Heart Failure: Diagnosis & Treatment

Heart failure is diagnosed through an assessment of your symptoms, a physical examination, and a series of tests. Treatment involves medications, lifestyle changes, and in some cases device therapies or surgery. Early diagnosis and the right treatment slow the progression of the condition, bring symptoms under control, and can significantly improve your quality of life. Staying on top of regular follow-up and maintaining lifestyle changes after treatment are among the most important parts of managing heart failure well.

Diagnosis

Heart failure cannot be diagnosed with a single test. Your doctor will consider your symptoms, medical history, and physical examination findings together to decide which investigations are needed.

Diagnostic methods include the following:

• Physical examination. Your doctor listens to your heart and lungs, checks for swelling in your legs, and measures your blood pressure and pulse. Fluid in the lungs, enlarged veins in the neck, and swollen legs are all important physical signs of heart failure.
• Blood tests. Markers called BNP or NT-proBNP are measured in the blood. These substances are released when the heart is under stress and are among the most important blood indicators of heart failure. The higher the value, the harder the heart is working. Kidney function, liver values, blood count, and thyroid hormones are also checked; both to investigate the cause of the heart failure and to understand your overall health.
• Heart ultrasound (echocardiogram). This is the most important imaging test for heart failure. Using sound waves, it produces moving pictures of the heart in action. It shows how strongly the heart is pumping, the condition of the heart muscle, whether the valves are working properly, and the size of the heart chambers. The measurement that shows what proportion of blood the heart pumps with each beat is especially important; it determines which type of heart failure you have and directly shapes your treatment plan.
• ECG (electrocardiogram). Records the heart's electrical activity. Evidence of a previous heart attack, rhythm disturbances, and thickening of the heart muscle can all be identified on an ECG.
• Chest X-ray. Shows whether fluid has built up in the lungs and whether the heart has become enlarged. It is a simple and quick test that provides useful early information.
• Exercise test. Assesses how the heart performs during physical activity. Understanding how limited your exercise capacity has become helps both with diagnosis and with planning the right treatment approach.
• Cardiac MRI. Produces much more detailed images of the heart muscle's structure and function. It is used when the echocardiogram does not provide sufficient information or when a disease of the heart muscle itself is suspected.
• Coronary angiography. Examines the heart's own blood vessels for narrowing or blockage. It is performed when coronary artery disease is suspected as the underlying cause of heart failure. If a blockage is found, a stent can sometimes be placed in the same procedure.

Treatment

The goal of heart failure treatment is to reduce the workload on the heart, bring symptoms under control, prevent episodes of worsening that require hospital admission, and preserve quality of life. For most people, treatment consists of medications, lifestyle changes, and regular monitoring. In some patients, device therapies or surgery are also part of the plan.

Treatment options include the following:

• ACE inhibitors and ARBs. One of the cornerstones of heart failure treatment. These medications relax the blood vessels, reducing the effort the heart has to make to pump blood, and protect the heart over the long term. Some people develop a dry cough with ACE inhibitors, in which case your doctor will switch to an ARB.
• Beta-blockers. Slow the heart rate and help the heart beat in a more regular and efficient pattern. They may cause some tiredness in the first few weeks, but this usually settles. Over the long term, they protect the heart and contribute to a longer life.
• Water tablets (diuretics). Help the body get rid of excess fluid through the kidneys. They can quickly reduce breathlessness and leg swelling. However, diuretics do not slow the progression of heart failure on their own; they work best alongside other medications.
• Aldosterone antagonists. Reduce the retention of salt and fluid in the body and protect both the heart and kidneys. When added to other treatments, they have a beneficial effect on the course of the disease.
• SGLT2 inhibitors. Originally developed to treat diabetes, these medications have been found to have powerful protective effects in heart failure too. They are now used in people with heart failure who do not have diabetes and have been shown to significantly reduce the risk of hospitalization and death. Taken as a tablet once a day.
• Sacubitril/valsartan. A combination of two different protective substances in a single tablet. It has been shown to be more effective than standard ACE inhibitors for both relieving symptoms and providing long-term protection in heart failure. It is now widely used in suitable patients.
• Iron supplementation. A significant proportion of people with heart failure have iron deficiency. Correcting iron deficiency reduces fatigue and improves the capacity for daily activities.
• Cardiac resynchronization therapy (CRT). In some patients, the left and right sides of the heart beat out of step with each other, which reduces pumping efficiency. A specialized pacemaker called a CRT device stimulates both sides simultaneously, helping the heart work in a much more coordinated way. It can produce a noticeable improvement in symptoms.
• Implantable defibrillator (ICD). Heart failure increases the risk of sudden dangerous heart rhythm disturbances. This small device is implanted under the skin of the chest, monitors heart rhythm continuously, and automatically steps in to restore normal rhythm if a dangerous situation is detected.
• Heart transplantation. If heart failure continues to progress despite all available treatments and the patient meets the necessary criteria, a heart transplant may be considered. In suitable patients it can dramatically improve both quality of life and survival.
• Mechanical circulatory support devices. In very advanced heart failure, mechanical pumps that assist the heart can be used in patients waiting for a transplant or in those who are not suitable transplant candidates. These devices take over much of the heart's pumping function.
• Treating the underlying cause. Addressing the reason why heart failure developed is critically important. A stent or bypass for blocked heart arteries, repair or replacement of a faulty heart valve, treatment of a rhythm disturbance, or bringing high blood pressure under control can all reduce the burden on the heart and slow the progression of the condition.

Preparing for Your Appointment

Coming prepared to your appointment (whether for a first assessment or an ongoing review) makes the time with your doctor considerably more productive.

What you can do:

• Note when symptoms began, how they have changed, and what makes them worse
• Record any weight changes over the past few weeks with the dates
• Mention how many pillows you need to sleep comfortably and whether breathing is difficult when lying flat
• Describe when leg swelling started and how it changes throughout the day
• List all your current medications, vitamins, and supplements
• Mention any previous diagnosis of heart disease, high blood pressure, diabetes, or kidney disease
• Note any family history of heart failure or sudden cardiac death
• Write your questions down in advance so you don't forget them

Questions you may wish to ask your doctor:

• What stage is my heart failure at?
• How strong is my heart's pumping function and what does that mean for me?
• Which medications will I be taking and what are the possible side effects?
• Might I need a device such as a pacemaker or defibrillator?
• How should I monitor my weight and at what point should I call you?
• How much salt and fluid can I have each day?
• Can I exercise and if so how much?
• How often should I come in for check-ups?

Questions your doctor may ask:

• How long have you had breathlessness and when does it tend to be worst?
• How many pillows do you need to sleep?
• Are you waking in the night struggling to breathe?
• Do you have swelling in your legs and when did you first notice it?
• Have you gained weight over the past few weeks?
• Have your daily activities become more limited and how far can you walk?
• Have you previously been diagnosed with a heart attack, high blood pressure, or diabetes?
• What medications are you taking and are you taking them regularly?