Heart failure - Treatment 

If you've been diagnosed with heart failure, you can reduce your risk of further episodes by making simple lifestyle changes. Stopping smoking will quickly reduce your risk of a future heart attack to near that of a non-smoker.

Other lifestyle changes, such as eating more healthily and being more physically active, will also improve your symptoms and reduce the pressure on your heart. Find out more about lifestyle changes in the Heart failure – prevention section.

Rehabilitation programmes

You may be offered an opportunity to attend a heart failure rehabilitation programme. Heart failure rehabilitation programmes vary widely throughout the country but most will cover the following basic areas:

• exercise
• education
• relaxation and emotional support

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

Want to know more?

• British Heart Foundation: cardiac rehabilitation
• Live Well: stop smoking
• Live Well: healthy eating
• Live Well: exercise and fitness

Most patients with heart failure are treated with medicines. Depending on your symptoms, you may need to take several medicines. The usual combination of medicines for heart failure includes:

• a diuretic
• an angiotension-converting enzyme (ACE) inhibitor
• a beta blocker
• an aldosterone antagonist

Your doctor will discuss the treatments available. The first drug or drugs you try may not work properly or suit you, so expect some changes until you and your GP find a combination that works well for you. You may be offered other medicines if these don’t work, or if you have another condition or other symptoms that also need treatment.

Diuretics

Diuretics help to relieve ankle swelling and breathlessness caused by heart failure. They work by helping to remove water and salt from the kidneys in the urine. There are many different types of diuretic, but some of the most widely used for heart failure are bendroflumethiazide, bumetanide and furosemide (also called frusemide).

ACE inhibitors

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

They often have a positive impact on the performance of the heart, and may improve your quality of life. However, they are not suitable for everyone. Examples of ACE inhibitors include ramipril, captopril, enalapril, lisinopril and perindopril. The most common side effect is a dry, irritating cough.

Beta-blockers

Research has shown that beta-blockers can help some people with heart failure. However, they are not suitable for people with asthma. They work by slowing your heart rate and perhaps by protecting your heart from the effects of adrenaline and a related chemical, 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.

Aldosterone antagonists

These drugs are suitable for some people with heart failure. They work in a similar way to diuretics, but can also help heal any scarring of the heart muscle.

The most widely used - aldosterone antagonist - is spironolactone. The main side effect of is high levels of potassium in the blood, which can cause problems. Your doctor will do regular blood tests to monitor your potassium level.

Angiotensin receptor blockers (ARBs)

ARBs have been shown to extend life and reduce symptoms in patients with heart failure. They work in a similar way to ACE inhibitors, by widening blood vessels and reducing blood pressure, and tend to be used as an alternative as they do not usually cause cough.

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

Hydralazine with nitrite

This combination of drugs open up (dilate) blood vessels, and are sometimes prescribed by heart specialists for people who are unable to take an ACE inhibitor or ARB.

Digoxin

Digoxin, related to a medicine derived from the foxglove plant, increases the strength of heart muscle contractions and can also slow down heart rate. 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 is beating irregularly).

Anticoagulants

Anticoagulants help to make it more difficult for your blood to clot. This helps 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 medicine

Antiplatelet medicine, for example aspirin, is used to stop blood platelets from forming clots in your blood. Aspirin is not usually taken with warfarin. Speak with your GP if you are concerned.

Want to know more?

• heartfailurematters.org: heart failure medications

Pacemakers

If your heart beats too slowly either or all or some of the time, you may need to have a pacemaker fitted. A pacemaker monitors the heart rate continuously, and if the rate drops too low, sends a signal down a wire to the heart muscle to tell it when to beat. There are several different types of pacemaker. The best one for you will depend on what type of heart rhythm or beat problem you have.

The pacemaker is be implanted in your chest by a cardiologist, normally under local anaesthetic. You will usually need to stay in hospital overnight to check that 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.

Cardiac re-synchronisation therapy

In some people with heart failure, the walls of the left ventricle (the main pumping chamber) don’t all contract simultaneously, but out of phase with each other. Cardiac resynchronisation therapy (CRT) is a treatment that tries to correct the problem by making the walls of the left ventricle all contract at the same time. The heart then works better.

A pacemaker generator buried under the chest wall is connected to three leads that are manipulated into the correct position in the heart. By sending a a small electrical current to leads connected to the different walls of the left ventricle, the heart is made to beat in a more coordinated way.

CRT tends to be 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

Implantable cardioverter defibrillators (ICDs)

People who have (or are at particularly high risk of having) an abnormal heart rhythm, called VT (ventricular tachycardia) or VF (ventricular fibrillation), may need to have a device fitted called an ICD. With ventricular tachycardia, the heart beats too fast and there is not enough time for the heart to fill with blood properly between beats (contractions), so not enough blood is pumped round the body.

In ventricular fibrillation, 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 ventricular tachycardia 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 ventricular fibrillation, it will defibrillate the heart immediately.

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

CRT-D

Devices that combine cardiac resynchronisation and the ICD function are implanted into patients needing both: two separate devices are not necessary. Such a device is usually called a CRT-D.

Want to know more?

• Health A-Z: pacemaker implantation
• British Heart Foundation: pacemakers
• British Heart Foundation: ICD

Medicines are the main treatment for heart failure but for some people, surgery is possible. For example, if you have a damaged heart valve, it is possible to repair it or replace it with an artificial one. If your heart failure is caused by a problem with the left ventricle of your heart, there are a few surgical options for treatment.

Heart valve surgery

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

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

Revascularisation

If your heart failure is related to coronary heart disease your doctor may suggest coronary angioplasty or a coronary artery bypass graft (CABG) to help get the blood flowing to your coronary arteries (the blood vessels leading up to the heart). If this is the right approach for you, your doctor will discuss it with you.

Heart transplantation

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.

It is a big decision to make. Heart transplants are complex surgical operations with risks. They have dramatically improved the survival rates and quality of life among people with severe heart failure but there is a shortage of hearts for transplantation and people may have to wait years for a suitable organ to become available because the donor heart must closely match their own.

Want to know more?

• British Heart Foundation: heart surgery