Congestive heart failure - Treating heart failure

Lifestyle changes

If you have been diagnosed with heart failure, you can reduce your risk of further episodes by making simple lifestyle changes.

Stopping smoking (if you smoke) will quickly reduce your risk of having a heart attack to near that of a non-smoker.

Other lifestyle changes – such as eating healthily, moderating your alcohol and salt intake, and taking regular exercise – will also improve your symptoms and reduce the pressure on your heart.

Read more about lifestyle changes and preventing heart failure.

Rehabilitation programmes

You may be given an opportunity to attend a heart failure rehabilitation programme. These programmes vary widely throughout the country, but most will cover basic areas, including:

• exercise
• education
• relaxation and emotional support

After completing your rehabilitation programme, it is important that you continue to take regular exercise and lead a healthy lifestyle to protect your heart and reduce the risk of further heart-related problems.

You can read more about cardiac rehabilitation on the British Heart Foundation website.

Medicines for heart failure

Most people with heart failure are treated with medicines. Depending on your symptoms, you may need to take several medicines. For people with heart failure and heart failure caused by left ventricular systolic dysfunction, these include:

• ACE-inhibitors
• angiotensin receptor blockers (ARBs)
• beta-blockers
• aldosterone blockers (spironolactone or eplerenone)
• diuretics
• ivabradine
• digoxin (occasionally)

Many patients with heart failure with preserved ejection fraction will require similar treatment.

The doses of these medications will be adjusted by your doctor. You may occasionally need to have blood tests to monitor your kidney function, especially when doses are altered.

Ask your doctor if you are not sure whether you are on the best dose for you. The first medicine you try may not work properly or suit you, so changes may be needed until you and your GP find a combination that works for you.

You may also be offered other medicines if you have another condition or other symptoms that also need treatment.

Diuretics

Diuretics (water pills) make you pass more urine and help relieve ankle swelling and breathlessness caused by heart failure.

There are many different types of diuretic, but some of the most widely used for heart failure are bumetanide and furosemide (also called frusemide). In some mild cases, a diuretic called bendroflumethiazide may be used.

A diuretic called metolazone may be used together with bumetanide or furosemide in people with severe fluid retention.

ACE inhibitors

Angiotensin-converting enzyme (ACE) inhibitors work by dilating your blood vessels (opening them up), which makes the blood flow more easily and reduces blood pressure. This makes it easier for your heart to pump blood around the body.

ACE inhibitors often have a positive impact on the heart's performance and may improve your quality of life. They reduce the risk of hospitalisation and prolong life.

Examples of ACE inhibitors include ramipril, captopril, enalapril, lisinopril and perindopril.

The most common side effect is a dry, irritating cough. If you have a troublesome cough, an ACE inhibitor may be switched to an ARB.

ACE inhibitors can also cause your blood pressure to fall too low, and they may upset kidney function. Your GP will monitor this.

Beta-blockers

Beta-blockers are usually used to treat people with heart failure caused by systolic dysfunction (where the left ventricle that pumps blood around the body doesn't work properly).

These drugs reduce the risk of hospitalisation and prolong life in patients with a low left ventricular ejection fraction (the amount of blood pumped out by the left side of your heart).

However, beta-blockers may not be suitable for people with asthma, although most patients with chronic obstructive pulmonary disease (COPD) will be able to tolerate them.

Beta-blockers work by slowing your heart down and protecting your heart from the effects of chemicals produced by the body called adrenaline and noradrenaline.

Your doctor may start you on a low dose and increase it over a few weeks or months. There are several different beta-blockers, but the ones used to treat heart failure in the UK are bisoprolol, carvedilol and nebivolol.

Ivabradine

As long as the heart is in a normal rhythm (sinus), ivabradine will slow the heart rate. It can be a useful alternative for some people when beta-blockers cannot be used or are not tolerated.

If beta-blockers do not slow the heart enough, the addition of ivabradine can provide added protection, leading to improved heart function and symptoms.

It can also reduce the risk of hospitalisation and prolong life in people with a low left ventricular ejection fraction.

Aldosterone antagonists

Aldosterone antagonists are suitable for some people with heart failure. They work in a similar way to diuretics, but they can stop the diuretics from washing out potassium and may also help reduce scarring of the heart muscle.

They improve symptoms, reduce the risk of hospitalisation, and prolong life in people with a low ventricular ejection fraction.

The most widely used aldosterone antagonists are spironolactone and eplerenone. Spironolactone may cause swelling and pain around the nipples in men and testicular atrophy (shrinking of the testicles). Eplerenone rarely causes such effects.

The most serious side effect of these medicines is that they can cause the level of potassium in your blood to go too high, which can cause problems. Your doctor will carry out regular blood tests to monitor your potassium level.

Angiotensin receptor blockers (ARBs)

Angiotensin receptor blockers (ARBs) work in a similar way to ACE inhibitors by widening blood vessels and reducing blood pressure. They tend to be used as an alternative because they do not usually cause a cough.

Examples of ARBs include candesartan, losartan, telmisartan and valsartan. Side effects include low blood pressure (hypotension) and high levels of potassium in your blood. Your doctor will carry out regular blood tests to monitor your potassium level.

Although ARBs do not cause coughs, they may not be quite as effective as ACE inhibitors.

Hydralazine with nitrate

When hydralazine is combined with nitrate, the blood vessels dilate (open up). These medicines are sometimes prescribed by heart specialists for people who are unable to take an ACE inhibitor or ARB.

Digoxin

Digoxin, derived from the foxglove plant, can increase the strength of your heart muscle contractions and slow down your heart rate. It can improve symptoms and reduce hospitalisation, but it does not appear to prolong life.

It is recommended for people who have symptoms despite treatment with ACE inhibitors, ARBs, beta-blockers and diuretics. It is used earlier in people who have both heart failure and a condition called atrial fibrillation (where the heart beats irregularly).

Anticoagulants

Anticoagulants make it more difficult for your blood to clot, helping to prevent a stroke.

Warfarin is the most commonly used anticoagulant, and requires careful monitoring by your GP or doctor to make sure you get the right amount.

Antiplatelet medicines

Platelets are cell fragments that are part of the clotting system. Aspirin and clopidogrel reduce the stickiness of blood platelets, which may reduce the risk of a heart attack or stroke.

Aspirin is not usually taken with warfarin. Speak with your GP if you are concerned.

Devices for heart failure

Pacemakers

You may need to have a pacemaker fitted if your heart beats too slowly, even if this only occurs occasionally.

A pacemaker monitors your heart rate continuously. If your heart rate drops too low, it sends a signal down a wire to your heart muscle to stimulate it.

There are several different types of pacemaker. The best one for you will depend on the type of heart rhythm or beat problem you have.

The pacemaker is implanted under the skin by a cardiologist (heart specialist), usually under local anaesthetic. You will usually need to stay in hospital overnight to check it is working properly. Serious complications from pacemakers are unusual.

Pacemakers need to be checked regularly by specialist technicians at a pacemaker clinic. You will also need to be careful about things that can affect how your pacemaker works, such as hospital equipment and security systems in shops or at airports.

Read more about pacemaker implantation. You can also find out more about pacemakers on the British Heart Foundation website.

Cardiac resynchronisation therapy

In some people with heart failure, the walls of the left ventricle (the main pumping chamber) do not work together and contract out of phase with each other.

Cardiac resynchronisation therapy (CRT) is a special type of pacemaker that can correct the problem, making the walls of the left ventricle all contract at the same time. This makes the heart more efficient.

Most pacemakers only have one or two wires to the heart, but CRT requires an extra wire that is a bit harder to get into place than the other wires.

CRT is considered for people who:

• have moderate to severe heart failure symptoms despite medication
• have a left ventricular ejection fraction (the amount of blood pumped out of the left ventricle) of less than 35%
• have evidence from an electrocardiogram (ECG) that there is a problem with the electrical activation of the left ventricle (a measurement called QRS width) – if it is longer than 150 milliseconds (ms), there is strong evidence of benefit; if it is 120 to 150ms, the evidence is less strong (a normal QRS is less than 100ms)

Implantable cardioverter defibrillators (ICDs)

People who have (or are at high risk of having) an abnormal heart rhythm, called ventricular tachycardia (VT) or ventricular fibrillation (VF), may need to have a device known as an implantable cardioverter defibrillator (ICD) fitted.

With VT, the heart beats too fast and there is not enough time for the heart to fill with blood between beats. This can lead to a blackout and may cause VF.

In VF, the heart rhythm is so abnormal that the heart no longer contracts, but "quivers" instead. This results in death unless an electrical shock is given to the heart to restart it.

An ICD works by constantly monitoring the heart rhythm. If VT is detected, the ICD will try to correct it. If this does not work, the ICD will try to bring the heart back to normal by giving it a small, controlled electrical shock.

If this fails, the ICD will deliver a larger shock. The electrical shocks are known as defibrillation. If the ICD detects VF, it will defibrillate the heart immediately.

As with pacemakers, ICDs are implanted in hospital, usually under local anaesthetic. Like pacemakers, you will need to avoid things that can interfere with the way the ICD works, such as airport security systems.

Read more about ICDs on the British Heart Foundation website.

CRT-D

Devices that combine cardiac resynchronisation and the ICD function are implanted into patients who need both. Two separate devices are not necessary. These combination devices are usually called CRT-Ds.

Surgery

Medicines are the main treatment for heart failure, but for some people an operation may help.

Heart valve surgery

If the valves of your heart are damaged or diseased, your doctor may suggest valve surgery. There are two types of valve surgery – valve replacement and valve repair.

The type of surgery you have will depend on what is wrong with the valve and how serious the problem is. Your doctor will discuss it with you.

Angioplasty or bypass (revascularisation)

If your heart failure is related to coronary heart disease, your doctor may suggest coronary angioplasty or a coronary artery bypass graft (CABG).

This will help get the blood flowing to your heart muscle and can improve angina, reduce the risk of a heart attack in some cases, and sometimes improve heart muscle function.

Left ventricular assist devices

A great deal of research has been carried out to try to make a mechanical heart that can replace heart function completely. So far attempts have met with limited success.

However, mechanical pumps have been developed to boost, rather than replace, the failing left ventricle. These are quite successful for people with severe heart failure that is difficult to control with medicines.

These pumps are complex and expensive, and are not suitable for everyone. They are usually only implanted into a patient surgically at a heart transplant centre.

Mechanical booster pumps require an external battery, so a wire has to be tunnelled underneath the skin. The wire can cause an infection, which is a major drawback of this type of technology.

In the UK, several hundred people are living at home with fairly active lives after having one of these pumps fitted.

Heart transplantation

In recent years, the survival rates and quality of life among people with severe heart failure has improved substantially.

However, some people have such severe heart failure that treatment with medicines or surgery does not help, and they may need to have their diseased heart replaced with a healthy one from a donor.

Having a heart transplant is a major decision. It is a complex surgical operation with risks. There is also a shortage of hearts for transplantation, and some people have to wait years for a suitable heart closely matching their own.

Read more about heart transplants. You can also find out more about other types of surgical heart treatments on the British Heart Foundation website.