These programs can improve physical fitness and quality of life.

There are also various things you can do yourself to strengthen your cardiovascular system (heart and blood vessels). These include: not smoking, not drinking too much alcohol, and staying as physically active as possible. People with advanced heart failure can reduce the amount of fluids they drink every day, and regularly monitor their body weight. This can help prevent swelling due to water retention, as well as reduce exhaustion.

It is also a good idea to develop a medication regimen together with your doctor, to avoid interactions between different drugs. Non-prescription medications should be included too. For instance, non-prescription painkillers like diclofenac and ibuprofen aren’t suitable for people who have heart failure because they add to the burden on the kidneys.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.

Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Chronische Herzinsuffizienz. AWMF-Registernr.: nvl-006. October 22, 2019.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on January 25, 2018
Next planned update: 2022


Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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