Heart Failure in the United States

Epidemiology

Cardiovascular diseases in general cause an estimated 17.9 million deaths annually, accounting for 32% of all-cause mortality globally.1  Heart failure (HF) affects approximately 26 million people around the world, and its prevalence increases each year, impacted by an aging population and improvements in survival.2

The American Heart Association (AHA) reported that 6.2 million people had heart failure in the United States between 2013 and 2016. In 2021, the AHA Statistical Update estimated the prevalence of heart failure to be 6 million, approximately 1.8% of the total US population.3 Researchers predict a 46% increase in heart failure prevalence by 2030, reaching more than 8 million people in the US.1

Congestive heart failure (CHF) is more prevalent in older age groups. A 2012 study showed a 4.3% prevalence of CHF in people between 65 and 70 years old.4

Etiology of Heart Failure and Risk Factors

Heart failure is the inability to provide sufficient cardiac output for adequate oxygenation and perfusion of the body’s tissues while maintaining normal filling pressures.5  It can present acutely or with gradual progression of symptoms.

The most common causes of heart failure are:4,6

  • Diabetes
  • Hypertension
  • Hyperlipidemia
  • Sedentarism
  • Smoking
  • Obesity
  • Coronary artery disease
  • Myocardial infarction

Genetics can play an important role as a risk factor for heart failure because many of the previously listed conditions are heritable, such as diabetes and hypertension. Arrhythmias and connective tissue disorders, such as Marfan syndrome, are heritable conditions with high risk of heart failure. Patients who have a medical history of these conditions should seek out a health care provider to regularly monitor for potential indications of heart failure.

Healthy lifestyle practices can lower heart failure risk. Common practices that can help maintain a healthy lifestyle and lower this risk include avoiding smoking tobacco, excessive alcohol consumption, high-fat foods, and high-sodium foods; practicing regular physical activity; and managing stress.

Heart Failure Prognosis in Case Studies

Research shows better patient outcomes when heart failure is diagnosed at younger ages. Poorer outcomes are associated with older age at time of diagnosis and in patients with kidney disease, diabetes, or who fall into class III or IV for heart failure in the New York Heart Association Functional Classification (see section below “Presentations of Heart Failure”).7

A meta-analysis that included 60 different studies with survival data for 1.5 million heart failure patients showed:8

  • 1 month survival in 95.7% (95% CI, 94.3%-96.9%) of the studied patients
  • 1 year survival in 86.5% (95% CI, 85.4%-87.6%) of the studied patients
  • 2 years survival in 72.6% (95% CI, 67.0%-76.6%) of the studied patients
  • 5 years survival in 56.7% (95% CI, 54.0%-59.4%) of the studied patients
  • 10 years survival in 34.9% (95% CI, 24.0%-46.8%) of the studied patients

This analysis also showed that an increased age at diagnosis was significantly associated with a reduced survival time. In a US-only data analysis, it was shown that the death rate caused by heart failure in the United States varies by state.9

Presentations

Heart failure is a chronic condition that has no cure, but it can be controlled with lifestyle changes, medication, and surgery. Heart failure symptoms can appear acutely or develop over time. Common signs and symptoms of heart failure are shortness of breath, fatigue, weakness, swelling of the lower extremities, and a rapid or irregular heartbeat.10,11,12

Two classification tables are used to determine levels of heart failure in the United States. These tables are used in tandem to determine the functionality and objective level of a person’s heart failure. 13

Table 1. Functional Classification

Heart Failure ClassPatient Symptoms
Class IPatients can complete ordinary physical activity without experiencing undue fatigue, palpitation, or shortness of breath.
Class IIPatients experience some fatigue, palpitation, or shortness of breath when doing ordinary physical activity.
Class IIIPatients experience fatigue, palpitation, or shortness of breath with low or moderate physical exertion.
Class IVPatients experience heart failure symptoms at rest and cannot complete any physical activity without discomfort.
Adapted from Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins; March 1, 1994.

Table 2. Objective Classification

Heart Failure StageObjective Assessment
Stage APatients do not have symptoms or structural heart abnormalities but are at risk of developing heart failure.
Stage BPatients do not have current or prior symptoms of heart failure but show signs of one of the following: structural heart disease, abnormal cardiac function, or elevated natriuretic peptide or cardiac troponin levels.
Stage CPatients have current or prior symptoms of heart failure caused by structural or functional abnormalities
Stage DPatients experience severe symptoms of heart failure while at rest and require advanced treatment therapies.
Adapted from Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins; March 1, 1994.

Heart Failure Diagnosis

To properly diagnose chronic heart failure, a health care provider first needs to know about the patient’s lifestyle (e.g., tobacco and alcohol consumption, diet, physical activity) and medical history, including family medical history, to understand if there are any underlying conditions (e.g., diabetes or high blood pressure) that may lead to heart failure.

It is also important to know if the patient has received cancer treatments because cancer is considered a risk factor for heart failure.

Classifications of heart failure depend on the left ventricle ejection fraction (LVEF)1:

  • Heart failure with preserved ejection fraction (HFpEF). This classification is also referred to as diastolic heart failure. The LVEF is greater than or equal to 50%, and it accounts for at least 50% of HF cases.
  • Heart failure with mildly reduced ejection fraction (HFmrEF). HFrEF is also known as systolic heart failure. The LVEF is less than or equal to 40%. Patients with HFrEF can show severe symptoms and need immediate treatment.14
  • Heart failure with reduced ejection fraction (HFrEF). This classification is for those cases in between HFrEF and HFpEF, with a LVEF in between 41% and 49%.14

Patients with Suspected Heart Failure Physical Exam Findings

  • Heart murmurs. Cardiac arrhythmias can indicate abnormal movement of the blood in the heart, and pulmonary rales.15
  • Blood pressure. A reading of 130/80 mm Hg or higher suggests hypertension, which can increase the risk for heart failure. A low blood pressure reading can also be indicative of late-stage heart failure in correlation with signs and symptoms suggestive of heart failure.
  • Blood flow. Examination of proper blood circulation from the arteries can reveal elevated jugular venous pressure in those with heart failure.
  • Edema. Edema in legs, feet, and ankles can indicate chronic heart failure.

Diagnostic Heart Failure Workup

In some cases of early heart failure, a physical examination won’t show any immediate signs, such as pulmonary rales or peripheral edema. In these cases, specific tests can be performed:6

Radiology

  • Electrocardiogram (ECG) measures the heart’s electrical activity, which may include a stress test. The ECG may show signs of low voltage indicative of amyloid heart disease, or evidence of a prior myocardial infarction.
  • Echocardiogram to search for abnormalities in the heart’s morphology, such as measuring the atrial and ventricular sizes, which could explain changes in ejection fraction, valvular dysfunction, or a structural remodeling. It also measures the filling pressure that, if elevated, could be a sign of HFpEF or HFmrEF.
  • Chest radiography to observe the heart size, look for pulmonary congestion, or identify the placing of an implanted cardiac device.16 In this radiography, the health care provider would look for a cardiac to thoracic width ratio above 50 percent, cephalization of the pulmonary vessels, Kerley B-lines, and pleural effusions.

Lab Tests for Heart Failure

Lab tests are used to search for metabolic abnormalities, including:

  • Complete blood count (CBC). The CBC may show a low level of red blood cells, a sign of heart failure.
  • Thyroid stimulating hormone (TSH). With the counting of TSH, thyroid disease can be assessed. This and other endocrine metabolic diseases are signs of heart failure.
  • Ferritin. Ferritin levels <100 mg /L are a sign of iron deficiency that causes anemia. Anemia is a common symptom of heart failure associated with reduced exercise capacity in patients with heart failure.
  • Troponin. Elevated troponin concentration occurs in 15% to 70% of patients with heart failure.
  • B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP). Increases in BNP and NT-pro-BNP are a sign of elevated ventricular pressure and volume, helping define heart failure in patients with shortness of breath.
  • Creatinine

Myocardial Biopsy

In exceptional cases, a myocardial biopsy could be considered when heart failure is suspected to be caused by a muscular disease.

Heart Failure Differential Diagnosis

There are many other diseases or conditions with similar symptoms to heart failure.17

Table 3. Similar Symptoms Presented in Other Conditions

Disease/condition/ syndromeSimilar Symptoms to Heart Failure
Chronic kidney diseaseSwelling or edema in lower extremities; shortness of breath; fatigue; weakness
CirrhosisSwelling or edema in lower extremities; shortness of breath; fatigue
Chronic obstructive pulmonary disease (COPD)Shortness of breath
AnemiaShortness of breath; fatigue; weakness
LymphedemaSwelling or edema in lower extremities
Acute respiratory distress syndrome (ARDS)Shortness of breath; rales
Pulmonary fibrosisShortness of breath; dry cough; fatigue
Pulmonary embolism (PE)Shortness of breath; chest pain; dizziness; arrhythmia; palpitations; cough
PneumoniaShortness of breath
Nephrotic syndromeSwelling or edema in lower extremities; fatigue
Postpartum cardiomyopathySwelling or edema in lower extremities; shortness of breath; fatigue; tachycardia; cough
AgingShortness of breath; fatigue
Heart Failure: Differential Diagnosis. Ioana Dumitru.

Management of Heart Failure

A health care provider can recommend different types of therapy depending on the stage of heart failure and severity of symptoms. Therapies may be recommended for long-term use to help manage heart failure and prevent or slow its progression. In some cases, heart surgery or implantation of a heart device may improve the patient’s condition.

Non pharmacotherapy

In cases where heart failure is established but the symptoms are minor, lifestyle modifications can help the patient effectively manage their symptoms.18

Table 4. Lifestyle Modifications to Manage HF

Lifestyle ModificationsRationale
Limiting or eliminating alcoholHeavy alcohol consumption has been linked to the development of other heart conditions (e.g., cardiomyopathy).
Quitting smoking and avoiding secondhand smokeSmoking decreases the level of oxygen in the blood, causing compensatory tachycardia which can aggravate heart failure.
Being activeExercising helps maintain a healthy heart, but the appropriate level of exercise for each patient varies. A health care provider should suggest the amount and type of exercise a patient needs to improve specific symptoms and reduce the risk of worsening heart failure.
Maintaining a healthy weightObesity can strain the heart as it attempts to meet the body’s metabolic needs. Maintaining a healthy weight is important during heart failure.
Eating healthy foodA low sodium diet helps avoid water retention. Limiting the amount of saturated and trans fats in the diet helps by decreasing the risk of heart diseases.
Getting vaccinatedVaccinations can protect against pulmonary infections and decrease morbidity and worsening heart failure. Important vaccines to consider are the ones against influenza, COVID-19, and pneumonia.
Avoiding stress and getting adequate sleepStressful situations cause tachycardia. Sleep deprivation can heighten stress.
Heart Failure. Overview. Mayo Clinic Staff.

Pharmacotherapy

Depending on the type of heart failure, a health care provider can prescribe one or a combination of drugs to manage heart failure symptoms.19,20,4

Table 5. Common Heart Failure Medications

Type of MedicationHow it WorksNotes
Beta blockersAct by blocking the release of adrenaline and noradrenaline, and result in a decrease of blood pressure. Some beta blockers used for treating heart failure in the United States include bisoprolol, carvedilol, and metoprolol.Achieve a lower heart rate, which is associated with better prognosis for patients in sinus rhythm but not for those with atrial fibrillation.
Angiotensin II receptor blockersHelp by expanding blood vessels and decreasing blood pressure. Some angiotensin II receptor blockers used for treating heart failure in the United States include losartan, candesartan, eprosartan, irbesartan, telmisartan, and valsartan.Can be safely used in patients who have previously had angioedema related to angiotensin-converting enzyme inhibitor medications.
Angiotensin-converting enzyme (ACE) inhibitorsRelax blood vessels to lower blood pressure and improve blood flow. Some ACE inhibitors used for treating heart failure in the United States include quinapril and ramipril.Increases salt concentration in the body. Potassium level monitoring is recommended. Nonsteroidal anti-inflammatory drugs (NSAIDs) may decrease the effectiveness of ACE inhibitors.
DiureticsHelp pass more urine, relieving the swelling of inferior extremities. Some diuretics used for treating heart failure in the United States include furosemide, bumetanide, torsemide, and ethacrynic acid.There are three types of diuretics: loop diuretics, thiazide diuretics with metolazone, and potassium-sparing diuretics. The latter are efficacious in the prognosis of congestive heart failure in symptomatic patients.21
Aldosterone antagonistsHelp reduce water retention by reducing the reabsorption of sodium. Some aldosterone antagonists used for treating heart failure in the United States include spironolactone, spironolactone suspension, and eplerenone.Used for the treatment of systolic heart failure. They have shown a decrease in mortality and hospital readmission rates.22
Positive inotropesHelp produce a stronger cardiac inotropic effect. Some positive inotropes used for treating heart failure in the United States include epinephrine, norepinephrine, and digoxin.Used in patients with HFrEF to help increase cardiac output.
Hydralazine/nitrate combinationCan be used in combination with other medications or for patients with contraindications to other medications.Used in patients with HFrEF. They have shown to reduce mortality by 34%.23
Soluble guanylate cyclase stimulatorsIncrease intracellular cGMP levels to ultimately produce smooth muscle relaxation and vasodilation.Prescribed to patients showing worsening symptoms in chronic heart failure. Used in both HFrEF and HFpEF.
Blood-thinning or anticoagulantsPrevent blood clots that can cause heart failure by stopping the formation of an embolus. Some blood thinners used for treating heart failure in the United States include apixaban, dabigatran, edoxaban, and rivaroxaban.Have shown to reduce the chances of a thromboembolic event by 17%.24
AntiplateletsHelp by inhibiting the enzymes that cause the platelets to clump together, avoiding the formation of blood clots. Some antiplatelets used for treating heart failure in the United States include aspirin, clopidogrel, prasugrel, and ticagrelor.Prescribed in patients with heart failure and a concomitant arterial disease such as atrial fibrillation.

Heart Failure Surgery

In cases of severe heart failure when lifestyle modifications and medication cannot improve symptoms, surgery might be needed to repair heart function.

Table 6. Surgical Options for HF25

Surgical OptionsHow it WorksNotes
Coronary bypass surgeryTo improve the blood flow to the heart, an artery from another part of the body (usually leg, chest, or arm) is removed and attached to the damaged section in the heart.Needed when arteries are severely blocked. Has shown a 16% decrease in mortality from any cause after 10 years.26
Cardiac resynchronization therapy (CRT) or pacemakerThe implanted device, called biventricular pacemaker, sends electrical signals to the ventricles to stabilize the pumping rhythm.Needed when the ventricles are not pumping in a synchronized way. CRT reduces the risk of severe heart failure events by 41% after two years.27
Implantable cardioverter-defibrillators (ICDs)Implanted under the skin of the chest to monitor the heart rhythm through wires that reach the heart through the veins. If there is an irregular heartbeat or if the heart stops, the ICD detects it and gives a small shock to stabilize the heartbeat.Has been shown to reduce relative mortality risk by approximately 25% after five years.
Ventricular assist devices (VADs)Mechanical circulatory support devices that help pump blood from the ventricles.Used in severe or end-stage cases of chronic heart failure. Safety alternative to cardiac transplantation with satisfactory clinical outcome.28
Heart valve surgerySurgeries that repair or replace valves that are not functioning properly.Has shown a survival rate of 77% at five years, and 53% survival at 10 years after surgery.29
Heart transplantThe patient’s heart is replaced by a donor’s healthy heart.Needed in cases of end-stage heart failure when medication or other surgeries don’t work. The survival rate one year after surgery is about 90%, and 70% at 5 years.30
 Hydralazine and nitrates in the treatment of heart failure with reduced ejection fraction. ESC Heart Fail. 2019;6(4):878-883.

Severe Heart Failure and Palliative Care for Patients

In severe cases of heart failure where treatments are insufficient to improve symptoms, a health care provider can recommend palliative care to ease the symptoms and improve the quality of life of the patient.25

Side Effects of Heart Failure Medications

Although they can be effective at treating heart failure symptoms, many drugs can cause side effects including indigestion, nausea, loss of appetite, constipation, and diarrhea. In these cases, switching medication or using other treatments may be recommended. Specific side effects of the most common heart failure medications are listed in Table 7. 20

Table 7. HF Medication Side Effects

MedicationSide EffectsNotes
Beta BlockersCan cause dizziness and nausea when first starting the therapy. In many cases these symptoms stop once patients get used to taking them. Beta blockers can slow the heart rate making it difficult to perform daily activities.Monitoring of heart rate and blood pressure is needed in patients on beta blockers.
DiureticsCan cause dehydration in patients when given in high dosages. The health care provider may suggest increasing fluid intake.Monitoring of electrolytes, specifically potassium levels, is needed whenever patients are on a diuretic.
ACE inhibitorsCan produce a dry, irritating cough in patients. In these cases, pharmacotherapy could be switched to angiotensin II receptor blockers. ACE inhibitors can also cause low blood pressure and kidney problems.Monitoring of blood pressure is needed at early periods after a patient starts taking ACE inhibitors.
Angiotensin II receptor blockersCan cause high potassium levels in the blood that may damage kidney function. Angiotensin II receptor blockers can also cause low blood pressure.Monitoring of electrolytes and blood pressure is needed when a patient is on angiotensin II receptor blockers. The combination of ACE inhibitors and angiotensin II receptor blockers should be avoided to decrease risk of low blood pressure, kidney damage, and high potassium levels.
American Heart Association. Medications used to treat heart failure.

Heart Failure Treatment: Drug-Drug Interactions

Heart failure is normally treated with multiple medications so drug interactions are common and should be carefully monitored. Drugs that treat heart failure comorbidities can interact with medication prescribed to treat other pre-existing conditions. Following are some common examples of drug-drug interactions to be aware of:31

  • Triple pharmacotherapy with ACE inhibitor, angiotensin II receptor blocker, and the hypertension drug, spironolactone, should be avoided since it can lead to severe hyperkalemia.
  • Special attention should be taken when treating heart failure patients who are also receiving chemotherapy. Many chemotherapy treatments can cause severe reactions with heart failure medication.
  • Analgesics of the NSAID family can exacerbate heart failure symptoms by producing peripheral vasoconstriction and sodium retention that can damage the kidneys. Additionally, NSAID can decrease the efficacy and increase toxicity of diuretics and ACE inhibitors.
  • Calcium channel blockers used to treat arrhythmias or hypertension may worsen heart failure by increasing the risk of cardiovascular events. An exception to these problems has been shown when using vasoselective calcium channel blockers which avoids activation of the sympathetic nervous system.
  • Antiarrhythmic medication used to correct heart rhythm can sometimes have a proarrhythmic effect that may worsen heart failure.

Complications of Heart Failure

Patients living with heart failure may also experience complications from the condition itself. The most common heart failure complications that arise and ways to manage them are listed in Table 8.18

Table 8. Heart Failure Complications and Management

ComplicationCausesManagement
Kidney failure or damageDecreased blood flow to the kidney because of heart failure.Patients may require dialysis treatment.
Liver damageFluid buildup develops when the additional pressure on the liver damages the organ.  Avoiding alcohol, losing weight, and avoiding salty foods. In some cases, medication or a liver transplant might be needed.
Heart valve issuesWith cardiac enlargement or if the heart’s pressure is too high due to heart failureMedicines like beta blockers or digoxin may improve symptoms. In some cases, surgery or a heart transplant might be needed.
ArrhythmiasWhen the atria and ventricles are not synchronized due to heart failure.Medicines like calcium channels blockers or beta blockers may improve symptoms.
Heart Failure. Overview. Mayo Clinic Staff.

Heart Failure Guidelines, 2022

Current US guidelines for the treatment of heart failure can be found in the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

References

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Author Bio

Francina Agosti is a freelance science and medical writer based in Canada. She holds a PhD in neuroscience, and she worked in academia for 10 years. Now she writes scientific and medical articles for digital magazines, and she also works as a scientific consultant for biotech and biopharma companies.