Heart failure — sometimes known as congestive heart failure — occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.
Certain heart conditions, such as narrowed arteries in the heart (coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and pump blood properly.
Proper treatment can improve the signs and symptoms of heart failure and may help some people live longer. Lifestyle changes — such as losing weight, exercising, reducing salt (sodium) in your diet and managing stress — can improve your quality of life. However, heart failure can be life-threatening. People with heart failure may have severe symptoms, and some may need a heart transplant or a ventricular assist device (VAD).
One way to prevent heart failure is to prevent and control conditions that can cause it, such as coronary artery disease, high blood pressure, diabetes and obesity.
Heart failure can be ongoing (chronic), or it may start suddenly (acute).
Heart failure signs and symptoms may include:
- Shortness of breath with activity or when lying down
- Fatigue and weakness
- Swelling in the legs, ankles and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise
- Persistent cough or wheezing with white or pink blood-tinged mucus
- Swelling of the belly area (abdomen)
- Very rapid weight gain from fluid buildup
- Nausea and lack of appetite
- Difficulty concentrating or decreased alertness
- Chest pain if heart failure is caused by a heart attack
When to see a doctor
See your doctor if you think you might be experiencing signs or symptoms of heart failure.
- Chest pain
- Fainting or severe weakness
- Rapid or irregular heartbeat associated with shortness of breath, chest pain or fainting
- Sudden, severe shortness of breath and coughing up white or pink, foamy mucus
Although these signs and symptoms may be due to heart failure, there are many other possible causes, including other life-threatening heart and lung conditions. Don't try to diagnose yourself.
Emergency room doctors will try to stabilize your condition and determine if your symptoms are due to heart failure or something else.
If you have a diagnosis of heart failure and if any of the symptoms suddenly become worse or you develop a new sign or symptom, it may mean that existing heart failure is getting worse or not responding to treatment. This may also be the case if you gain 5 pounds (2.3 kilograms) or more within a few days. Contact your doctor promptly.
Heart failure often develops after other conditions have damaged or weakened the heart. However, heart failure can also occur if the heart becomes too stiff.
In heart failure, the main pumping chambers of the heart (the ventricles) may become stiff and not fill properly between beats. In some people, the heart muscle may become damaged and weakened. The ventricles may stretch to the point that the heart can't pump enough blood through the body.
Over time, the heart can no longer keep up with the typical demands placed on it to pump blood to the rest of the body.
Your doctor can determine how well your heart is pumping by measuring how much blood is pumped out with each beat (ejection fraction). Ejection fraction is used to help classify heart failure and guide treatment. In a healthy heart, the ejection fraction is 50% or higher — meaning that more than half of the blood that fills the ventricle is pumped out with each beat.
But heart failure can occur even with a normal ejection fraction. This happens if the heart muscle becomes stiff from conditions such as high blood pressure.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart's main pumping chamber.
Type of heart failure
Left-sided heart failure
Fluid may back up in the lungs, causing shortness of breath.
Right-sided heart failure
Fluid may back up into the abdomen, legs and feet, causing swelling.
Systolic heart failure (also called heart failure with reduced ejection fraction)
The left ventricle can't contract vigorously, indicating a pumping problem.
Heart failure with preserved ejection fraction
The left ventricle can't relax or fill fully, indicating a filling problem.
Any of the following conditions can damage or weaken your heart and can cause heart failure. Some of these can be present without your knowing it:
- Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. The disease results from the buildup of fatty deposits in the arteries, which reduces blood flow and can lead to heart attack.
A heart attack occurs suddenly when a coronary artery becomes completely blocked. Damage to your heart muscle from a heart attack may mean that your heart can no longer pump as well as it should.
- High blood pressure. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, this extra exertion can make your heart muscle too stiff or too weak to properly pump blood.
- Faulty heart valves. The valves of the heart keep blood flowing in the proper direction. A damaged valve — due to a heart defect, coronary artery disease or heart infection — forces the heart to work harder, which can weaken it over time.
- Damage to the heart muscle. Heart muscle damage can have many causes, including certain diseases, infection, heavy alcohol use, and the toxic effect of drugs, such as cocaine or some drugs used for chemotherapy. Genetic factors also can play a role.
- Inflammation of the heart muscle (myocarditis). Myocarditis is most commonly caused by a virus, including the COVID-19 virus, and can lead to left-sided heart failure.
- A heart problem that you're born with (congenital heart defect). If your heart and its chambers or valves haven't formed correctly, the healthy parts of your heart have to work harder to pump blood, which may lead to heart failure.
- Abnormal heart rhythms (arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast, creating extra work for your heart. A slow heartbeat also may lead to heart failure.
- Other diseases. Long-term diseases — such as diabetes, HIV, an overactive or underactive thyroid, or a buildup of iron or protein — also may contribute to chronic heart failure.
Causes of sudden (acute) heart failure also include:
- Allergic reactions
- Any illness that affects the whole body
- Blood clots in the lungs
- Severe infections
- Use of certain medications
- Viruses that attack the heart muscle
A single risk factor may be enough to cause heart failure, but a combination of factors also increases your risk.
Risk factors for heart failure include:
- Coronary artery disease. Narrowed arteries may limit your heart's supply of oxygen-rich blood, resulting in weakened heart muscle.
- Heart attack. A heart attack is a form of coronary artery disease that occurs suddenly. Damage to your heart muscle from a heart attack may mean your heart can no longer pump as well as it should.
- Heart valve disease. Having a heart valve that doesn't work properly raises the risk of heart failure.
- High blood pressure. Your heart works harder than it has to if your blood pressure is high.
- Irregular heartbeats. These abnormal rhythms, especially if they are very frequent and fast, can weaken the heart muscle and cause heart failure.
- Congenital heart disease. Some people who develop heart failure were born with problems that affect the structure or function of their heart.
- Diabetes. Having diabetes increases your risk of high blood pressure and coronary artery disease. Don't stop taking any medications on your own. Ask your doctor whether you should make changes.
- Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure in some people. Don't stop taking these medications on your own, though. If you're taking them, ask your doctor if you need to make any changes.
- Certain other medications. Some medications may lead to heart failure or heart problems. They include nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications; and certain medications used to treat high blood pressure, cancer, blood conditions, irregular or abnormal heartbeats, nervous system diseases, mental health conditions, lung and urinary problems, inflammatory diseases, and infections.
- Alcohol use. Drinking too much alcohol can weaken the heart muscle and lead to heart failure.
- Sleep apnea. The inability to breathe properly while you sleep results in low blood-oxygen levels and an increased risk of irregular heartbeats. Both of these problems can weaken the heart.
- Smoking or using tobacco. If you smoke, quit. Using tobacco increases your risk of heart disease and heart failure.
- Obesity. People who have obesity have a higher risk of developing heart failure.
- Viruses. Certain viral infections can cause damage to the heart muscle.
Complications of heart failure depend on the severity of heart disease, your overall health and other factors such as your age. Possible complications can include:
- Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment.
- Heart valve problems. The valves of the heart, which keep blood flowing in the right direction, may not work properly if your heart is enlarged or if the pressure in your heart is very high due to heart failure.
- Heart rhythm problems. Heart rhythm problems may lead to or increase your risk of heart failure.
- Liver damage. Heart failure can cause fluid buildup that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to work properly.
The key to preventing heart failure is to reduce your risk factors. You can control or eliminate many of the risk factors for heart disease by making healthy lifestyle changes and by taking the medications prescribed by your doctor.
Lifestyle changes you can make to help prevent heart failure include:
- Not smoking
- Controlling certain conditions, such as high blood pressure and diabetes
- Staying physically active
- Eating healthy foods
- Maintaining a healthy weight
- Reducing and managing stress
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.
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.
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.
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.
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.
- 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.