Cardiology - Heart Failure

Introduction

This leaflet is for people who have been diagnosed with heart failure and for their families and friends. It will help you to understand the condition, the tests used to make a diagnosis and the treatments you may receive.

The leaflet explains:

What heart failure is
What can cause heart failure
The common symptoms
How it is diagnosed
The treatment options
How you can help manage your condition

What is heart failure?

The heart is a muscular pump that sends blood to every part of your body to provide oxygen and nutrients for muscles and organs. Heart failure is the term used to describe the inability of the heart to pump sufficient blood to meet the body’s needs.

Image of heart

It is commonly a chronic long term condition which can be managed effectively with medication and other therapies to maintain a good quality of life. This is called chronic heart failure.

It can sometimes require urgent treatment if of new onset or where it has become unstable. This is often called acute heart failure.

There are several forms of heart failure and many reasons why it may develop which are explored in this leaflet.

If you have been diagnosed with heart failure you will be referred to and seen by a heart failure specialist who will work within a wider multi-disciplinary team (MDT) to plan and implement any required treatments or interventions.

The MDT will liaise with your GP to optimise your care and treatment. Once your condition is stable your GP will monitor your condition periodically and liaise with the heart failure specialist team, should your symptoms change.

Types of heart failure

The heart is divided into four chambers with valves opening and closing between these chambers to enable the flow of blood in and out of the heart to the rest of the body.

The type of heart failure may relate to the area of the heart that is affected and how well it is able to do its job. There are numerous terms used by specialists:

Heart failure with reduced left ventricular systolic function (HFREF)

The bottom left chamber of the heart has become weakened causing less blood to be pumped around the body.

Heart failure with preserved ventricular function: (HFPEF or Diastolic Dysfunction)

The heart has normal pumping strength but has difficulty filling with blood due to becoming stiff.

Right heart failure

The right side of the heart has become weakened and is unable to adequately pump blood to the lungs.

The hearts ability to pump sufficient blood may also be affected by how well the valves are working and the presence of an irregular heart rhythm.

What can cause heart failure?

The most common cause of an individual developing heart failure is coronary artery disease which accounts for around two thirds of all cases with many patients having experienced a heart attack. Blood supply to the heart may be reduced or a blockage (blood clot) may occur which damages the surrounding heart muscle when less oxygen is supplied. If the heart’s ability to pump then becomes impaired, heart failure may develop and symptoms arise.

Heart muscle may also become weakened due to:

A viral illness leading to inflammation of heart muscle (Myocarditis)
Harmful substances such as excess alcohol intake over an extended period
Toxic substances such as recreational drug use or prescribed treatments e.g. Chemotherapy
High blood pressure (Hypertension)
A faulty heart valve
A heart defect present from birth (congenital)
Abnormal heart rhythms (arrhythmias)
Other medical conditions placing strain on the heart over time such as respiratory disease, anaemia, thyroid gland disease and diabetes
Women who have recently given birth can develop heart muscle problems which may lead to heart failure

The term Cardiomyopathy may be used where heart muscle has become weakened, thickened or stiff due to the above causes.

In some people the cause of the heart muscle weakening remains unknown or ‘idiopathic’.

What are the symptoms of heart failure?

Breathlessness and cough

These commonly occur when fluid collects in the lungs. This ‘congestion’ is called pulmonary oedema. Your breathing may be more difficult when exercising or when lying flat. Breathlessness may wake you up from sleep leading to the need to sit up or get out of bed to feel better.

You may also feel breathless on general exertion as the harder you work the greater the amount of oxygen is needed to be transported to your muscles, which in turn means your heart has to pump harder.

Fatigue and weakness

This is a common sign of early heart failure, occurring either at rest or after minimal activity. Getting oxygen to the muscles that are performing is more difficult due to the heart not being able to pump the blood as effectively. The body also prioritises the vital organs oxygen supply over that of skeletal muscles and so the muscles may receive a reduced supply.

Fluid retention (oedema)

The feet, ankles, legs and abdomen may become swollen due to a build-up of excess fluid in the body’s tissues due to salt and water retention.

Weight gain

It is important to closely monitor your weight as this will indicate when you are retaining too much fluid. Weigh yourself every morning before getting dressed and before eating breakfast. If your weight increases by 2lbs (1kg) in one day you may be building up fluid and should consider if your breathing is affected or you notice any swelling. If you put on 5lbs (2.5kgs) over 3 days inform your heart failure nurse or doctor.

Lack of appetite and nausea

Fluid may accumulate in the digestive organs leading to feelings of fullness or bloating. A well-balanced diet is important. If you suffer these symptoms try eating smaller, more frequent meals.

Diagnosing heart failure

If you have shortness of breath or ankle swelling your doctor may consider a diagnosis of heart failure. They will discuss your symptoms and medical history as well as examining you.

Your doctor may consider other conditions with symptoms similar to heart failure and will therefore arrange several tests to identify the reason for your symptoms. These tests may include:

NY-proBNP: This is a prohormone detected by a blood test as it released by the heart when it is under stress
ECG: a non-invasive recording of the hearts electrical activity
Chest x-ray: To look for congestion in the lungs and estimate the heart size
Lung function test: Several measurements can be taken including how much air your lungs can hold; how well they can expel air; how well oxygen is absorbed and the strength of the breathing muscles
Echocardiogram: An ultrasound scan of the heart. It can provide information on the size, shape and strength of heart muscle, as well as the valves of the heart. Repeat scans may be considered by your specialist when treatment has been optimised or where there is a change in your condition
Cardiac MRI: An advanced scanning technique which is capable of identifying any issues with blood supply to the heart muscle and so can assist your specialist in establishing the cause of your heart failure where it is not known
Coronary angiogram: Commonly performed following a heart attack to assess the blood vessels around the heart muscle. A narrow catheter is passed into the blood vessels via a small incision in the wrist or groin. A dye is administered and images taken via x-ray. Any identified narrowing may be opened through balloon and stenting to restore blood flow. Some results may indicate the need for coronary bypass surgery. Although not considered to improve heart muscle strength, such procedures may reduce symptom burden and improve quality of life
Myocardial perfusion scan (MPS): A non-invasive imaging test that shows how well your heart is being supplied with blood. Substances containing a small amount of radioactivity (Tracers) are used to highlight different areas of the body being scanned – such as heart muscle (myocardium)
Routine blood tests will also be performed to monitor kidney function in response to treatment and also identify potentially treatable co-morbidities such as anaemia

Medicines used to treat heart failure

Heart failure is a serious condition that needs treatment. All people with heart failure will benefit from medication.

The medicines you will be offered will depend on the type of heart failure you have, its cause and your situation. Your doctor or heart failure specialist nurse will discuss the treatment options with you, including their benefits and information about possible side effects. It often takes a little time to find the right combination of medications, doses and their timings to suit the individual.

It is important to understand what you are taking and why.

You may need to take several medicines and at different times which may be confusing. If you are unsure speak to your doctor, nurse or pharmacist who will help you to organise the timings to make them easier to take.

Be sure to bring a list of your current medications to each clinic visit.

The following information lists the most commonly prescribed medicines depending on the type of heart failure you have been diagnosed with:

Medicine for left ventricle systolic dysfunction

ACE Inhibitors e.g. Ramipril, Perindopril, Lisinopril, Enalapril

Relax blood vessels making it easier for blood to pump through them
Improve life expectancy and reduce symptoms
Commenced at a low dose and gradually increased with blood tests to monitor kidney function
Side effects may include: cough, dizziness and facial swelling
Report and side effects to your doctor or heart failure specialist nurse

Angiotensin II Receptor Antagonists (ARBs) e.g. Candesartan, Losartan, Valsartan

An alternative to an ACE Inhibitor when not tolerated
As with ACE Inhibitors, your kidneys will be monitored following any dose increases

Beta-blockers e.g. Bisoprolol, Carvedilol, Nebivolol

Can make your heart muscles work more efficiently by slowing down the heart rate, reducing the amount of work the heart has to do
Improve life expectancy and reduce symptoms
Some people may initially feel worse when commencing these types of drugs
If you are already taking a Beta-blocker for Angina or high blood pressure your doctor or specialist may change it to one specific for heart failure
Common side effects include tiredness and cold extremities (fingers and toes). A small number of people may notice weight gain or increasing breathlessness.
You may not be able to take them if you have a lung condition such as Asthma
If you notice any side effects, contact your doctor of heart failure specialist nurse

Mineralocorticoid Receptor Antagonists (MRAs) e.g. Spironolactone, Eplerenone

Help to treat and prevent the build up of excess fluid in the body
They block the action of a hormone called Aldosterone which is responsible for the regulation of salt and water in the body
Improve life expectancy and reduce symptoms
These medicines can sometimes raise the Potassium in the blood. Your doctor or specialist will monitor kidney function with blood tests when adjusting your dosage.
Rarely, side effects may include breast enlargement or tenderness in men (Spironolactone)

SGLT2-inhibitors e.g. Dapagliflozin, Empagliflozin

Can be used to treat diabetes (lowers blood sugar levels; for patients with diabetes, there may be a need to adjust other diabetes treatments)
Have been shown to improve prognosis in patients with left ventricular systolic dysfunction in patients both with and without diabetes
Have a mild diuretic (water tablet) effect
Can increase chances of experiencing urine infections
Rarely can lead to a condition called ‘euglycaemic diabetic ketoacidosis’; seek help straightaway if you experience any combination of the following symptoms:
- A sweet smell to your breath, a sweet or metallic taste in your mouth or a different smell to your sweat or urine
- Feeling sick (nausea) or being sick (vomiting), tummy (abdominal) pains
- Losing weight quickly, feeling very thirsty, breathing unusually quickly or difficulty breathing
- Confusion, tiredness or sleepiness

Medicine that may be offered to patients for left ventricle systolic dysfunction

Angiotensin Receptor Neprilysin Inhibitors (ARNIs)

Sacubitril-Valsartan (Entresto)

An alternative to ACE Inhibitors and Angiotensin II receptor antagonists
May be considered by your doctor or heart failure specialist nurse where symptoms persist despite the use of optimal ACE-I/ARB dosage
Improve life expectancy ad reduce symptoms
Side effects may be similar to ACE-I/ARBs but is more likely to reduce blood pressure

Hydralazine-Nitrate combination

May be offered if you are unable to tolerate ACE-I/ARBs/ARNIs
You may be offered this combination if you still have troublesome heart failure symptoms despite first-line treatment, particularly if you are of African or Caribbean origin

Ivabradine

Slows down your heartbeat and may be prescribed if your heart is going too fast and doing more work than it needs to
It can be given with a beta-blocker or as an alternative
It cannot be prescribed if you have certain abnormal heart rhythms
Sometimes, it may slow the rate too much and cause dizziness and tiredness. Some people may experience vision problems. If this occurs, contact your doctor or heart failure specialist nurse who can adjust the medicine accordingly

Medicine that will be offered to all patients with heart failure and fluid retention

Diuretics (water tablets) e.g. Furosemide, Bumetanide

These help your kidneys to get rid of excess fluid and salt by making you pass more urine
Help to relieve swelling and breathlessness caused by fluid build-up. Your weight may therefore go up and down
Dosage will be adjusted accordingly to your symptoms
Diuretics are usually taken in the morning to avoid having to get up frequently at night
You may choose to take them later in the day when you have morning appointments

Other potential medications

Digoxin

May be offered in the symptoms of heart failure are difficult to treat
Can be affected by other drugs, so you must tell your doctor or specialist about any other drugs, herbal remedies or other treatments you are taking
Potential side effects associated with too much Digoxin in the blood include: loss of appetite, nausea, headaches
Report any side effects to your doctor or heart failure specialist nurse

Anti-anginals

Used to treat angina symptoms including chest pain or tightness and breathlessness
Types include calcium-channel blockers, nitrates, vasodilator
They are not used to treat heart failure but may be prescribed by a specialist if angina symptoms are present
Some examples must be avoided if you have heart failure which your specialist will take into consideration

Anticoagulants

Think the blood to stop blood clots from forming
May be prescribed by your doctor or cardiologist where you are considered to have an increased risk of clots
Conditions increasing risk include certain irregular heartbeats (arrhythmias) and following some heart valve replacement surgeries

Non-medical treatments for heart failure

In some circumstances other treatments or therapies beyond medicines may be considered by your doctor or specialist if they are considered to improve your symptoms and/or quality of life.

Exercise/Cardiac Rehabilitation

Moderate exercise can be beneficial to your heart. It can improve energy, stamina and fitness. This may help improve your symptoms and your ability to cope with them. It may help regulate your blood pressure, improve circulation, promote weight loss and lower cholesterol levels. Structured exercise classes may be of benefit to your condition and will be discussed with by your heart failure specialist nurse if appropriate. Please ask your nurse if you would like to participate in a professionally supervised menu-based programme of cardiac rehabilitation.

You will need to find a balance between exercise and rest. Rest and relaxation are also important, particularly if you are suffering from tiredness or disturbed sleep.

Surgery

It is not common for heart failure to be treated with surgery. Some patients may benefit where surgery can correct a condition that has led to heart failure symptoms.

Valve replacement

Heart failure is sometimes the result of damaged heart valves. These valves regulate the flow of blood through the hearts chambers. Surgery to repair or replace a faulty valve may relieve symptoms by improving the blood flow through the heart.

Percutaneous coronary angioplasty (PTCA) / Coronary artery bypass surgery (CABG)

Heart Failure symptoms may be improved by increasing blood supply to the heart muscle in those individuals with significant coronary artery disease. Bypass surgery and angioplasty can help to improve the blood supply to heart muscle.

Device therapy

Some individuals with heart failure may benefit from an advanced pacemaker device. This is called Cardiac resynchronisation therapy (CRT).

If your symptoms are severe it may be caused by the lower chambers of the heart beating out of time to each other. If so, a CRT-Pacemaker or CRT-Defibrillator can re-coordinate the heart muscle and improve its contractions.

This will be discussed with you if considered of benefit by your doctor or heart failure specialist nurse.

Heart Transplant

In some circumstances an individual may be referred on to a transplant specialist unit for assessment.

Your doctor or heart failure specialist nurse will discuss this with you if it is relevant to your situation and condition.

Lifestyle measures

Beyond medicines and procedures there are actions you can take to reduce your symptoms, slow disease progression and improve your quality of life.

Diet

It is important to eat a balanced diet. Aim for 5 pieces of fruit/ vegetables per day and limit your intake of saturated fats.

Be aware of portion sizes. More guidance is available at the following link: www.nhs.uk/livewell/5aday/pages/portionsizes.aspx

Avoid adding salt. Excess salt (Sodium) may worsen your symptoms as it can lead to fluid retention (oedema). Try using alternatives: herbs, spices, pepper, mustard or Lemon.

‘Lo-Salt’ substitutes are not recommended as they still contain salt and are higher in potassium.

The following foods are usually high in Sodium so it is important to try and cut back on such:

Ham, bacon, sausages
Salted nuts and peanut butter
Processed meats e.g. salami or hot dogs
Canned soups and dry soup mixes
Bovril, beef tea and Oxo
Pre-packed ready meals
Snack foods e.g. crisps, pretzel
Salad dressings
Fast food
Sauces: tomato, chilli, soy, Worcestershire

*avoid heartburn medicines that contain sodium carbonate or bicarbonate

Try to eat more fresh fruit and vegetables instead of canned foods.

Look for low salt labels or use the traffic light system often found on cans and packaging.

Watch your weight

If you are overweight your heart has to work harder.

You may find that you become breathless on minimal exertion.

Eating healthy will help you to feel better, lose weight and reduce the strain on your heart.

Reducing your intake of saturated fat and cholesterol is a step in the right direction.

Reduce intake of:

Whole milk, cream, milk, butter, egg yolks, cheese, cakes and pies, crisps and biscuits, fatty red meats, chips, roast potatoes and other fried foods

Increase intake of:

Semi-skimmed/skimmed ice cream, milk, low fat frozen yoghurt, low fat spread, low fat cheeses, fresh fruit and vegetables, lean cut red meat, fresh fish, chicken, turkey, wholemeal bread, boiled potatoes, pasta, and rice.

Alcohol

Drinking too much alcohol may damage your heart muscle. It reduces the heart’s ability to contract and so may worsen your condition.

Current guidelines are that you should not drink more than 14 units per week and if you regularly drink this amount it’s best to space it out evenly over 3 or more days. In certain circumstances your healthcare provider may request that you abstain completely from alcohol.

1 unit = small glass of wine or ½ pint Lager/Beer, Cider, one 25ml measure of spirit.

If reducing alcohol intake is a problem, help is online at www.nhs.uk/live-well/alcohol-support/

Smoking

If you smoke, stopping smoking is the single most important thing you can do to live longer. Smoking can deprive the heart of oxygen, make the heart beast faster and raise blood pressure for a short time after each cigarette. Stopping smoking will reduce this unnecessary burden and help to improve symptoms.

Contact details for local stop smoking support is listed at the back of this booklet. Alternatively visit:

www.nhs.co.uk/smokefree

www.quit.org.uk

Alternatively smart phone users can download the smokefree app.

Immunise

Flu and Pneumonia can increase the risk of complications for people with heart failure. Vaccination is recommended for any individual with a serious medical condition. Your GP should offer you the Flu vaccine on a yearly basis and a once-only immunisation against pneumonia. Contact them if you have concerns about the vaccine or if you have not been offered it.

Exercise

You will need to find a balance between exercise and rest. Rest and relaxation are also important, particularly if you are suffering from tiredness or disturbed sleep.

Watch your fluid intake

Fluid management is an important part of managing heart failure and you may be prescribed diuretics (water tablets) to remove excess water and sodium. Your doctor or heart failure specialist nurse will advise you if it is necessary to restrict your fluid intake. Water tablets may make you feel thirsty. To ensure that you do not drink too much fluid it is important to monitor your fluid intake.

You should drink no more than 2 ½ - 3 ½ pints per day (1 ½ -2 litres).

This includes your daily intake of tea, coffee, water, juice, carbonated drinks.

You may benefit from tallying up your daily intake by finding out how much water your mug or glass holds.

Some people find it helps to use a 2 litre bottle, stored in the fridge, to keep track of their intake.

If you are concerned about a dry mouth try sucking a boiled sweet, or using chopped fruit, ice cubes or chewing gum.

Sex and heart failure

Sexual health is an important part of an individual’s overall physical and emotional well-being.

Most people with heart failure can continue sexual relations once symptoms are under control. Follow these simple guidelines:

Avoid sex immediately after eating a heavy meal
Choose a time when you are rested and relaxed, in a peaceful and familiar setting
If you start to feel tired or breathless during intercourse, stop and rest for a short time

If your condition is severe and you can’t tolerate exercise, find less demanding ways to express love and affection.

Feelings of stress, anxiety and depression are common following a diagnosis of heart failure and may cause a lack of interest. If you suffer depression contact your doctor for help.

Occasionally some men may suffer erectile dysfunction. There are a range of treatment options available and you should contact your doctor for help.

Contraception is recommended for ladies of childbearing age, pregnancy may lead to a deterioration in your condition.

Driving

Most people with heart failure will be able to drive. It depends on if your symptoms are stable and wouldn’t distract you whilst driving or affect your ability to drive safely.

With heart failure specifically you don’t need to tell the DVLA if you have a car or motorcycle licence, but you must inform them if you drive for a living and have a licence to drive a bus, coach or lorry.

Standards for drivers with heart conditions are published by the DVLA and can be accessed via:

https://www.gov.uk/government/publications/inf1884-car-or- motorcycle-drivers-with-heart-conditions or ring: 0300 790 6806

You should refrain from driving and seek advice from your doctor if you have been experiencing dizziness, fainting of blackouts.

If you are unable to drive you may be eligible to apply for a disabled persons bus pass. You should contact your local council for this, or apply online: https://www.gov.uk/apply-for-disabled- bus-pass.

If you carry a HGV or PCV licence the DVLA may ask your specialist or hospital to carry out various tests to help the DVLA to decide if you may still drive.

Car insurance

Whatever type of licence you hold, you should inform your insurance company of any heart condition you have been diagnosed with and any treatments you have or are requiring. If you don’t your insurance may not be valid.

Travel

Most people with a heart condition are able to go on holiday, including heart failure.

Think about the following:

Staying in accommodation that’s easy to reach and close to amenities
Keep an up-to-date list of your medications in your purse or wallet
If you have a pacemaker or defibrillator, ensure you have your device card with you
You may also wish to obtain a letter from your Doctor explaining your condition, medicines & allergies
It is a good idea to take enough medication for your holiday plus two extra days in case of flight delays
Avoid high altitude destinations where the oxygen is lower in the air. This may increase breathlessness or cause angina
Destinations at altitude (>1500Metres) are generally not advised or where the temperature and/or humidity is excessive. Discuss your travel plans with your doctor or heart failure specialist nurse

Flying

If your heart failure is controlled and stable you should have no difficulties with mild reductions in oxygen levels in an aeroplane, provided you symptoms are stable before you travel. Seek advice before travelling if your symptoms have changed.

Reduce the risk of DVT by staying active when on a flight, regularly changing your position and walking up and down the aisle when able to do so. Keep well hydrated and avoid alcohol and caffeine during the flight.

Travel insurance

Make sure you have the right travel insurance to cover your condition(s).

The British heart foundation can supply a list of favourable insurance companies:

https://www.bhf.org.uk/informationsupport/support/practical- support/travel-insurance

TOP TIPS TO REMEMBER: THE DO’S AND DON’TS:

Do follow your doctor and heart failure specialist nurse’s recommendations
Do start exercising slowly and gradually build up your activity
Do try to have a regular routine so exercise becomes a part of your lifestyle
Do involve your friends and family such as walk in the park at the weekend
Do monitor your weight. It can be helpful to keep a diary and bring to your appointments. One is included at the end of this leaflet
Do increase the proportion of healthy food options in your day-to-day diet
Don’t worry if you have a period of inactivity. . Start again, begin slowly and build up once more
Don‘t exercise if you are unwell or experiencing chest pain, increased breathlessness, dizziness or palpitations
Don’t engage in static activity e.g. pushing cars, moving heavy furniture or lifting weights above your head
Don’t immediately exercise after meals (allow 1½ to 2 hours) or if the weather is very hot or humid
Do contact your doctor or heart failure specialist nurse if you are concerned about any changes in your condition

When to call for help or contact your specialist

Some symptoms need prompt reporting to your doctor or heart failure specialist nurse.

You can reduce the chances of being admitted to hospital by being aware of the following earning signs:

Sudden weight gain: 3-5lbs (1-2.5Kgs) over one to three days
Increased breathing difficulties – especially at night and not related to exercise
Increased leg swelling
Increases swelling in abdomen or a feeling of fullness
A frequent dry, hacking cough
Any side effects from your medications

You should call an ambulance if:

You have severe breathlessness at rest
You are experiencing angina which is not relieved by GTN spray

If you are unsure as to what to do call you can contact an NHS advisor by ringing 111 (24 hours a day) who will give you further advice.

Weight Diary

Table to record your weight

Useful contacts

British Heart Foundation - www.bhf.org.uk
BHF Heart Helpline: 0300 330 3311

Cardiomyopathy Association - www.cardiomyopathy.org

Pumping Marvellous support group - https:// pumpingmarvellous.org/

Practical information on heart failure for patients and carers: www.heartfailurematters.org

DVLA - drivers’ medical enquiries: online via direct.gov or telephone: 0300 790 6806

Citizens Advice Bureau - Advice line telephone: 0845 120 3703
www.citizensadvice.org.uk

Direct Government

Portal to public service information from the UK government, including directories, online services, news and information of relevance to specific groups:
www.direct.gov.uk/disability
www.direct.gov.uk/carers

NHS Talking Therapies (previously known as Healthy Minds):

Pennine Care NHS Talking Therapies (previously Healthy Minds) - Pennine Care NHS Foundation Trust

Bury Live Well Service - Bury Council Directory of services - Living Well Rochdale

Your Health Oldham – If you live in Oldham, we can help you with health issues including smoking, alcohol, weight management and exercise

Heart Failure Specialist nurses:
Fairfield General Hospital - 0161 778 2450
Royal Oldham Hospital - 0161 627 8059
Oldham Community - 07977 343 616
Rochdale Infirmary - 0161 778 2450

Smoking cessation:
Bury - 0845 223 9001
Oldham - Positive Steps 0800 288 9008
Rochdale - Living well 01706 751 190

Date of Review: March 2023
Date of Next Review: March 2025
Ref No: PI_M_511 (BRO)