Heart failure

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

• Shortness of breath and difficulty breathing
• Tiredness and exhaustion
• Build-up of fluid in the feet, ankles or legs or – less commonly – in the genital area or abdomen (belly)
• Weight gain caused by the build-up of fluid

Other possible symptoms include a rapid heartbeat, urinating often at night, difficulties concentrating and a cough.

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:

• Coronary artery disease (CAD) and heart attack
• High blood pressure
• Heart valve problems
• Abnormal heartbeat

In coronary artery disease (CAD), 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 heart attack, 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 become less elastic. This makes it harder for the heart to pump enough blood through the body. In order to counteract this problem and make sure that all parts of the body are supplied with blood, 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 – especially if they involve the heart getting bigger. Examples of such conditions include inflammations, congenital heart muscle abnormalities, heart valve defects and abnormal heart rhythms like atrial fibrillation. Heart muscle tissue can also be damaged by alcohol, drugs and some medications.

The main risk factors for heart failure are:

• Type 2 diabetes
• Smoking
• Drinking alcohol
• Being severely overweight (obese)
• Not getting enough exercise
• Some medications for the treatment of cancer

Having several family members with rare heart diseases, like genetic heart muscle disease, increases your own 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. It is equally common in men and women.

If your heart stops pumping enough blood suddenly – such as what happens during a heart attack, when a larger part of the heart muscle tissue dies – then it is considered to be “acute” heart failure and is a medical emergency.

By contrast, chronic heart failure develops over a longer period of time. It may go unnoticed at first. But if the heart’s performance continues to decrease, it will lead to noticeable symptoms sooner or later.

Doctors assess how advanced heart failure is based on its severity:

• Symptom-free (asymptomatic) heart failure does not yet cause any symptoms. Certain tests like echocardiography can detect that the heart isn't performing as well as it should.
• Mild heart failure: causes symptoms like exhaustion or shortness of breath during more strenuous physical exercise like climbing stairs or walking uphill. But light physical exertion is possible without any symptoms.
• Moderate heart failure causes symptoms even during everyday activities and light physical exercise, like walking on a level surface.
• Severe heart failure causes symptoms at rest or during even the slightest physical exercise. Some people with severe heart failure are bedridden.

Doctors also consider how well the heart fills with blood and how much blood the heart’s left ventricle pumps per beat.

The way in which heart failure continues to develop over time depends on things like what is causing it and whether you have other medical problems. In some people the symptoms can be kept under control for many years, the progression of the disease can be slowed down, the symptoms can be improved and life expectancy can be increased. But sometimes the heart becomes weaker after a short amount of time.

If another treatable medical problem (e.g. damaged heart valves or high blood pressure) is responsible for the heart failure, it is sometimes possible to stop the heart failure from getting worse or have it go away by treating the cause.

In most people, though, the cause of heart failure can't be treated, and the heart becomes weaker over time.

Advanced heart failure can make it difficult or even impossible to carry out typical everyday activities. This can greatly impact your quality of life.

Heart failure can also cause other problems such as an abnormal heartbeat, pneumonia, fluid build-up and poorly healing wounds on the lower legs.

A sudden build-up of fluid in the lungs (pulmonary edema) is an emergency and 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 a swollen belly, 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 shortness of breath, exhaustion, and fluid build-up,. Abnormal heart sounds (murmurs) or crackling sounds when breathing can offer confirmation. In order to diagnose heart failure properly, though, doctors have to do various tests, including:

• ECG (electrocardiogram) to measure the electrical activity of your heart and your heartbeat
• Blood test
• 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 is also important that doctors try to find out what’s causing the heart failure so that any underlying diseases can be treated, if possible.

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

• Treating the underlying disease: If the heart failure developed because of another type of cardiovascular disease, such as high blood pressure, that underlying disease is treated.
• Medication: Medication can reduce the strain on the heart and relieve the symptoms. The exact medication used will depend on the type of heart failure you have, for instance.
• 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.

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 strain the kidneys.

If you have severe heart failure, you may also need an implantable device to prevent sudden cardiac death or help your heart to pump enough blood.

Doctors recommend that people who have heart failure get the flu, COVID-19 and pneumococcal vaccines in addition to the basic vaccinations (e.g. tetanus).

There are also various things you can do on your own 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. If you have advanced heart failure you usually need to reduce the amount of fluids you drink every day. This can help prevent swelling due to fluid retention, as well as reduce exhaustion. You can talk with your doctor to find out how much you can drink. Daily checks of your weight can give you an early sign of whether you still have fluid retention. Then it’s a good idea to go to the doctor to see whether it is being caused by the heart failure getting worse.

When people are ill or need medical advice, they usually go to see their family doctor first. In our topic “Health care in Germany” you can read about how to find the right doctor. If you are already being treated for heart disease by a cardiologist you should also go there. Our list of questions can help you to prepare for your appointment.