AT A GLANCE: Heart failure can develop gradually, so symptoms such as fatigue, shortness of breath or swelling should not be dismissed as normal aging. Here are five key things patients will learn about heart failure from Oliardiologist at Atrium Health Wake Forest Baptist, in this article:
- Heart failure does not mean the heart has stopped. It means the heart is not pumping blood as efficiently as the body needs.
- Common symptoms of heart failure include shortness of breath, persistent coughing or wheezing, fatigue, swelling, reduced ability to exercise, weight changes, and increased heart rate.
- High blood pressure, diabetes, coronary artery disease, excess weight, valve disease, genetics and some viral infections can raise heart failure risk.
- Diagnosis often includes symptoms, a physical exam, blood tests, chest X-ray, and an echocardiogram to identify the type of heart failure.
- Treatment may include medications, fluid and sodium guidance, cardiac rehabilitation, support groups, and lifestyle steps to help manage symptoms.
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Heart failure can begin quietly. A person may notice they are more winded walking across a parking lot, too tired to finish routine tasks or experience swelling in their feet and ankles. Because those changes can be easy to explain away as aging, stress or being out of shape, many people do not realize the heart may be struggling to pump blood as well as the body needs
But heart failure does not mean the heart has stopped. It is a chronic condition that can often be managed with the right diagnosis, treatment plan and follow-up care. And because it can develop alongside high blood pressure, coronary artery disease, diabetes, obesity or heart valve disease, physicians say recognizing symptoms early—and knowing when to seek care—can make a meaningful difference
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In this installment, Oliardiologist at Atrium Health Wake Forest Baptist and Wake Forest University School of Medicine, took the time to discuss what patients should know about heart failure symptoms, diagnosis, treatment and prevention
Atrium Health is part of Advocate Health, which is part of the AMA Health System Member Program that provides enterprise solutions to equip leadership, physicians and care teams with re
Heart failure is inefficiency of the heart
“Heart failure is basically an inefficiency of the heart and that can be related to either having a weakening of the muscle of the heart or a stiffening of the muscle,” Dr. Gilbert said. “The stiffening can be part of the normal aging process for some people but is accelerated under certain circumstances
“Those circumstances are things like having high blood pressure, diabetes, or having excessive weight on the body, which can make the heart less efficient and more stiff,” she added. “You can almost think of it as an accelerated aging process.”
“Almost 7 million people in the United States have heart failure,” Dr. Gilbert said. “And believe it or not, the latest statistic from the Heart Failure Society of America was that one in four people will have heart failure during their lifetime.”
A classic symptom of heart failure is shortness of breath
“The symptoms of heart failure are broad. Most classically you think of people having shortness of breath with physical activities and then when they’re laying down,” Dr. Gilbert explained. “If they’re having trouble laying down and they’re having to sit up to breathe, that’s because of some congestion in the lungs that can build up and cause that symptom. That’s what we call orthopnea
“Waking up abruptly because of shortness of breath is called paroxysmal nocturnal dyspnea,” she added, noting that other symptoms of heart failure include “lightheadedness and fluctuations in weight in both directions.”
“The two broad categories are systolic heart failure, which is weakening of the heart, and diastolic heart failure, which is stiffening of the heart,” Dr. Gilbert said, noting “they’re about 50/50 in terms of prevalence in the population.”
“Numerically speaking, heart failure is defined by ejection fraction, which indicates the amount of blood the left ventricle delivers with each beat,” she explained. “A value of less than or equal to 40% defines heart failure with reduced ejection fraction; 41–49% is heart failure with mildly reduced ejection fraction; and greater than or equal to 50% means heart failure with preserved ejection fraction.”
These categories are relevant to guidance on medications as there are different recommendations for medical therapies with each.
With heart failure, “about 60% of diagnoses come from coronary artery disease, known as ischemic heart disease,” Dr. Gilbert said. “The rest are due to a combination of valve disease, high blood pressure, and a broad range of nonischemic etiologies, including genetics, viruses, toxics, connective tissue diseases, or unclear causes.”
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Recognize heart failure risk factors
“For heart failure with preserved ejection fraction, variables that worsen cardiac efficiency, such as excessive weight on the body, diabetes, hypertension, coronary artery disease are the major factors,” Dr. Gilbert said. “The same risk variables increase the risk of heart failure with ejection fraction, but additional contributors include genetics, viruses and cardiotoxic agents, such as certain forms of chemotherapy.”
During the COVID-19 public health emergency, “for example, there was a notable increase in viral cardiomyopathies,” she said
Heart failure is diagnosed through a combination of things
“A diagnosis of heart failure requires a combination of clinical signs or symptoms with labs or imaging findings supporting fluid retention,” Dr. Gilbert said. “The laboratory marker indicative of fluid retention is something called BNP-brain natriuretic peptide-or an NT-proBNP, which rises when the heart is under stress or failing.”
“The echocardiogram is the workhorse for diagnostics, clarifying and categorizing which type of heart failure it is,” she said.
There are four stages of heart failure
“There are four stages—A, B, C and D—and A is consistent with at-risk, meaning that you don’t have symptoms. You don’t even have structural heart disease, but you have risk factors, such as high blood pressure,” Dr. Gilbert said. “This would be a wonderful time to intervene for people to prevent getting heart failure.”
“Stage B suggests the presence of structural heart disease without symptoms,” she said. “A more frequent scenario this might be seen is in young individuals with inherited cardiomyopathies. Their age allows improved compensatory mechanisms that may delay the development of symptoms.”
“Then stage C is where there’s actual clinical heart failure, meaning structural heart disease plus symptoms,” Dr. Gilbert said. “And stage D is severe heart failure where we have an impossible time controlling the symptoms to where we need to think about next steps, such as heart transplants and durable heart pumps.”
Medicine for heart failure depends on the cause
“Our first job is to always try to identify reversible causes of heart disease. While we are pursuing those answers, we simultaneously focus on symptoms of mitigation and medication optimization,” Dr. Gilbert said. “This often involves administration of diuretics to optimize fluid levels prior to aggressively titrating medications with mitigate the derogatory nature of the disease process.”
For heart failure treatment, “we have four pillars of medical therapies that have been shown to individually improve outcomes and reduce risk of mortality for patients. In combination, their benefits are exponential for improving outcomes for patients,” she said. “The first category is Angiotensin-Converting Enzymes Inhibitors (ACE inhibitors), Angiotensin Receptor Blockers (ARBs) and Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), which all block a pathway called the Renin-Angiotensin-Aldosterone System (RAAS). Blocking this pathway relieves cardiac stress, prevents fluid retention, and prevents cardiac remodeling. The 2nd class is beta-blockers, which reduce the workload of the heart.”
“Third, there’s mineralocorticoid receptor antagonists, which help block some of the derogatory hormones that are perpetuated with heart failure and help with recovery as well,” Dr. Gilbert said. “The last category is SGLT2 inhibitors. These were originally marketed, investigated and developed as diabetes medications, but the benefits were so profound for patients with heart failure that they have now been remarketed to heart failure medications with diabetes benefits.”
“For people with preserved ejection fraction, this has been a very exciting era for new drugs that have been able to support this condition,” she said. “It used to be that the mainstay for therapy we had was diuretics and mineralocorticoid receptor antagonists, but with the advent of those SGLT2 inhibitors, we’ve had a number of studies in the last decade that have been life changing for people.”
“What has also been impactful for people with preserved ejection fraction is the GLP-1 receptor medications with weight loss that we’ve seen a lot of promising data coming through for improving outcomes and reducing hospitalizations for that group,” Dr. Gilbert explained.
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Watch what you drink if you have fluid retention
Guidance “can be a little bit controversial in terms of fluid restriction for people with heart failure, but my general advice to patients is that if you struggle with fluid retention, watch how much you’re drinking.”
“In circumstances when they’re really struggling with the fluid retention, I will advise stricter restrictions, probably (limiting fluids to) 48 to 64 ounces (daily), depending on their situation,” she said
Know what your dietary budget is for the day
“As far as sodium restriction goes, guidelines have become stricter over time, previously allowing for up to 4000 mg of salt daily in the general population, more recently decreased to 2300 mg,” Dr. Gilbert explained. “For those with cardiac conditions, the recommendations are more stringent with recommendation to limit to 1500 mg daily. These changes reflect an acknowledgement of the derogatory impact of sodium on our bodies.”
“That is why it is important to read food labels. I describe it as their dietary budget for the day. They have 1500 dollars to spend in a day and if they want to spend a thousand on a small French fry, then they’re going to need to eat yogurt and pineapple for the rest of the day,” she said. “It’s not to say you can never eat those things, but you have to understand how to live within your dietary budget.”
Support groups can help with mental health
Heart failure can take a toll not only on the body, but also on mental health. Depression, anxiety and stress can develop after a heart failure diagnosis, which is why physicians say emotional well-being should be part of ongoing care and support
To help with the mental health aspect of heart failure, “support groups are really some of the greatest ways to acknowledge and relate to other people going through your condition,” Dr. Gilbert said. “There are national organizations available for that.”
For example, “Mended Hearts is a well-acknowledged national organization, and the American Heart Association has fabulous patient support networks,” she said.
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Cardiac rehabilitation can also help
“One of the greatest things that patients with reduced ejection fraction can do is cardiac rehabilitation because it is an intrinsic support group where patients can network with others with their same condition, exercising, moving and progressing,” Dr. Gilbert said. “You’re in classes together learning about dietary restrictions, and healthy eating and lifestyles.”
“You can definitely seek out the organizational aspects, but cardiac rehabilitation, which is recommended in the guidelines for people with heart failure, is a really positive way to encourage boost confidence in terms of physical activity and socialization—both important for fighting depression and isolation,” she explained.
Mitigate lifestyle factors to prevent heart failure
“What you can do to prevent heart failure is mitigate the lifestyle factors that I mentioned before, such as coronary artery disease, diabetes, high blood pressure—all of which can have derogatory cardiovascular effects,” Dr. Gilbert said. “To assist with this and to stay ahead of risk factor development is routine health maintenance, such as having annual physical exams for regular screenings
“All of these items are intended to keep people well and identify disease early to prevent more severe and extreme stages of disease,” she added
Know when to seek help
“The key to managing heart failure is to take your medicines, watch your diet, live a healthy lifestyle, monitor your symptoms, and keep your healthcare appointments,” Dr. Gilbert said. “If you gain more than two pounds in a day or more than five pounds in a week, have swelling in your ankles, feet or abdomen that is getting worse, experience breathing difficulty or experience chest pain, it’s time to call your doctor. Don’t wait for your next appointment.”
“These symptoms, especially if you are experiencing more than one at the same time, mean that your heart needs help,” she said. “The good news is that help is available.”
If you have heart failure, you can live a long life
Heart failure “is not a death sentence by any means. There is so much that we’re able to offer to support people these days with heart failure,” Dr. Gilbert said, noting that “keeping up with the medications while the heart is sick and even after it recovers is important. And so is exercise, so keep moving.”
“My own father was diagnosed with heart failure when I was about 10 years old,” she shared. “He lived another 10 years, which inspired me to go into medicine
“If we can achieve the harmony of physical activity, good body weight, medication adherence, and risk factor mitigation, we can fight the disease,” Dr. Gilbert said
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