Heart failure

Heart failure means that your heart isn't pumping blood around your body as well as it should.

Symptoms

The symptoms and effects on your body will depend on the side that is affected.

Symptoms of heart failure can be severe. It can be treated though, allowing you to control the effects of the condition and continue to live a normal life.

Read more about the symptoms of heart failure

Causes

Heart failure can be caused by a number of conditions such as high blood pressure or heart attack.

It tends to affect people over the age of 65, and is more common in men than women.

Read more about the causes of heart failure

The main symptom of heart failure is breathlessness. This, together with some other common symptoms are explained below.

Breathlessness

Breathlessness might occur, or become more noticeable, when walking or exerting yourself.

People with more severe heart failure might experience breathlessness when resting and may notice that this gets worse when they lie flat.

During the night, you may wake and feel an urgent need to sit up and get a breath in. A cough and a frothy spit can also accompany the breathlessness.

Tiredness and lethargy

Tiredness and lethargy are also common symptoms of heart failure.

This is a result of poor blood flow to the body organs including the muscles.

Leg swelling

People with heart failure have a tendency to retain fluid. This appears as swollen ankles and legs because of excess fluid building up.

You may notice that your shoes don't fit and socks appear tight or leave a prominent indent above the ankle.

Loss of appetite

People with heart failure can also notice a loss of appetite.

This is because the liver and stomach can become enlarged, due to excess fluid, making you feel sick (nausea) and have a loss of appetite.

In many cases, the cause of heart failure is unknown or uncertain.

Conditions that can cause heart failure include:

• heart attack (coronary heart disease)
• inherited heart disease (for example, cardiomyopathy)
• high blood pressure (hypertension)
• heart rhythm or valve abnormalities
• viral infection and damage from the immune system (myocarditis)

Heart failure on left and right side

Heart failure on the left side can sometimes lead to heart failure on the right side.

If you are experiencing symptoms of heart failure, your GP will discuss these with you.

If they suspect that you have heart failure, they are likely to suggest that you have a number of tests to confirm the diagnosis.

Tests

Tests to confirm the diagnosis of heart failure include:

• blood pressure check
• urine sample
• blood sample - to check your blood count and liver function. You may get a BNP test (B-type natriuretic peptide), this is a hormone related to heart failure
• chest X-ray - to see whether you heart is enlarged and check your lungs for fluid
• electrocardiogram (ECG) - this records the electrical activity and rhythms of your heart
• an echocardiogram - an ultrasound scan that will check the pumping action of your heart and the function of the valves in your heart

More about tests for heart conditions

Heart failure results from impairment of the heart's pumping action. Commonly this is related to heart muscle damage that cannot be repaired. However, many treatments available can help to keep the condition under control and help to relieve the symptoms.

In addition, many of the conditions that cause heart failure can also be treated effectively. This reduces the pressure on your heart and prevents further deterioration.

Medicines

The information below highlights the medication that you may be prescribed by your GP or specialist. This will be after discussing treatment options with you and identifying the appropriate choice for your individual circumstances.

Standard medicines

The standard medicines for treating heart failure are:

• angiotensin converting enzyme (ACE) inhibitors
• angiotensin receptor blockers (ARBs)
• beta blockers
• diuretics (water tablets)
• mineralocorticoid receptor antagonists (MRAs)

Angiotensin converting enzyme (ACE) inhibitors

ACE inhibitors relax and widen your blood vessels. This helps to improve the flow of blood around your body, which reduces the amount of work your heart has to do.

ACE inhibitors have been shown to improve the symptoms of heart failure, reduce the need for hospital admission and improve life expectancy caused by heart failure.

Your symptoms should improve within a few weeks of starting treatment.

The main side effects of ACE inhibitors are dizziness (caused by your blood pressure being too low) and a cough. You will need to have regular blood tests, at least once every year, while taking an ACE inhibitor.

If you are taking an ACE inhibitor, you should check with your doctor or pharmacist before taking any other medicines. In particular, nonsteroidal anti-inflammatory medicines (such as ibuprofen) should not be taken with an ACE inhibitor. You should also avoid products containing high levels of potassium, such as salt substitutes.

Types of ACE inhibitors

Captopril, enalapril, lisinopril and ramipril

Angiotensin receptor blockers (ARBs)

ARBs work in a similar way to ACE inhibitors.

Unlike ACE inhibitors, ARBs do not cause a cough. For this reason, they are often prescribed for people who cannot tolerate an ACE inhibitor due to cough.

Types of ARBs

Candesartan and valsartan

Beta-blockers

If your heart isn’t working properly, your body produces hormones to try and make it work better by making your heart pump faster and raising your blood pressure. However, if this continues, it can have harmful effects on your heart.

Beta-blockers block the action of these hormones. This slows your heart down and reduces your blood pressure, meaning that the heart has less work to do.

Beta-blockers have been shown to reduce the symptoms of heart failure, reduce the need for hospital admission and improve life expectancy caused by heart failure.

People with moderate or severe heart failure usually need to start with a low dose of beta-blocker, which will be slowly increased. This is because some people experience a temporary increase in their heart failure symptoms during the first few weeks of treatment.

If you feel that your symptoms are getting worse, do not stop your beta blocker. Seek medical advice.

Types of beta blockers

Bisoprolol, carvedilol and nebivolol

Diuretics (water tablets)

When you have heart failure, your heart cannot pump blood around your body as well as it should, so fluid builds up in your body. This fluid can collect in your lungs, making you breathless, or in your legs and ankles, making them swell (oedema). Diuretics increase the amount of water and salt that is removed from your body as urine. As more fluid passes out, there is less fluid left in your blood, so the excess water in your lungs and legs is drawn back into your blood, relieving your symptoms of breathlessness and oedema.

Diuretics are usually taken in the morning. The effect of making you pass more water starts about half an hour after taking them, and you may find you need to go to the toilet several times over the next few hours. Their effect wears off after about 6 hours, so you should not need to get up at night to go to the toilet.

The accumulation of fluid in your body can be measured as a gain in weight, and the loss of fluid (caused by the diuretic) can be measured as weight loss. Therefore by weighing yourself every day you can pick up any sudden increase in weight.

A sudden increase in weight means that your heart failure is not well controlled and you should seek help urgently from your doctor or heart failure nurse.

Types of diuretics

Bumetanide and furosemide

Mineralocorticoid receptor antagonists (MRAs)

MRAs work by blocking the action of a chemical called aldosterone in the body. Aldosterone causes salt and fluid to build up, so MRAs help to prevent this, reducing the symptoms of heart failure, reducing the need for hospital admission and improving life expectancy caused by heart failure.

The main side effect of MRAs is dizziness (caused by your blood pressure being too low). You will need regular blood tests, at least twice a year, to measure a salt called potassium which can become too high in some people.

If you are taking an MRA, you should check with your doctor or pharmacist before taking any other medicines. In particular, nonsteroidal anti-inflammatory medicines (such as ibuprofen) should not be taken with an MRA. You should also avoid products containing high levels of potassium, such as salt substitutes.

If you experience diarrhoea and/or vomiting, stop the MRA and contact your doctor.

Types of MRAs

Spironolactone and eplerenone

Specialist medicines

Medicines that might be used by a specialist include:

• angiotensin/neprilysin inhibitors
• ivabradine
• digoxin

Angiotensin/neprilysin inhibitors

This is a new type of drug to treat heart failure. It is a combination of valsartan (an ARB) and a medicine called sacubitril. It may be used for people with more severe heart failure, or people with ongoing symptoms despite the standard treatments described above. It has been shown to reduce the symptoms of heart failure, reduce the need for hospital admission and improve life expectancy.

If you are already taking an ACE inhibitor or an ARB, this will need to be stopped for 36 hours before you start to take the angiotensin/neprilysin inhibitor. This is to reduce the risk of serious side effects occurring.

You will need regular blood tests, at least once per year, while taking this medicine.

Types of angiotensin/neprilysin inhibitors

Entresto®

Ivabradine

Ivabradine reduces the number of times your heart beats each minute (your heart rate), meaning that the heart has less work to do. It has been shown to reduce the need for hospital admission in people with heart failure.

Ivabradine is not suitable for everyone with heart failure. It is only needed if you have a fast heart rate despite being treated with a beta blocker or if you cannot tolerate a beta-blocker. It is not suitable for people with a particular type of irregular heart rhythm called atrial fibrillation.

Digoxin

Digoxin can also reduce the heart rate and improve the symptoms of heart failure. It is most useful in people who have irregular heart rhythms.

It is important that you get the right dose of digoxin for you. You will need to have regular blood tests to check this. If you have too much digoxin you may develop nausea, headaches and blurred vision. If you experience any of these whilst you are taking digoxin, you should contact your doctor.

Heart transplant

A heart transplant may be an option for people with severe heart failure, but it is not an option for everyone.

It is also dependant on the availability of a suitable donor heart.

Mental wellbeing

People with heart failure often experience various types of emotional distress or behavioural disturbance. Problems such as depression and anxiety are especially common.

These conditions not only affect individuals’ emotional state but can also affect their symptoms of heart failure and influence the success of their medical care.

Fortunately, there are effective treatments for depression and anxiety available including psychological interventions such as cognitive behaviour therapy and antidepressant medication. Addressing these problems will make it easier to follow your heart failure treatment plan.

Your healthcare professional or GP will be able to help assess any concerns you have regarding your psychological wellbeing.

Immunisations

If you have heart failure, you have a higher risk of complications from flu and pneumococcal infection. To reduce this risk, you'll be offered a:

• yearly flu vaccine
• one-off pneumococcal immunisation

There are many ways to reduce your chances of heart failure.

The following measures can help to reduce the strain on your heart by avoiding risk factors such as obesity and blood pressure problems, and by making sure the heart muscle is healthy.

Avoid smoking

If you would like to stop smoking:

• call Quit Your Way Scotland for advice free on 0800 84 84 84 (7 days, 8.00am to 10.00pm)
• visit our healthy living section on smoking for information to help you to stop

Avoid drinking excessive amounts of alcohol

Find information and advice on reducing alcohol intake in our healthy living section on alcohol.

Take regular exercise

Find information and advice to help you keep active and take regular exercise in our healthy living section on physical activity.

Eat a healthy diet

A diet low in saturated fats and salt is recommended as salt assists fluid retention.

Find information and advice on having a healthy diet in our healthy living section on diet and nutrition.

Immunisations

Get immunised against flu and pneumococcal infections if you're in an at-risk group.

More about immunisations in Scotland

If you have high blood pressure

If you have high blood pressure, maintain good control of it.

Use medication if and as prescribed and always attend review appointments.

If you are diabetic

If you are diabetic, maintain good control of it and always attend review appointments.

Manage your diet as explained by your specialist nurse or Dr and use medication if and as prescribed.