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The heart faithfully keeps blood flowing for a lifetime. Like any muscle, however, illness or injury can weaken the heart, draining its ability to pump enough blood to the body, a condition called “heart failure.” As ominous as the name sounds, heart failure does not mean the heart has stopped working. While it is a serious and life-threatening medical condition, a host of medical treatments and committed lifestyle changes can slow or even stop its progress.
What is congestive heart failure?
Congestive heart failure (CHF) is a complex, progressive condition in which the heart does not pump enough blood to the rest of the body.
The heart chambers that pump blood out are called the ventricles. The right ventricle pushes blood into the lungs where it picks up oxygen. The left ventricle pushes oxygenated blood out to the rest of the body to supply cells and tissues with needed oxygen. Congestive heart failure is largely a condition of the left ventricle, but the right ventricle might also be affected—usually as a result of left ventricular dysfunction.
Left-sided heart failure is further classified into one of two categories. Heart failure with reduced ejection fraction, or systolic heart failure, means the ventricle is failing to contract sufficiently to pump enough blood out. Left-sided heart failure with preserved ejection fraction, or diastolic heart failure, describes conditions in which the ventricle is too stiff to sufficiently relax when they fill with blood, resulting in too little blood in the ventricle to pump out.
Congestive heart failure develops as blood flow out of the heart slows, resulting in blood flow back to the heart to become backed up. It can be caused by any number of conditions affecting the heart muscle, heart valves, blood vessels, or metabolism, including
- Heart attack
- High blood pressure
- Coronary artery disease
- Inflammation of the heart muscle (myocarditis)
- Diabetes
- Obesity
- Smoking
- Sedentary lifestyle
- Heart valve disease
- High triglycerides
When the heart pumps a lower volume of blood, the body compensates with a cascade of responses that in the long run makes the condition worse:
- The sympathetic (involuntary) nervous system speeds up the heart and increases the strength of each heartbeat.
- Sensing lowered blood pressure, the body releases hormones to prevent water and salt from being expelled in the urine, causing fluid retention and swelling.
- The body releases angiotensin to tighten blood vessels and increase blood pressure.
All of these compensatory responses put further strain on the heart and cause physical changes to the heart that further impair the heart’s ability to pump blood. Heart failure, then, is a progressive disease. It will worsen over time. Symptoms begin to present when the heart starts to have difficulty compensating.
Aside from the progressive worsening of heart function, congestive heart failure can produce many life-threatening complications such as
- Atrial fibrillation
- Stroke
- Respiratory distress
- Extreme swelling (anasarca)
- Blood clots
- Kidney disease
- Liver damage
- Lung congestion
An estimated 6.5 million Americans have heart failure, with the lifetime risk for heart failure near 20% in people who live to the age of 80. The one-year mortality rate is 22% and the five-year mortality rate is 43%. Early diagnosis and treatment are crucial. Caught early, the prognosis for heart failure can be good and, in some cases, the condition can even be reversed.
How is congestive heart failure diagnosed?
Congestive heart failure is diagnosed primarily from a history and a physical examination. A primary care physician may be the first healthcare professional to recognize symptoms during a routine physical, but a cardiologist will make the final diagnosis.
A medical history will help identify risk factors such as high blood pressure, smoking, obesity, lack of exercise, and diabetes. Be prepared to answer questions like:
- Is there a family history of congestive heart failure?
- Are you short of breath?
- Have you been fatigued or unable to do physical work?
- If you have swelling or edema, when did it start?
- Have you had chest pain?
Research has shown that the most accurate indicators of heart failure are physical symptoms, so a physical exam is the most important diagnostic tool. Symptoms are due to either reduced heart pumping volume (such as fatigue or weakness) or swelling and fluid retention (such as shortness of breath or edema). Heart failure symptoms include:
- Shortness of breath (dyspnea) especially when lying down (orthopnea)
- Weakness
- Fatigue
- Swelling in the legs and ankles (edema) or abdomen (ascites)
- Heart palpitations
- Weight gain
- Nausea
- Lowered appetite
The doctor will also take your pulse and listen to the heart to identify distinctive symptoms of heart failure:
- Alternating weak and strong pulse
- A shift in the location of the maximum pulse that can be felt on the chest surface
- Presence of a brief vibration that can be heard through a stethoscope as one of the ventricles fills with blood, called the S3 gallop
In addition to a physical exam, the cardiologist will use tests to confirm the diagnosis:
- Blood tests
- An electrocardiogram (EKG) to rule out other conditions
- A chest X-ray to identify distinct physical changes to the heart or identify other symptoms, such as water on the lungs
- An echocardiogram to measure blood output from the ventricle
The diagnosis will also include identifying the severity of the condition. The most commonly used scale is the New York Heart Association (NYHA) that classifies the condition based on the amount of physical activity the patient can perform:
- Class I: No limitations on physical activity
- Class II: Mild limitations on physical activity
- Class III: Moderate limitations on physical activity but comfortable at rest
- Class IV: Symptoms occur at rest; no physical activity possible without discomfort
Treatment will depend on the condition’s stage.
Congestive heart failure treatment options
Congestive heart failure treatments consist of lifestyle changes, medications, and, in more advanced cases, device therapy, surgery, or heart transplantation. If heart failure is due to an underlying cause, the treatment plan will focus on controlling or reversing that cause.
Lifestyle changes
All heart failure treatment will involve lifestyle modifications including
- Dietary changes
- Restrictions on salt intake
- Fluid intake restrictions
- Exercise
- Avoiding cigarettes, alcohol, and recreational drugs
Medications
Medications can control the body’s responses to heart failure that worsen the condition. Diuretics reduce fluid retention and swelling, blood pressure medications reduce blood pressure, and beta-blockers slow down the heartbeat. More advanced heart failure may be treated by drugs that widen blood vessels or help maintain normal heart rhythm.
Device therapy
For more advanced heart failure, a cardiac surgeon will implant battery-powered devices to eliminate irregular heartbeats or restore a normal biventricular heart rhythm. In cardiac resynchronization therapy, an implanted pacemaker monitors the heartbeat and occasionally delivers small electric shocks to keep the heart rate normal. For more advanced cases, an implantable cardioverter-defibrillator (ICD) monitors heart rate and delivers electric shocks to the heart to stop life-threatening rhythm abnormalities.
Surgery
Advanced heart failure may eventually require surgical interventions such as:
- Coronary revascularization such as coronary artery bypass surgery or angioplasty, restores the function of coronary arteries.
- Ventricular restoration involves making surgical changes to the heart to restore the ventricles to their normal size and shape.
- Ventricular assist devices are implanted mechanical pumps that partially or completely replace the function of the heart’s ventricles
- Heart transplant is the surgical replacement of the diseased heart with a healthy heart.
Congestive heart failure medications
Medications are in most cases the primary treatment for heart failure. Medications are used in combination to manage the effects of heart failure such as fluid retention, swelling, vasoconstriction, and increased heart rate. In more advanced cases, medications are used to maintain a normal heart rhythm or to keep heart failure patients alive before surgery or heart transplant.
Diuretics
Diuretics reduce fluid retention by increasing the amount of sodium, and with it water, excreted by the body through the kidneys. These drugs are excellent for managing signs and symptoms due to fluid retention, including edema and/or difficulty breathing. Loop diuretics, such as torsemide, bumetanide, and furosemide, are commonly used. Thiazide-like diuretics, such as metolazone, may be used in conjunction with loop diuretics in patients who are difficult to manage. Other medications that are not classified as diuretics but promote excretion of fluid have been studied as possible adjunctive therapy in the management of heart failure.
ACE inhibitors, ARBs, and MRAs
The first-line medications for heart failure are ACE inhibitors (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin receptor blockers). The body responds to heart failure by producing angiotensin, a protein that causes blood vessels to tighten and increase blood pressure. The increased blood pressure increases the efficiency of each heartbeat but also puts more strain on the heart, causing further changes to the heart that reduce blood output. ACE inhibitors, such as lisinopril, ramipril, or enalapril, and angiotensin receptor blockers (ARBs), such as valsartan, losartan, or candesartan, block angiotensin, keep blood pressure low, and therefore slow or prevent some of the cardiac remodeling that would otherwise occur with this compensatory pathway.
Mineralcorticoid receptor antagonists (MRAs), such as spironolactone and eplerenone, work by blocking a hormone called aldosterone. Aldosterone causes high blood pressure which in turn can increase the strain on the left ventricle, contributing to the development of or worsening already present heart failure. Blocking aldosterone with this class of medications has demonstrated a reduction in poor outcomes in patients with heart failure.
Beta-blockers
Beta-blockers (carvedilol, metoprolol, bisoprolol) are used in heart failure patients to slow down the heart and reduce the strength of heart contractions to prevent further changes to the heart. These beta-blockers also decrease blood pressure. Ivabradine is a newer class of medication that slows heart rate, similar to beta-blockers, but does not have any effect on blood pressure. It may be added onto beta-blocker therapy in patients with ongoing elevated resting heart rates or in patients unable to tolerate maximizing dosages of beta-blockers due to side effects (such as the lowering of blood pressure).
Neprilysin inhibitors
Heart failure patients may be prescribed a combination of an ARB with a neprilysin inhibitor. Entresto, a combination of valsartan (an ARB) and sacubitril (a neprilysin inhibitor), is the most common prescription. Sacubitril protects a substance, called b-type natriuretic peptide (BNP), from being degraded in the body. The heart naturally produces BNP in response to heart failure and its effects on the body are beneficial, including dilating blood vessels, increasing the elimination of water and sodium, reducing blood pressure, and reducing strain on the heart.
Vasodilators
Vasodilators lower blood pressure by widening blood vessels. Heart failure patients who are not succeeding with or cannot take ACE inhibitors, ARBs, and beta-blockers may be prescribed a combination of a nitrate, such as isosorbide dinitrate, and hydralazine, another vasodilator.
Antiarrhythmics
For some heart failure cases, patients may have irregular heart rhythms and be put on medications that help maintain a normal heart rhythm called antiarrhythmics. Medications like digoxin are used to lower the risk of hospitalization.
Inotropes
Positive inotropes increase the heart’s blood flow output and are the drug of last resort for heart failure patients. Dobutamine or milrinone are administered as a continuous intravenous infusion to keep a heart patient alive while waiting for surgery or a heart transplant.
What is the best medication for congestive heart failure?
Most heart failure patients will be prescribed a diuretic, ACE inhibitor, and beta-blocker to manage the effects of heart failure. Drug treatment, however, will be tailored to the patient’s age, symptoms, stage of heart failure, and tolerance for side effects.
| Best medications for congestive heart failure | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Vasotec (enalapril) | ACE inhibitor | Oral | 2.5 mg to 20 mg twice daily | Dizziness, low blood pressure, fainting |
| Diovan (valsartan) | Angiotensin receptor blocker (ARB) | Oral | 20 mg to 160 mg twice daily | Headache, dizziness, fatigue |
| Entresto (sacubitril/valsartan) | Angiotensin receptor-neprilysin inhibitor | Oral | 49/51 mg to 97/103 mg twice daily | Low blood pressure, high blood potassium, cough |
| Toprol XL (metoprolol succinate ER) | Beta blocker | Oral | 12.5 mg to 200 mg once daily | Dizziness, slow heart rate, accidental injury |
| Aldactone (spironolactone) | Diuretic | Oral | 12.5 mg once daily to 25 mg twice daily | Drowsiness, lightheadedness, breast growth in men |
| BiDil (isosorbide dinitrate/hydralazine HCL) | Nitrate / vasodilator | Oral | One to two 20 mg/37.5 mg tablets three times a day | Headache, dizziness, lightheadedness |
| Lanoxin (digoxin) | Cardiac glycoside | Oral | 0.125 mg to 0.25 mg once daily | Nausea, diarrhea, weakness |
| Corlanor (ivabradine) | HCN channel blocker | Oral | 2.5 mg to 7.5 mg twice daily | Slow heart rate, high blood pressure, atrial fibrillation |
| Farxiga (dapagliflozin) | SGLT2 inhibitor | Oral | 5 mg to 10 mg once daily | Dehydration, low blood sugar, urinary tract infections |
| Dobutamine | Inotrope | Continuous intravenous infusion | Infusion rate will depend on weight | Increased heart rate, high blood pressure, premature heartbeat |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of congestive heart failure medications?
Most heart failure patients will be prescribed a diuretic and one or more blood pressure medications, so the most common side effects experienced will be low blood pressure, dizziness, lightheadedness, and fainting. Other heart failure medications have different side effects, so consult with a healthcare professional if you have any questions or concerns about side effects.
Diuretics reduce the amount of water and salt in the body, so the most common side effects are dehydration and low blood pressure.
Both ACE inhibitors and angiotensin receptor blockers (ARBs) are blood pressure medications, so the most common side effects are low blood pressure and its results, such as dizziness, lightheadedness, and fainting. The most serious side effects of ACE inhibitors and ARBs are high potassium levels and kidney damage. Patients who are unable to handle ACE inhibitors will be moved to angiotensin receptor blockers.
Beta-blockers block epinephrine (adrenaline), so side effects include slow heartbeat, low blood pressure, cold hands, weakness, and fatigue.
The neprilysin inhibitor sacubitril is always combined with an angiotensin receptor blocker, valsartan, so side effects are similar to ARB side effects: low blood pressure, high blood potassium, and kidney problems.
Vasodilators rapidly lower blood pressure by widening blood vessels. As a result, both nitrates and hydralazine are well-known for causing severe headaches, flushing, and low blood pressure.
Digoxincan cause serious side effects such as chest pain, fast heartbeat, slow heartbeat, and irregular heartbeat. Ivabradine can also cause irregular heartbeats. These are safety concerns, so they are often used as a last resort and in as low a dose as possible.
Inotropes are the drug of last resort and are used to keep patients alive before surgery or heart transplant. They can cause serious side effects such as increased heart rate, high blood pressure, palpitations, premature heartbeats, and chest pain.
What is the best home remedy for congestive heart failure?
Lifestyle changes are a critical component of heart failure treatment. Diet, exercise, and other lifestyle modifications significantly slow down the progress of heart failure and, in early stages, can even reverse the condition. A cardiologist and other healthcare professionals will educate patients about necessary lifestyle modifications like:
- Eat a nutritious diet
- Reduce sodium and fluid intake
- Avoid smoking, alcohol, and recreational drugs
- Lose weight and maintain a healthy weight
- Monitor swelling in your legs, ankles, and feet
- Exercise within the limits advised by a cardiologist
Frequently asked questions about congestive heart failure
Can you reverse congestive heart failure?
Early-stage congestive heart failure due to conditions such as high blood pressure, diabetes, or other treatable condition can be reversed by controlling the underlying cause, making significant lifestyle changes, and taking heart failure medications. In particular, exercise can help remodel the heart if the proper medications and lifestyle changes are adopted.
What is the life expectancy of someone with congestive heart failure?
The mortality rate for heart failure is 22% in the first year following diagnosis and 43% in the first five years following diagnosis. The mortality rate for advanced heart failure is 90% in the first year. Life expectancy, then, depends on the severity of the condition and the lifestyle changes adopted by the patient.
What are the treatment options for congestive heart failure?
Congestive heart failure is treated by lifestyle modifications and medications, including diuretics, ACE inhibitors or ARBs, and beta-blockers. More advanced heart failure may require different medications, an implanted device, or surgery.
What foods should be avoided with congestive heart failure?
Dietary changes are a major part of heart failure treatment, and they will require certain foods to be reduced or eliminated in the diet:
- Salt: Above all else, avoid salty foods. Sodium contributes to the swelling and fluid retention that damages the heart, lungs, and other organs in patients with heart failure.
- Alcohol: Alcohol damages the heart muscle and will worsen heart failure.
- Fats: Saturated fats and trans-unsaturated fatty acids (“trans fats”) are associated with coronary heart disease, so your cardiologist or nutritionist will reduce your intake of saturated and trans fats.
- Carbohydrate snacks: Crackers, chips, cookies, popcorn all put on the pounds without adding much nutrition to the diet. Life expectancy is significantly reduced in heart failure patients who carry excess weight.
- Water: Fluid retention is common to heart failure and damages the heart and other organs, so only drink as much water and other liquids as advised by your cardiologist or nutritionist.
How do you reverse congestive heart failure naturally?
If treated in its earliest stages, heart failure may be reversible with changes in diet, exercise, weight, and other lifestyle modifications. Once symptoms appear, medications will be required to prevent further changes to the heart. In the most advanced stages, survival will depend on medications, implantable devices, or surgery.
Should you drink a lot of water if you have congestive heart failure?
Fluid retention is nearly universal in patients with Class II-IV heart failure, producing symptoms such as shortness of breath and causing damage to the heart and other organs. Drinking too much water will worsen symptoms, so your cardiologist or nutritionist will prescribe a daily limit on water and fluid intake.
Is exercise good for congestive heart failure?
Exercise will be prescribed for all but the most advanced cases of congestive heart failure, but the exertion level will vary. Exercise helps to slow adverse physical changes in the heart and, for patients in the earliest stages of heart failure, may help to remodel the heart and potentially reverse the condition.