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Heart failure

Also listed as: Heart failure - congestive

Signs and Symptoms
Causes
Risk Factors
 
Diagnosis
Treatment Approach
Supporting Research

Heart failure doesn’t mean your heart has failed or stopped beating. It means that your heart, which is a muscle that pumps blood to all parts of your body, is not working as well as it should be and can’t pump as much blood as your body needs. As your heart's pumping action lessens, blood may back up in your lungs, liver, or legs. This can cause shortness of breath, leg swelling (called edema), and other problems. In addition, organs in your body may not get the oxygen and nutrients they need, meaning that they also can’t function properly.

Heart failure is a chronic (ongoing) condition that usually develops over time. It is usually caused by underlying conditions, such as high blood pressure or heart disease. These conditions damage your heart, making the heart muscle stiff or thick. The damaged muscle either can’t relax properly to let the pumping chambers of the heart -- the ventricles -- fill with enough blood, or it can’t contract properly to let the ventricles pump out enough blood. The left ventricle is the main pumping chamber, and heart failure usually starts on the left side. When the left ventricle can’t contract enough, it’s called systolic heart failure. When the left ventricle can’t fill with enough blood, it’s called diastolic heart failure. You can have a combination of both types of heart failure.

Although some conditions that cause heart failure are irreversible, you can manage the condition and improve your health and quality of life with a combination of lifestyle changes and medications.

People with heart failure should be under the care of a cardiologist.

Signs and Symptoms

You may experience one or more of the following symptoms of chronic heart failure:

  • Swollen feet, ankles, and sometimes abdomen
  • Weight gain from fluid retention
  • Shortness of breath and cough
  • Racing or skipping heartbeat (palpitations)
  • Stomach upset, nausea and vomiting, and loss of appetite
  • Difficulty sleeping
  • Fatigue, weakness, and a reduced ability to exercise
  • Lightheadedness
  • Difficulty concentrating or staying alert

The more advanced your heart failure, the more likely you are to have symptoms.

Acute heart failure occurs when something suddenly damages your heart (such as a heart attack, blood clot in the lungs, allergic reaction, or severe infection). Symptoms are similar to those for chronic heart failure, but they are more serious and get worse quickly. Acute heart failure is life threatening, and you should seek immediate emergency medical attention.

Causes

The most common causes of heart failure are high blood pressure and coronary artery (heart) disease. Other causes of heart failure include:

  • Heart attack
  • Damaged heart valves (valves separate the chambers of the heart and keep blood flowing in the right direction)
  • Cardiomyopathy (weakening of the heart muscle, which may be from infection, diseases such as rheumatoid arthritis or lupus, alcohol or drug abuse, or unknown reasons)
  • Congenital heart disease (heart defects at birth)
  • Myocarditis (inflammation of the heart from a virus)
  • Abnormal heart rhythms (arrhythmias)

Risk Factors

You are at risk for developing heart failure if you:

  • Have high blood pressure
  • Have diabetes
  • Have had a heart attack or have heart disease of any kind
  • Have high blood pressure or diabetes
  • Are overweight
  • Have sleep apnea
  • Take certain medications
  • Abuse alcohol, smoke cigarettes, or use cocaine

Diagnosis

Your health care provider will take a detailed medical history and do a physical exam. Your health care provider will examine your heart and lungs, checking for enlargement of the heart and fluid in the lungs. Other signs of heart failure that your health care provider will look for include enlarged neck veins, swelling in your legs or abdomen, and tenderness of the liver. A chest x-ray can help determine if there is fluid on your lungs or enlargement of your heart -- two factors that often go along with heart failure.

After the initial diagnosis, your health care provider will look for the underlying cause of heart failure. Your health care provider may order these tests:

  • Blood tests, to check kidney or thyroid function
  • Echocardiogram, to determine systolic heart failure or diastolic heart failure
  • Ejection fraction, to see how much blood your heart is pumping out
  • Electrocardiogram (ECG), to look for heart rhythm problems
  • Coronary catheterization (angiogram), to look for narrowed arteries

Treatment Approach

With proper treatment, you can control symptoms of heart failure and improve your health. Many lifestyle changes, such as losing weight, cutting down on salt, and exercising regularly can make a difference in your condition. Medications are also available to help your heart better pump blood. Complementary and alternative therapies can be helpful, too, when used along with standard medical treatment. Heart failure is a serious condition and you should always seek medical care; do not take any herbs or supplements without your doctor’s supervision.

Lifestyle

Carefully monitoring your health and helping to manage your condition makes a big difference in keeping heart failure under control. The results of one study found that healthy lifestyle habits (normal body weight, not smoking, regular exercise, moderate alcohol intake, and consumption of breakfast cereals and fruits and vegetables) were associated with a lower risk of heart failure. The highest risk was in men adhering to none of the 6 lifestyle factors, and the lowest was among men adhering to 4 or more healthy lifestyle factors. To do this, track your weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that the pump function of your heart is getting worse. Make sure you weigh yourself at the same time each day and on the same scale.

Other important measures include:

  • Take your medications as directed. Carry a list of medications with you wherever you go.
  • Cut down on salt. Most people with heart failure should consume no more than 2,000 mg of sodium per day. Keep in mind that most salt in your diet doesn’t just come from the salt shaker, but also from processed foods that already contain high levels of sodium. (See “Tips to lower your sodium intake” below.)
  • If you smoke, quit.
  • Exercise and stay active. Walk or ride a stationary bicycle, for example. One study showed that a walking program was safe for people with heart failure and helped improve symptoms. Another study found that a regular tai chi practice improved quality of life and mood in patients with chronic heart failure. Talk to your doctor before starting any new exercise program; he or she can help you find one that’s right for you.
  • Lose weight if you are overweight.
  • Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest, too. Keep your feet elevated to decrease swelling.
  • Manage your stress and stay connected to others. One study found that patients who attend an 8-week support group where mindfulness was also taught had less depression and anxiety and fewer physical symptoms a year later.

Tips to lower your sodium intake

  • Look for foods labeled "low-sodium," "sodium-free," "no salt added," or "unsalted." Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods.
  • Don't cook with salt or add salt to what you are eating. Use pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (such as monosodium glutamate and MSG).
  • Avoid foods that are naturally high in sodium, such as anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), olives, pickles, sauerkraut, soy and Worcestershire sauces, and cheese.
  • Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
  • Use oil and vinegar instead of bottled dressings on salads.
  • Eat fresh fruit or sorbet when having dessert.

Medications

Angiotensin-converting enzyme (ACE) inhibitors -- widen blood vessels and make it easier on your heart to pump blood. Side effects can include chronic cough. ACE inhibitors include:

  • Benazepril (Lotensin)
  • Captopril (Capoten)
  • Fosinopril (Monopril)
  • Lisinopril (Zestril)
  • Enlapril (Vasotec)

Angiotension II receptor blockers (ARBs) -- also dilate blood vessels and may be used in people who can’t take ACE inhibitors. They include:

  • Irbesartan (Avapro)
  • Candesartan (Atacand)
  • Losartan (Cozaar)
  • Valsartan (Diovan)

Digoxin (Lanoxin) -- helps your heart pump more blood by increasing the strength of its contractions.

Beta-blockers -- slow heart rate and lower blood pressure. Beta-blockers include:

  • Acebutolol (Sectral)
  • Atenolol (Tenormin)
  • Bisoprolol (Zebeta)
  • Carvedilol (Coreg)
  • Propanolol (Inderal)
  • Metoprolol (Lopressor, Toprol-XL)

Diuretics (water pills) -- keep fluid from building up in your body by making you urinate more. There are different types of diuretics that can affect potassium and magnesium levels in your body, so your doctor will check your levels frequently.

Isosorbide dinitrate and hydralazine hydrochloride (BiDil) -- BiDil combines two drugs that dilate blood vessels. It is approved for use in African-Americans who have heart failure, as an addition to standard therapy.

Nutrition and Dietary Supplements

Always check with your cardiologist before adding supplements to your regimen for treating and preventing heart failure. It is best to work with a health care provider trained in the use of nutritional medicine. Many people with heart conditions take multiple medications, including blood-thining medications, blood pressure medications, and others. The supplements below can interct with these and many other medications and may not be right for people with certain medical conditions. You should use the supplements listed below only under the supervision of your cardiologist and a doctor who understands the contraindications and interactions associated with these supplements.

  • Magnesium -- Magnesium is essential to heart health. This mineral is particularly important for maintaining a normal heart rhythm and is often used by physicians to treat irregular heartbeat (arrhythmia). People with heart failure are often at risk for developing an arrhythmia. In addition, some diuretics (water pills) may cause your body to lose too much magnesium. For this reason, your doctor may recommend a supplement. Always ask your doctor before taking a magnesium supplement if you have heart failure.
  • Carnitine (500 mg 2 times per day) -- Some early studies suggest that L-carnitine supplements may reduce your chances of developing heart failure after a heart attack and improve exercise capacity if you already have heart failure. Carnitine is a nutrient that helps the body convert fatty acids into energy. This energy is used primarily for muscular activities throughout the body. Most studies used a special form of carnitine called propionyl-L-carnitine.
  • Coenzyme Q-10 (CoQ10, 100 - 200 mg per day) -- Levels of CoQ10 can be low in people with heart failure. Several research studies suggest that CoQ10 supplements can help reduce swelling in the legs, enhance breathing by reducing fluid in the lungs, and increase exercise capacity in people with heart failure. Not all studies agree, however. More research is needed to see if CoQ10 has any real benefit. In the meantime, talk to your doctor about whether this supplement would be good as well as safe for you.
  • Creatine -- Creatine is a naturally occurring amino acid (protein building block) found mainly in muscles. In a few studies of people with heart failure, injections of creatine (in addition to standard medical care) provided improvement in heart function and ability to exercise compared to those who received placebo. Taking creatine orally improved muscle function and endurance. More studies are needed to determine whether oral creatine has any benefit for people with heart failure.
  • Vitamin B1 (Thiamine) -- Thiamine may be related to heart failure in several ways. First, low levels of thiamine can contribute to the development of heart failure. On the flip side, people with severe heart failure can lose a significant amount of weight, including muscle mass (called cachexia), and become deficient in many nutrients, including thiamine. In addition, diuretics (water pills) can cause your body to lose too much thiamine. Talk to your doctor about measuring your level of vitamin B1 and whether you should take thiamine.
  • Amino acids -- A few small studies suggest these amino acids might be helpful for heart failure, but more research is needed:
    • Arginine (needed for the body to make nitric oxide, which helps blood flow)
    • Taurine (helps heart muscle contract)

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider. Many people with heart conditions take blood-thinning medications and blood pressure medicines, among others. The supplments below can interact with these and many other medicines and may not be right for people with certain conditions. These should be used only under the supervision of your cardiologist and a doctor who understand the contraindications and interactions associated with these supplements.

  • Hawthorn -- Hawthorn (Crataegus spp.), a member of the rose family, was used by physicians in the early 1800s to treat circulation and respiration (breathing) problems. The flowers and berries have been used traditionally to treat irregular heartbeat, high blood pressure, chest pain, atherosclerosis (hardening of the arteries), and heart failure. Several scientific studies suggest that hawthorn improves the heart’s ability to pump blood in people with heart failure. It also significantly improved symptoms (like reduced shortness of breath and fatigue) and helped people exercise longer. There is not enough research to determine definitively whether hawthorn can work safely with other medications, or how it compares to drugs such as ACE inhibitors. Talk to your doctor to see if hawthorn is right for you.
  • Berberine (300 - 500 mg 4 times per day) -- Berberine, an active ingredient of goldenseal (Hydrastis canadensis) and other herbs, can dilate blood vessels. In one study, people who took berberine for 8 weeks had better heart function and were more able to exercise than those who took placebo. A few other studies suggest that when berberine is combined with standard medicines for heart failure, it can improve heart function and quality of life. Talk to your doctor about whether it is safe and appropriate for you to take berberine in addition to your usual care.

Prognosis and Complications

Heart failure is a serious disorder that leads to a lower life expectancy. It is generally a chronic illness, but many forms of heart failure can be controlled by treating the underlying causes, making lifestyle changes, and taking medication.

Potential complications include:

  • Pulmonary edema (fluid buildup in the lungs)
  • Total failure of the heart to function (circulatory collapse or shock)
  • Arrhythmias (irregular heart rhythm) including fatal arrhythmias

Supporting Research

Al-Hasso. Coenzyme Q10: a review. Hosp Pharm. 2001;36(1):51-66.

Bleske BE, Zineh I, Hwang HS, Welder GJ, Ghannam MM, Boluyt MO. Evaluation of hawthorn extract on immunomodulatory biomarkers in a pressure overload model of heart failure. Med Sci Monit. 2007 Dec;13(12):BR255-258.

Caminiti G, Volterrani M, Marazzi G, Cerrito A, Massaro R, Arisi A, Franchini A, Sposato B, Rosano G. Tai chi enhances the effects of endurance training in the rehabilitation of elderly patients with chronic heart failure. Rehabil Res Pract. 2011;2011:761958.

Chatterjee K, Rame J.E. Systolic heart failure: Chronic and acute syndromes. Critical Care Medicine. 2008;36(1).

Churbasik S. Evidence of the effectiveness of hawthorn extract. Am J Med. 2003;115(7):585; author reply 585-586.

Degenring FH, Suter A, Weber M, Saller R. A randomized double blind placebo controlled clinical trial of standardized extract of fresh Crataegus berries (Crataegisan) in the treatment of patients with congestive heart failure NYHA II. Phytomedicine. 2003;10:363-9.

Djousse L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302(4):394-400.

Eaton LJ, Kinkade S. Hawthorn extract improves chronic heart failure. J Fam Pract. 2003;52(10):753-753.

Evangeliou A, Vlassopoulos D. Carnitine metabolism and deficit – when supplementation is necessary? Curr Pharm Biotechnol. 2003;4(3):211-219.

Fong HH, Bauman JL. Hawthorn. J Cardiovasc Nurs. 2002;16(4):1-8.

Fugh-Berman A. Herbs and dietary supplements in the prevention and treatment of cardiovascular disease. Prev Cardiology. 2000;3:24-32.

Fumagalli S, Fattirolli F, Guarducci L, Cellai T, Baldasseroni S, Tarantini F, Di Bari M, Masotti G, Marchionni N. Coenzyme Q10 terclatrate and creatine in chronic heart failure: a randomized, placebo-controlled, double-blind study. Clin Cardiol. 2011;34(4):211-7. doi: 10.1002/clc.20846. 

Gao ZY, Xu H, Shi DZ, Wen C, Liu BY. Analysis on outcome of 5284 patients with coronary artery disease: The role of integrative medicine. J Ethnopharmacol. 2011. [Epub ahead of print]. 

Gavagan T. Cardiovascular disease. Primary Care. 2002;29(2):323-338, vi.

Hodges P. Heart failure: epidemiologic update. Crit Care Nurs Q. 2009;32(1):24-32.

Holubarsch CJ, Colucci WS, Meinertz T, Gaus W, Tendera M. Survival and prognosis: investigation of Crataegus extract WS 1442 in congestive heart failure (SPICE) – rationale, study design and study protocol. Eur J Heart Fail. 2000;2(4):431-437.

Houston MC. Treatment of hypertension with nutraceuticals, vitamins, antioxidants and minerals. Expert Rev Cardiovasc Ther. 2007 Jul;5(4):681-91.

Ince C, Schulman SP, Quigley JF, et al. Usefulness of magnesium sulfate in stabilizing cardiac repolarization in heart failure secondary to ischemic cardiomyopathy. Am J Cardiol. 2001;88(3):224-229.

Khatta M, Alexander BS, Krichten CM, Fisher ML, Freudenberger R, Robinson SW et al. The effect of conenzyme Q10 in patients with congestive heart failure. Ann Int Med. 2000;132(8):636-640.

Koh SG, Brenner DA, Korzick DH, Tickerhoof MM, Apstein CS, Sauper KW. Exercise intolerance during post-MI heart failure in rats: prevention with supplemental dietary propionyl-L-carnitine. Cardiovas Drugs Ther. 2003;17(1):7-14.

Lau CW, Yao XQ, Chen ZY, Ko WH, Huang Y. Cardiovascular actions of berberine. [review]. Cardiovasc Drug Rev. 2001;19(3):234-244.

Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Saunders Elsevier: Philadelphia, PA. 2007;Ch.23.

Mant J, Al-Mohammad A, Swain S, et al. Guideline Development Group. Management of chronic heart failure in adults: synopsis of the National Institute for Health and clinical excellence guideline. Ann Intern Med. 2011;155(4):252-9.

Mendoza CE, Rodriquez F, Rosenberg DG. Reversal of refractory congestive heart failure after thiamine supplementation: a report of a case and review of literature. J Cardiovas Pharmacol Ther. 2003;8(4):313-316.

Mingorance C, Rodríguez-Rodríguez R, Justo ML, Alvarez de Sotomayor M, Herrera MD. Critical update for the clinical use of L-carnitine analogs in cardiometabolic disorders. Vasc Health Risk Manag. 2011;7:169-76.

Morelli V, Zoorob RJ. Alternative therapies: Part II. Congestive heart failure and hypercholesterolemia. [Review]. Am Fam Physician. 2000;62(6):1325-1330.

Orea-Tejeda A, Orozco-Gutiérrez JJ, Castillo-Martínez L, Keirns-Davies C, Montano-Hernández P, Vázquez-Díaz O, Valdespino-Trejo A, Infante O, Martínez-Memije R. The effect of L-arginine and citrulline on endothelial function in patients in heart failure with preserved ejection fraction. Cardiol J.2010;17(5):464-70.

Pauly DF, Pepine CJ. The role of carnitine in myocardial dysfunction. Am J Kidney Dis. 2003;41(4 Suppl 4):S35-43.

Pittler MH, Schmidt K, Ernst E. Hawthorn extract for treating chronic heart failure: meta-analysis of randomized trials. Am J Med. 2003;114(8):665-674.

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Serati AR, Motamedi MR, Emami S, Varedi P, Movahed MR. L-carnitine treatment in patients with mild diastolic heart failure is associated with improvement in diastolic function and symptoms. Cardiology. 2010;116(3):178-82. 

Shechter M. Magnesium and cardiovascular system. Magnes Res. 2010;23(2):60-72. 

Singh U, Devaraj S, Jialal I. Coenzyme Q10 supplementation and heart failure. Nutr Rev. 2007 Jun;65(6 Pt 1):286-93. Review.

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Smith L. Diagnosis and Management of Chronic Heart Failure in Adults. American Family Physician. 2007;75(5).

Sullivan MJ, Wood L, Terry J, Brantley J, Charles A, McGee V, Johnson D, Krucoff MW, Rosenberg B, Bosworth HB, Adams K, Cuffe MS. The Support, Education, and Research in Chronic Heart Failure Study (SEARCH): a mindfulness-based psychoeducational intervention improves depression and clinical symptoms in patients with chronic heart failure. Am Heart J.2009 Jan;157(1):84-90.

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Tauchert M. Efficacy and safety of crataegus extract WS 1442 in comparison with placebo in patients with chronic stable New York Heart Association class-III heart failure. Am Heart J. 2002;143(5):910-915.

Weeks SG, Glantz SA, De Marco T, et al. Secondhand smoke exposure and quality of life in patients with heart failure. Arch Intern Med. 2011;171(21):1887-93.

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Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Forman D, Davis RB, Phillips RS. Tai chi exercise in patients with chronic heart failure: a randomized clinical trial. Arch Intern Med. 2011;171(8):750-7. 

Zeng XH, Zeng XJ, Li YY. Efficacy and safety of berberine for congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 2003;92(2):173-176.

Zenuk C, Healey J, Donnelly J, Vaillancourt R, Almalki Y, Smith S. Thiamine deficiency in congestive heart failure patients receiving long term furosemide therapy. Can J Clin Pharmacol. 2003 Winter;10(4):184-8


Review Date: 1/12/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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