What is heart failure? 

The term heart failure refers to a clinical syndrome whereby the heart is unable to pump effectively enough to meet the body’s blood and oxygen needs. You may also hear it referred to as congestive heart failure. Despite the name (many cardiologists are not fans of the name because of the anxiety it can induce), most patients with heart failure do not have a heart that is imminently failing. The vast majority of the time, this is a chronic and very treatable condition. Patients on appropriate therapy can expect to have a reasonable quality of life and may survive decades with this condition.  

What causes it? 

There is a very long list of causes of heart failure, but some causes are far more common than others. Common causes include: 

• Coronary artery disease (i.e., narrowings or blockages in the arteries that supply the heart with blood, usually from a process called atherosclerosis, which means “hardening of the arteries”
  
• Hypertension (i.e., high blood pressure) 
• Heart valves that are too regurgitant (i.e., leaky) or stenotic (i.e., tight).  

Other causes that may contribute or lead to heart failure include: 

• Cancer chemotherapy
• Street drug use (e.g., cocaine, methamphetamines)
• Certain sustained tachyarrhythmias (i.e., fast heart rhythms)
• Congenital heart conditions
• Excessive alcohol consumption  

There are also genetic causes where a patient may have a new gene mutation or inherits a gene mutation that leads to cardiomyopathy (i.e., an intrinsic problem with the heart muscle that one is born with). This can lead to an abnormally thickened heart, abnormally dilated (i.e., enlarged) heart, or other types of cardiomyopathies.  

Sometimes, the specific cause of a patient’s heart failure cannot be determined. There are several ways cardiologists classify heart failure (e.g., acute versus chronic, a predominantly left or right sided heart problem, etc.) but the most common classification relates to whether there is a problem with the strength of the main pumping chamber of the heart (i.e., the left ventricle) or not. 

What are the signs and symptoms?  

The cardinal signs and symptoms of heart failure include: 

• Shortness of breath 
  
• A reduction in functional/exercise capacity 
  
• Lower extremity swelling/edema
  
• Fatigue
  
• Difficulty sleeping due to shortness of breath (e.g., difficult lying flat, or waking up due to a hunger for air).  

However, heart failure can also lead to abdominal symptoms as well, such as abdominal swelling/discomfort. As you can see, these can be quite nonspecific and really depend on the individual patient and that patient’s specific heart condition. Laboratory and imaging studies - including chest x-rays, echocardiograms, and cardiac MRIs and CT scans - can also provide valuable information and clues as to whether heart failure is contributing to a patient’s symptoms as well as what the specific cause may be. 

Are symptoms different for men versus women? 

Generally speaking, there are no significant gender-specific differences in symptoms for heart failure. However, it is known that symptoms in women for cardiac conditions historically were not taken as seriously as symptoms in men. Women were also less represented than men in large clinical trials in cardiology. With increasing recognition and awareness of cardiovascular disease in women, this is fortunately becoming less true. 

How do I know if I’m at risk for heart failure? 

Common risk factors for the development of heart failure include: 

• Cigarette (and cigar) smoking (firsthand and secondhand)
  
• High blood pressure
  
• Diabetes mellitus
• High LDL levels (i.e., “bad cholesterol”) 
  
• A sedentary lifestyle 
  
• An unhealthy diet 
  
• Excessive alcohol consumption
  
• Street drug use 

These are largely modifiable risk factors and should be treated aggressively with a combination of medicines and lifestyle modifications. Advanced age and a genetic predisposition to developing heart failure are also risk factors, but these are non-modifiable. Lack of adherence with medical follow-up, prescribed medications, and lifestyle advice are also significant causes of hospitalizations for heart failure. 

Is there anything I can do to lower my chances of heart failure? 

Absolutely. Regular aerobic exercise, a heart-healthy diet, abstaining from cigarette smoke exposure, and treating the risk factors above that may lead to heart failure are all crucial. These will improve one’s cardiovascular health overall, as risk factors for heart failure are also risk factors for other cardiovascular conditions such as coronary artery disease or certain arrhythmias. This requires medical follow up, adherence with medicines and some degree of self-motivation, determination, and ownership of one’s personal health. Never hesitate to ask your cardiologist the rationale behind making a lifestyle change recommendation, prescribing a medication or ordering a diagnostic test. Heart failure management is a journey that includes both the patient and healthcare providers, and the importance of patient education regarding their condition cannot be overstated. 

If I have heart failure, what are my treatment options? 

Once diagnosed with heart failure, the treatment is usually a combination of lifestyle recommendations and medications that are proven to extend one’s life, prevent hospitalizations, improve quality of life and functional capacity, or a combination thereof. Minimizing salt intake in the diet is usually recommended to help prevent fluid buildup in the body.  

In certain patients, intracardiac devices such as implantable cardioverter-defibrillators (ICDs) or specialized pacemakers that provide cardiac resynchronization therapy (CRT, i.e., help both sides of the heart contract at the same time) are recommended. Sometimes, procedures or open heart surgeries may be required. When specific causes of heart failure are identified (e.g., a tight aortic valve), those causes should be targeted and addressed. Nowadays, there are transcatheter approaches to treating certain heart valve disorders that are far less invasive than open heart surgery and may be an option depending on the patient’s age, comorbidities, functional status and other factors.  

Generally speaking, heart failure is a lifelong condition that requires lifelong follow-up. Like most conditions in cardiology, there is often no cure, but there are excellent treatment options. Sometimes, however, the cause of heart failure may be reversible. If all treatment options have been exhausted and one’s heart failure is at an advanced stage, heart transplantation or surgically implanted pumps called left ventricular assist devices (LVADs) are considered for certain patients. 

Are there any links between COVID and heart failure? 

Yes, there are. The COVID-19 virus may infect the heart muscle directly and cause inflammation of either the heart muscle (called myocarditis), the lining of the sac that surrounds the heart (called pericarditis), or both. It is important to appreciate that many viruses (including the annual strain of influenza or “the flu”) can cause myocarditis, and this condition has been known in the medical community for decades and has probably affected humans for millennia.  

Because of the constant press and social media attention to COVID-19 and intense study of the virus during the pandemic, myocarditis due to COVID-19 has been prominent in the news. It is not, however, a novel condition. Most afflicted adults with myocarditis have a benign course without long-term complications. Avoidance of intense physical activity until the heart is healed and anti-inflammatory medicines may be recommended. A very small minority will sustain significant heart damage that requires long-term treatment. The Pfizer and Moderna vaccines have been linked to myocarditis in an extremely small number of cases (on the order of 1 case per 10,000-20,000 vaccine doses). Almost always, this has been observed with the second vaccine dose in young adolescent males or men under the age of 30. The benefits of immunization against COVID-19 through vaccination are believed to outweigh the risks by the majority of cardiologists and public health experts.  

I’m afraid to go to the hospital right now. Should I delay treatment? 

No. Generally speaking, treatment should not be delayed as delays can cause one with heart failure to slide deeper into a worsened state of their condition. That being said, it is often possible to avoid hospitalizations through outpatient visits (or virtual visits) with one’s cardiologist or internist and medication adjustments. The hospital is not the only pathway for treatment.