Congestive Heart Failure
Heart failure is classified into four stages (Stage A through Stage D) that reflect the development and progression of the condition. Treatment depends on the stage of heart failure.
The first two stages (Stage A and Stage B) are not technically heart failure, but indicate that a patient is at high risk for developing it.
Management of Risk Factors and Causes
Stage A. In Stage A, patients are at high risk for heart failure but do not show any symptoms or have structural damage of the heart. The first step in managing or preventing heart failure is to treat the primary conditions that cause or complicate heart failure. Risk factors include high blood pressure, heart diseases, diabetes, obesity, metabolic syndrome, and previous use of medications that damage the heart (such as some chemotherapy).
Important risk factors to manage include:
- Coronary artery disease. Treatment includes a healthy diet, exercise, smoking cessation, medications, and, possibly, bypass or angioplasty. [For more information, see In-Depth Report #3: Coronary artery disease and angina.]
- Cholesterol and lipid problems. Treatments include lifestyle management and medications, especially statin drugs. [For more information, see In-Depth Report #23: Cholesterol.]
- High blood pressure. A normal systolic blood pressure is considered below 120 mm Hg, and a normal diastolic blood pressure is below 80 mm Hg. Patients with diabetes, atherosclerosis, or chronic kidney disease should maintain blood pressure readings of 130/80 or less, while other patients with high blood pressure should aim for readings no higher than 140/90. Effective reduction of blood pressure reduces the risk of heart failure by 30 - 50%. [For more information, see In-Depth Report #14: High blood pressure.]
- Diabetes. Treating diabetes is extremely important for reducing the risk for heart disease. ACE inhibitors are especially beneficial, particularly for people with diabetes. Recent research suggests that metformin, a drug used to treat diabetes, may also help prevent heart failure. [For more information, see In-Depth Report #60: Diabetes - type 2; and In-Depth Report #9: Diabetes - type 1 ]
- Obesity. [For more information, see In-Depth Report #53: Weight control and diet ]
- Valvular abnormalities, such as aortic stenosis and mitral regurgitation. Surgery may be required.
- Abnormal health rhythms (arrhythmias). Ventricular assisted devices, notably biventricular pacers (BVPs), can help prevent hospitalizations for patients with these conditions.
- Anemia. Patients with heart failure and underlying anemia should have their anemia corrected. On occasion, this may require erythropoiesis-stimulating drugs. [For more information, see In-Depth Report #57: Anemia.]
- Thyroid function. Various medications are used to treat overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism). [For more information, see In-Depth Report #38: Hypothyroidism.]
- Drugs. Avoid drugs that can worsen heart failure symptoms. Talk with your doctor about your heart failure before taking nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (verapamil and diltiazem), thiazolidinediones (drugs used for diabetes), antitumor necrosis factor medications, and most drugs used to treat irregular heart rhythms (arrhythmia).
- Diet and Exercise. It is particularly important to reduce sodium (salt) intake to less than 1,500 mg a day. Patients should engage in medically supervised exercise programs. Dietary changes and exercise are important for treating all stages of heart failure.
Treatment Based on Heart Failure Stage
Stage B. Patients have a structural heart abnormality seen on echocardiogram or other imaging tests but no symptoms of heart failure. Abnormalities include left ventricular hypertrophy and low ejection fraction, asymptomatic valvular heart disease, and a previous heart attack. In addition to the treatment guidelines for Stage A, the following types of drugs and devices may be recommended for some patients:
- Angiotensin-converting enzyme (ACE) inhibitors, or angiotensin-receptor blockers (ARBs) for patients who cannot tolerate ACE inhibitors.
- Beta blockers for patients with a recent or past history of heart attack. Also for patients who have not had a heart attack but who do have reduced LVEF identified in diagnostic tests.
Stage C. Patients have a structural abnormality and current or previous symptoms of heart failure, including shortness of breath, fatigue, and difficulty exercising. Treatment includes those for Stage A and B plus:
- Restrict dietary sodium (salt). Lowering sodium in the diet can help diuretics work better.
- ACE inhibitors or angiotensin-receptor blockers (ARBs).
- Beta blockers (bisoprolol, carvedilol, and sustained release metoprolol).
- Diuretics are recommended for most patients, with loop diuretics such as furosemide generally being the first-line choice.
- Aldosterone inhibitors are recommended for many patients. Digitalis may be prescribed for some patients.
- A hydralazine and nitrate combination (BiDil) should be used for African-American patients who are taking an ACE inhibitor, beta blocker, and diuretic and who still have heart failure symptoms.
- Exercise training for appropriate patients.
- Implantable cardiac defibrillators (ICDs) may be considered for patients with very low ejection fraction or those who have had dangerous arrhythmias.
- Cardiac resynchronization therapy (pacemaker), with or without ICD, for some patients.
Stage D. Patients have end-stage symptoms that do not respond to standard treatments. Treatment includes appropriate measures used for Stages A, B, and C plus:
- Strict control of fluid retention.
- Heart transplantation referral for appropriate patients.
- Left-ventricular assist devices (LVADs) as permanent therapy for patients who are not candidates for heart transplants. LVADs are surgically implanted to help pump blood through the body.
- Hospice and end-of-life care information for patients and families.
Managing Triggers of Heart Failure Symptoms
Whenever heart failure worsens, whether quickly or chronically over time, various factors must be considered as the cause:
- Dietary indiscretion. Sometimes as little as eating a sausage or some sauerkraut with a high sodium content is enough to precipitate an acute episode. Failure to comply with fluid and salt restrictions must be considered whenever heart failure worsens.
- Alcohol. Depending on the severity of a patient's heart failure, one or more drinks may suddenly worsen symptoms.
- Medication compliance. Patients may forget or purposely skip a medication, or they may not be able to afford or have access to medications.
- Angina or heart attack. Worsening of coronary artery disease may make the heart muscle less able to pump enough blood.
- Arrhythmias. Increases in the heart rate, or a slowing of the heart rate below normal, may also affect the ability of the heart to function. Likewise, an irregular heart rhythm such as atrial fibrillation may cause a flareup.
- Anemia. It is unclear whether anemia causes heart failure or is a symptom of heart failure. Some anemias may be treated with iron replacement therapy. A more significant anemia can cause a worsening of heart failure and should be treated promptly.