What Are Treatments for Heart Failure?

Understanding heart failure

In simplest terms, heart failure, or congestive heart failure, occurs when the heart can’t pump enough blood to meet the body’s needs. It’s surprisingly common—about 6.2 million adults in the United States have it. That’s a lot of people walking around with heart failure.

But not all of them have heart failure symptoms—which include fatigue, fluid accumulation in the limbs and lungs, shortness of breath, and leg swelling—or problems severe enough to require treatment.

There are four stages of heart failure. Stage A is the earliest, or pre-heart failure, stage.

People in this stage may never even experience symptoms, but they are at higher risk for heart failure due to a family history, high blood pressure, heart disease, a condition like diabetes, a past history of heart-damaging infections like rheumatic fever, or use of drugs, alcohol, or medication that can damage the heart.

Some do advance as their heart function worsens. They may develop symptoms that become potentially life-threatening and require special therapies such as ventricular assist devices or a heart transplant. (Learn more about inherited heart conditions.)

Heart function is measured by ejection fraction—the percentage of blood ejected from the left ventricle, the heart’s main pumping chamber.

A normal ejection fraction is between 50 and 70 percent. If you have an ejection fraction below 40 percent, it can be considered a sign of heart failure, and 40 to 49 percent might be borderline.

Ejection fraction is measured in a variety of ways, including by echocardiogram, or ultrasound of the heart.

Here’s the breakdown of management and treatments for all four stages of heart failure.

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There are four stages of heart failure

Stage A

Stage A indicates a high risk for heart failure, but no symptoms of heart disease or heart failure are present. (By the way, these are the types of heart diseases doctors need you to know.)

Treatment for stage A heart failure

Since there are no symptoms yet, treatment is “aggressive risk reduction,” says Michele Hamilton, MD, director of the Advanced Heart Failure Program in the Smidt Heart Institute at Cedars-Sinai, in West Los Angeles. That means controlling and managing high blood pressure, diabetes, and high cholesterol with lifestyle changes (if possible) and medication.

If you’re at stage A, now is the time to spring into action. Break unhealthy eating habits that make your heart work harder than it needs to. Enlist help to quit smoking or lose weight if you need to. Cut back on alcohol and manage stress.

Also, carve out time to exercise. The American Heart Association recommends at least 150 minutes of moderate intensity aerobic activity (like brisk walking) per week. If that seems daunting, think of it as about 22 minutes a day. Talk to your doctor first before you start any exercise program.

Stage B

Stage B is defined as structural heart disease that affects heart function, with no outward signs or symptoms of heart failure. This means you already have a heart problem—such as coronary heart disease- or heart attack-related damage or an inherited heart condition—that falls under the term structural heart disease.

And you might not even be aware you have (or have had) heart problems because some conditions such as a heart infection or valvular regurgitation (leaky valves) might not result in noticeable symptoms. (Here’s how to prevent heart disease.)

Most people with stage B heart failure will have an ejection fraction below 40 percent.

Treatment for stage B heart failure

Treating stage B heart failure includes all the recommendations in stage A, and sometimes medication or more cardiac-specific medications and procedures, such as artery and valve repair. (These are the ways to keep your valves healthy.)

“For example, catheter-based or surgical intervention can not only prevent the progression of disease, but normalize the structural abnormalities that define the condition,” says Dr. Parker.

If you have coronary artery disease (blocked heart arteries), you might have a catheterization-based procedure such as an angioplasty or stent placement. During an angioplasty, a tiny balloon is threaded through your blood vessels via a catheter and inserted in an artery to help widen it and improve blood flow to your heart. In some cases a stent, a tiny metal mesh coil or tube, is placed to expand the inside of an artery to keep it open.

A more complex procedure called coronary artery bypass grafting surgery may be necessary for patients with blockages in the heart arteries. This involves using an artery in the chest wall or removing veins from the legs and grafting them to coronary arteries. The healthy vessel acts as a detour around the diseased area, allowing blood flow to be redirected to the heart muscle.

Medications for stage B often include:

ACE (angiotensin-converting enzyme) inhibitor—relaxes arteries and veins so that they open up and create less work for the heart

ARB (angiotensin receptor blocker)—also used to relax blood vessels, but commonly taken by people who don’t tolerate ACE inhibitors

ARNI (angiotensin receptor neprilysin inhibitor)—also relaxes blood vessels

Beta-blocker—blocks the “flight or fight response” and slows your heartbeat and lowers blood pressure

Diuretic (water pill)—helps reduce fluid retention, a hallmark symptom of heart failure, as the condition can reduce blood flow to your kidneys

Potassium supplement—restores potassium levels. Potassium is needed for a healthy heart rhythm and diuretics can deplete levels. (Here are signs you may have a potassium deficiency.)

Potential complications

The greatest risk at this stage is to ignore the condition, because complications can arise from inaction.

“If you don’t do anything to change this, you have about a one in 10 chance of dying this year,” says Hugh Parker, MD, a cardiologist with UCHealth Heart and Vascular Center – Cherry Creek and assistant professor with the CU School of Medicine in Denver.

In other words: You should try to adopt a heart-healthy lifestyle and take your medications as prescribed.

Stage C

If you have structural heart disease and have had prior or current symptoms of heart failure you’re classified as having stage C heart failure.

“In stage C heart failure the heart has become weak and does not squeeze well,” says Monica Colvin, MD, a cardiologist who specializes in advanced heart failure and transplant cardiology at the Michigan Medicine Frankel Cardiovascular Center, in Ann Arbor.

“The symptoms of heart failure such as shortness of breath, fatigue, and exercise intolerance have also developed as a result of imbalances of hormonal processes in the body that help to regulate sodium and fluid, she says. “Blood flow, known as cardiac output, has declined from its usual state.”

Treatment for stage C heart failure

Treatment builds on the recommendations for stages A and B. At stage C, African-American patients may also be prescribed a hydralazine/nitrate combination, which improves how well the heart fills and pumps blood if symptoms continue.

(People who are Black are at greater risk of heart failure than other people their same age, and it’s more likely to be linked to high blood pressure than coronary artery disease. People given this treatment live longer than those who don’t get it, research suggests. And while the guidelines do differentiate treatment for black patients, please note, that they are controversial in terms of race-based medical treatments, according to reports by the American Family Physician and the American Medical Association.)

Some people may benefit from cardiac rehabilitation, a supervised exercise program that strengthens the heart. It can help reduce heart failure symptoms such as tiredness, low energy, and chest pain—not to mention give a much-needed energy and mood boost. It can be done on an outpatient basis or in your own home.

Procedures

Hospitalization and procedures are more common in stage C. They may include ones already mentioned and the following:

Pacemaker

A pacemaker is a small device surgically implanted under your skin. It’s connected to a lead, a thin wire, that is threaded through a vein into the heart. A biventricular pacemaker can help patients correct the electrical delay in their heart muscle contractions so that the chambers can beat in regular sequence. It may also improve heart failure symptoms and give you more energy.  Feedback from the device is sent to your doctor, and it requires regular follow-ups.

Implantable cardioverter-defibrillator (ICD)

This small, surgically implanted device is used to record, monitor, and stop life-threatening heart arrythmias. It goes into action within seconds to correct an abnormal rhythm with a jolt of electricity. (Ever see a TV show where a doctor yells “Clear!” and uses a defibrillator to shock the heart back into functioning? This is a bit like a small, internal version of that.) People who have an ICD inserted must stay away from large electromagnetic fields. Readings from the device are sent to your doctor, and it requires regular follow-ups.

Self-monitoring

At home, patients should monitor their weight daily. A two- to three-pound weight gain in one day (if your diet hasn’t changed) could mean heart failure is worsening because extra fluid isn’t getting flushed from the body as it should.

While drinking plenty of water is a common healthy practice, gulping down large quantities isn’t good for people with heart failure as it creates more work for the heart to pump the excess fluid away. Fluid recommendations vary by patient, but 64 ounces (two quarts) is considered the norm.

Potential complications

“Patients with stage C heart failure often have comorbidities (the simultaneous presence of two or more other medical conditions or diseases) like diabetes, kidney dysfunction, obesity, or COPD (chronic obstructive pulmonary disease),” says Dr. Hamilton. These “make the management more complicated and have to be addressed at the same time.”

Stage D

People who have heart failure symptoms even at rest and are getting worse even if they are taking the right medication are considered to have stage D heart failure.

“When heart failure continues to worsen despite medical, surgical, and device treatments, it is referred to as stage D heart failure,” says Dr. Colvin. “Patients with stage D heart failure tend to have severe symptoms and frequently get admitted to the hospital. Many times they have symptoms of breathlessness and fatigue at rest.”

(This is the best heart hospital in every state.)

Treatment for stage D heart failure

“At this stage, medications and other therapies for heart failure have failed,” says Dr. Colvin. “Patients with stage D heart failure are at high risk of dying. Therefore, more advanced therapies are considered at this stage.” Those include:

Left ventricular assist device (LVAD)

A type of heart pump implanted in the heart to help with pumping. It keeps patients alive and can improve heart failure symptoms while waiting for a heart transplant. It’s also used with patients who aren’t eligible for a transplant or those who have decided against receiving a heart transplant.

The benefits of more energy, fewer medications, and overall improved quality of life are well worth the effort it takes to care for the implant at home. During the day, the LVAD controllers and batteries are carried in a bag or a special vest worn over clothing. At night, battery cables are disconnected and plugged into an AC-powered LVAD cable.

Caring for The LVAD requires regular sterile dressing changes to prevent infections where the drive-line tubing comes through the skin.

Specialization dressings protect equipment while showering, but tub bathing and swimming are off-limits. LVADs aren’t recommended for people with other life-threatening conditions, acute kidney failure, severe infections, or severe brain injuries.

(These are the signs of an unhealthy heart.)

Heart transplant

Heart transplants replace a failing heart that can no longer function adequately to meet the body’s needs.

“In order for patients to be successful with a heart transplant, they must meet certain medical criteria and should not have other medical conditions—aside from the heart condition, that could shorten their lives or interfere with the success of a heart transplant,” says Dr. Colvin.

A transplant team of doctors, nurses, social workers, psychologists, and financial counselors reviews each candidate to determine whether the patient meets the criteria and will be successful with a heart transplant, Dr. Colvin adds. Yet, some patients don’t want a heart transplant.

“In those cases, palliative care and hospice can offer patients with Stage D heart failure a better quality of life than pursuing surgery,” she says.

Prognosis after heart transplant or LVAD

Both heart transplant and LVAD have become standard therapies for some patients with stage D heart failure and are highly successful in extending life, and improving heart failure symptoms and quality of life.

“LVAD therapy is highly successful and has survival at one and two years, similar to heart transplants,” says Dr. Colvin. Heart transplant patients also have an encouraging prognosis. “Over 90 percent of heart transplant recipients are alive one year after transplant,” she adds. “Most can expect to live at least 11 years, and many live even longer—in many cases, up to 20 years and more.”

The last word

Stages A through D of heart failure are each unique and will require different treatment options depending on severity.

It’s best to continue following heart-healthy practices, like healthy eating habits and exercise, take your prescription medications (if needed), and make lifestyle changes to take charge of your condition. Also, speak with your doctor about all available treatment options for your particular stage of heart failure.

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