Left- vs. Right-Sided Heart Failure: Know the Differences
Treatment Options When Heart Failure Worsens
By Michael Balk, MD, as told to John Donovan
When we talk about heart failure, the first thing I do with people is ask a number of questions about diet and other potential conditions that may cause the heart failure. The most common probably is high blood pressure. Then there's coronary disease. Diabetes. Some viruses can affect the heart. Obesity probably has a big role. Sleep apnea is super common.
We have important data that these comorbidities -- conditions that are present with another condition -- affect the survival rates of people with heart failure. If you treat the obesity, treat the sleep apnea, treat the high blood pressure, you're likely to live longer.
So we have to go through all the sort of "normal" things that can cause heart failure. And there are some conditions that we call restrictive cardiomyopathies, too, buildup of materials inside the heart. Those are much more rare. (A cardiomyopathy is simply a disease of the heart.)
Once we determine causes, then we can get a better idea of treatment.
Different PathsWe break treatment down into categories. First, there's going to be the lifestyle modification category. Then there's the medication category. In particular, we use the term "Guideline Medical Therapy" to describe medications that have clearly been shown to improve survival, make people live longer, and lower the chances of hospitalization. In fact, doctors are held to a standard in prescribing these medications, for a reason: They work.
After that, we have more advanced therapies to prevent arrhythmias, or irregular heart rhythms. Those include things like defibrillators and pacemakers. And we have newer devices that weren't available 20 years ago that can make people with weak hearts get better, if they have a particular type of heart disease called left bundle cardiomyopathy.
We also have advanced treatments which include:
Sometimes we do those as a bridge to transplants, sometimes it's what we call destination therapy (when you're not a candidate for transplant). We might put one of these devices in, or give you a home infusion through an IV to keep you feeling well.
But it all starts with lifestyle.
A Change in How You LiveDiet is so important. Of course, how much salt you eat is the big one. We have a sort of general limit of 1,500 milligrams of sodium that we want people on. Lowering the salt lowers the amount of fluid that stays inside your body, lowers blood pressure, and makes it easier for your heart to pump blood.
Then, of course, there's exercise.
You think, "How does exercise work?" Well, when you think about heart failure, it's a supply-demand imbalance. Your heart can't pump enough blood for your body's needs. But if you can make your body more efficient, you can get by with less.
It's no different than when we made cars smaller. You can't put a 4-cylinder engine in a big old Cadillac and expect it to have enough power. If you have a heart that's pumping half as strong, it's analogous to running a 4-cylinder engine in a big car from the 1960s. It doesn't work so well. So if we work on doing more activity, we can make you more efficient and make a lot of progress there.
Once we talk about the initial sort of lifestyle things, we're going to go over what you need to do every day like:
There are many types of medicines that doctors use to treat heart failure, including:
Diuretics help the body get rid of salt and water. They probably don't do much in terms of survival. They're there to treat the symptoms, to make you feel better. But many times we administer other medicines to make the heart stronger, and we won't have to give them as much diuretics.
We have a whole host of other medications that have just made a dramatic change. When I was a med student 35 years ago, you would never give a beta blocker to someone with heart failure. Never. It was thought they made hearts weaker. Well, it turns out blocking adrenaline, which is what a beta blocker does, actually improves survival. It makes the heart stronger, because blocking the adrenaline calms the heart down.
A medicine came out a number of years ago called carvedilol, which was just a life-changer when it came to heart failure. I can vividly remember in the early '90s giving medications like this thinking, "This makes no sense whatsoever." Ultimately, it became standard of care.
Only three beta blockers are what we consider Guideline Therapy. They work. Each has been shown independently to improve survival, make people live longer, make them feel better, and decrease their rate of re-hospitalization:
ACE inhibitors, and their sisters ARBs, lower blood pressure and make it easier for the heart to pump blood forward. We call that "unloading the heart." Those medicines, for probably 30 years now, we've known that they improve survival, make people live longer, and actually can make the heart shrink in size and can prevent the heart from getting worse.
Those medicines led to a newer medicine called a neprilysin inhibitor. It can lower blood pressure, and really improve how your heart works. It's pretty striking.
A couple more show some benefit. But these are the mainstays of therapy.
Remember, too, not all drugs are the same. There's actually another set of combinations of medicines that you can use instead of ACE inhibitors called hydralazine and nitrates. Those seem to do well with African Americans. Oftentimes, depending on the person, we basically customize their medical therapy.
Surgical OptionsWhen you're talking about treatment, if your heart failure is due to a bad valve or a blockage, obviously we work on that, too. That's where surgery, say a valve replacement or an angioplasty, will sometimes help.
We can put in a pacemaker to control irregular heart rhythms. That can help. Implanted defibrillators, in most cases, are there to prevent sudden death. They monitor irregular heartbeats and can provide an electrical shock to fix them. But they don't actually make your heart stronger. There is a type of defibrillator we have now, a bi-ventricular pacemaker defibrillator (BiVICD, or biventricular implantable cardiac defibrillator), used for a specific kind of heart failure, that can improve sudden death rates and sometimes help your heart work better.
When you get to the next phase -- LVADs (the left ventricular assist devices) -- that's a big deal. You have to go inside the heart, you have to open the chest, etc. But, again, for people that are failing all the other things, that's an option, before a transplant.
Hope for Those With Heart FailureJust in the last 30 years, there's been a fundamental change in how we approach heart failure, especially with respect to beta blockers. Seeing the heart work better … it used to blow our mind when we'd see an ejection fraction (a measurement of how well the heart is working) of 5 or 10%, something really bad. Then you put them on these medicines and we'd check back in 6 months and it's normal. That's so cool. And the heart shrinks. It starts off big and gets smaller. It gets better.
Wow.
There's lots of great stuff that we can do to make people feel better and live longer. And I think that's the important thing: that people should not give up hope. It's totally encouraging.
Congestive Heart Failure And Heart Disease
Heart failure is when your heart can't pump enough blood to provide your body with the blood and oxygen it needs. If you have this condition, it doesn't mean your heart stops working. It means your heart doesn't work as efficiently as usual. Blood moves through your heart and body at a slower rate, and pressure in your heart raises.
The condition affects nearly 7 million Americans. About 1 in 4 people will get diagnosed with it in their lifetime. Heart failure is the main reason why people older than 65 go to the hospital.
An irregular heartbeat may be a symptom of heart failure. (Photo credit: E+/Getty Images)
Heart failure pathophysiology
Pathophysiology is the process that leads to heart failure. When your heart doesn't pump strongly enough, your body adapts so it can meet your body's need for blood.
The chambers of the heart may stretch so they can hold more blood to pump through your body. Or the heart muscle gets stiff and thicker to keep the blood moving. Over time, the extra work causes cells in the heart to die. The heart muscle walls get weaker and are less able to pump.
When your heart doesn't work well, your body releases hormones that narrow your blood vessels and make your kidneys hold onto more fluid (water) and salt. The extra fluid and salt raise your blood pressure and make your heart work even harder. Fluid builds up in your arms, legs, ankles, feet, lungs, or other organs. Doctors call this condition congestive heart failure.
In time, your heart gets so weak that it can't pump enough blood to meet your body's needs. That's heart failure.
Heart failure vs. Heart attack
Heart failure is different from a heart attack.
During a heart attack, a blood clot or the buildup of a sticky substance called plaque in your arteries blocks blood flow to your heart. Without oxygen, part of the heart muscle begins to die. You need quick treatment to open up the blocked blood vessel and restore blood flow to the heart.
Heart failure is a slower process. Your heart gradually becomes damaged from working too hard. Over time, it becomes less able to pump enough blood out to meet your body's needs.
Heart failure is caused by many conditions that damage the heart muscle, including:
You may not have any symptoms of heart failure. If you do have symptoms, they might be constant or come and go. They can be so mild you barely notice them or severe enough to affect your daily life.
Early signs of heart failure in adults
Look for these five early warning signs of heart failure:
Other heart failure symptoms include:
Heart failure can affect the left side of the heart, the right side of the heart, or both sides. Doctors also classify heart failure based on how well the heart can still pump.
Left-sided heart failure. This is the most common type. The left side of the heart, called the left ventricle, does most of the pumping. In left-sided heart failure, the left ventricle can't pump as much blood. The extra blood pools in the pulmonary veins—blood vessels that carry blood away from the lungs.
Doctors divide left-sided heart failure into two types based on the heart's pumping ability:
Systolic heart failure happens when the heart muscle doesn't contract with enough force to pump enough blood out to the body. Another name for this is heart failure with reduced ejection fraction (EF). EF measures how well your heart pumps with each beat.
Diastolic heart failure is when the heart contracts normally, but the ventricles don't relax properly or are too stiff. Less blood can fill the heart. Another name for this is heart failure with preserved EF.
Your doctor can tell you which of these conditions you have.
Your doctor will ask questions like these about your medical history:
Your doctor will also ask about your symptoms and do a physical exam. They will listen to your heart and look for signs of heart failure. And they will check for other illnesses that may have made your heart muscle weak or stiff.
Your doctor may also order tests like these to find the cause of your heart failure and to see how severe it is:
There are more treatment options available for heart failure than ever before. Lifestyle changes, medication, and careful monitoring are the first steps. If the condition gets worse, you may need to see a doctor who specializes in treating heart failure.
The goals of heart failure treatment are to prevent it from getting worse, relieve symptoms, and improve your quality of life.
Your doctor might first recommend lifestyle changes like these for early-stage heart failure:
Some common types of medicines used to treat heart failure are:
Your doctor may also recommend a program called cardiac rehabilitation to help you exercise safely and keep up a heart-healthy lifestyle. This program usually includes workouts that are designed just for you, along with advice to help you quit smoking and change your diet.
Cardiac rehab also offers emotional support. You'll meet other people with heart failure who can help you stay on track.
If those treatments don't work, you may need one of these procedures:
Coronary bypass surgery to route blood around a blocked artery.
Heart valve repair or replacement to fix or repair a damaged valve in your heart.
Implantable cardioverter defibrillator to put your heart back into a normal rhythm if it goes out of rhythm.
Cardiac resynchronization therapy, also called a biventricular pacemaker, to help your two lower heart chambers pump blood at the same time.
Ventricular assist device to pump in place of your heart until you can have surgery to fix the problem.
A heart transplant is an option for people with very severe heart failure who haven't improved with surgery or medicine. The surgeon replaces your damaged heart with a healthy heart from a donor.
Can heart failure be reversed?
That depends on the cause. Doctors consider heart failure reversed when the EF goes back to normal.
Some of the conditions that cause heart failure improve on their own, such as:
You may be able to bring the EF to normal if you:
The longer you've had heart failure and the more damage there is to your heart, the harder it is to reverse. A heart transplant may be the only way to reverse severe heart failure.
Heart failure often progresses or gets worse over time.
The American Heart Association and American College of Cardiology divide heart failure into four stages, based on how severe it is. Your doctor will recommend treatments for your stage of heart failure.
In the early stages, lifestyle changes like diet and exercise plus medication may be enough to treat heart failure. Later stages may need surgery or a heart transplant to correct.
Stage A. You're at a risk of heart failure because of a condition like high blood pressure, diabetes, or blood vessel disease. But you don't have any symptoms or problems with your heart.
Stage B. You don't have symptoms, but you do have raised pressure in your heart or problems with your heart's structure.
Stage C. You have or have had symptoms of heart failure.
Stage D. Your heart failure symptoms are severe enough to get in the way of your daily life or put you in the hospital.
The New York Heart Association divides heart failure into four categories based on how much it affects your activity level:
Class 1. Heart failure doesn't affect your activity.
Class 2. Heart failure slightly limits your activity. You have symptoms like tiredness, shortness of breath, heart palpitations, or chest pain when you do daily activities.
Class 3. Heart failure noticeably limits your activities. Even mild activity causes tiredness, shortness of breath, heart palpitations, or chest pain.
Class 4. You have heart failure symptoms even when you're at rest.
Follow these tips to protect your heart and slow heart failure:
Treat high blood pressure. In heart failure, blood vessels narrow. Your heart must work harder to pump blood through those narrowed vessels. It's important to keep your blood pressure controlled so that your heart can pump more effectively without extra stress.
Monitor your symptoms. Weigh yourself every day and check your body for swelling. These are signs that you're holding onto fluid. Call your doctor if you gain 3 pounds in 1 day or 5 pounds in 1 week or if you notice any swelling.
Keep a balance of fluids. Your doctor may ask you to write down how much fluid you drink and how often you go to the bathroom. The more fluid you carry in your blood vessels, the harder your heart must work to pump the extra fluid through your body. You may need to reduce the amount of fluid you drink to lower your heart's workload and prevent heart failure symptoms.
Limit salt (sodium). Sodium is naturally in some foods and added to others for flavor or to make food last longer. If you follow a low-sodium diet, you should retain less fluid, have less swelling, and breathe more easily.
Be aware of new or worsening symptoms. Call your doctor if you have new symptoms or if the symptoms you had get worse.
Take your medications as prescribed. Medicines improve your heart's ability to pump blood, lower stress on your heart, slow heart failure, and prevent your body from holding onto fluid. Heart failure drugs help your blood vessels widen and relax, which lowers blood pressure.
Schedule regular doctor appointments. During follow-up visits, your doctors will make sure that you stay healthy and your heart failure doesn't get worse. They will go over your weight and list of medications. If you have questions, write them down and bring them to your appointment. Call your doctor with any urgent questions between visits. Notify all your doctors about your heart failure, medications, and any restrictions. Also, check with your heart doctor about any new medications prescribed by another doctor. Keep good records and bring them with you to each doctor visit.
In an effort to prevent further heart damage:
How can I prevent further damage to my kidneys?
Heart failure raises your risk of chronic kidney disease. Your damaged heart sends less blood to your kidneys. Without oxygen-rich blood, your kidneys can't filter your blood as well. Heart failure and kidney disease also share risks like diabetes and high blood pressure.
These are some ways to protect your kidneys:
A few medications can cause problems for people with heart failure, including:
If you take any of these drugs, discuss them with your doctor.
It's important to know the names of your medications, what they're used for, and how often and at what times you take them. Keep a list of all your medications and bring them with you to each of your doctor visits.
Don't stop any heart failure medication without first talking to your doctor. Even if you have no symptoms, your medications lower your heart's workload so that it can pump better.
There are several things you can do to improve your quality of life if you have heart failure. Among them:
Heart failure diet
A few changes in your diet can reduce the workload on your heart and help improve your symptoms.
In heart failure, surgery may sometimes prevent further damage to the heart and improve the heart's function. Procedures used include:
Heart failure management is a team effort, and you are the key player on the team. Your heart doctor will prescribe your medications and manage other medical problems. Other team members—including nurses, dietitians, pharmacists, exercise specialists, and social workers—will help you achieve success.
If you notice anything unusual, don't wait until your next appointment to discuss it with your doctor. Call them right away if you have:
Go to the ER or call 911 if you have:
With the right care, heart failure may not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.
Everyone with a long-term illness such as heart failure should discuss their desires for extended medical care with their doctor and family. An advance directive or living will is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are fully competent in case you are unable to make these decisions at a later time.
About one-quarter of Americans will develop heart failure in their lifetime. Conditions like high blood pressure, diabetes, and CAD raise the risk. If your doctor has diagnosed you with heart failure, make sure you are on a treatment plan and that you follow your doctor's advice to protect your heart from further damage.
Around half of people with congestive heart failure live for at least 5 years. How long you live depends on how severe your heart failure is and how you treat it.
Top Heart Disease Treatment And Prevention Advancements In 2023
As 2023 comes to a close, cardiologists are reflecting on some of the advancements and breakthroughs in their field over the past 12 months.
Heart disease is a pressing issue in the United States. The American Heart Association reports that more than 130 million adults (about 45.1% of the population) will develop some form of cardiovascular disease by 2035, which will lead to $1.1 trillion in projected total costs.
This reality means researchers and clinicians are invested nationwide in developing better interventions and treatments to address the rising prevalence of heart disease among Americans.
To put in perspective how serious this is, heart disease stands as the leading cause of death regardless of gender and spans most racial and ethnic groups in the United States, according to the Centers for Disease Control and Prevention (CDC).
Heart disease kills one person for every 33-second interval nationwide.
Healthline spoke with several experts who weighed in on the major breakthroughs and innovations of the past year as well as promising developments on the horizon in 2024.
Dr. Joseph C. Wu, Ph.D., FAHA, American Heart Association president and director, Stanford Cardiovascular Institute and Simon H. Stertzer Professor of Medicine & Radiology at Stanford School of Medicine, said that glucose-lowering drugs have been a game changer for people with type 2 diabetes, helping them to reduce cardiovascular events and improve their heart health.
Research is now suggesting these same drugs may also improve heart health in people with obesity who aren't also living with diabetes.
"In one trial of semaglutide, a medication shown to lower the risk of heart problems in people with diabetes and approved for long-term weight management, people with heart failure with preserved ejection fraction and obesity fared better on the drug than on placebo," Wu said.
What is preserved ejection fraction?
Wu explained that this happens "when the heart muscle becomes thick and stiff and can't pump out enough blood to meet the body's needs."
"The semaglutide group had greater reductions in heart failure-related symptoms, greater improvements in the ability to exercise and greater weight loss," he added.
Wu also singled out a late-breaking trial of the GLP-1 (glucagon-like peptide 1) receptor agonist drug that was presented at the American Heart Association's Scientific Sessions 2023.
In that trial, researchers looked into whether semaglutide benefitted people who are living with overweight or obesity who did nothave diabetes, but who had cardiovascular disease.
The findings show that the drug was "superior to placebo in reducing cardiovascular-related death, nonfatal heart attacks, and nonfatal strokes," Wu told Healthline.
Dr. Steven Nissen, a cardiologist at Cleveland Clinic, pointed to a different type 2 diabetes medication that he said is also a "blockbuster" — tirzepatide.
He cited findings released this year that showed thecardiovascular benefits of the dual-acting GIP and GLP-1 agonist, which was originally made available solely for diabetes under brand name Mounjaro, and was recently approved for weight loss and the treatment of obesity under the name Zepbound.
"We've had these drugs, but we didn't really know whether they'd have a favorable effect on cardiovascular outcomes on people who are being treated for obesity," he said.
The research conducted on this drug had a "very robust result," Nissen stressed.
It was shown to have a 20% reduction in body weight for people who were overweight, while showing clear, "promising hard endpoints" of lower risk of cardiovascular death, stroke, myocardial infraction, or heart attack.
"That's a big reduction, it's a turning point in the battle against obesity," he added.
Dr. Karol Watson, PhD, an attending cardiologist and a Professor of Medicine/Cardiology at the David Geffen School of Medicine at UCLA, said all of the big 2023 developments in cardiovascular health center on preventive measures for lipid and hypertension management.
Watson, who is also the director of the UCLA Women's Cardiovascular Health Center, the UCLA-Barbra Streisand Women's Heart Health Program, the co-director of the UCLA Program in Preventive Cardiology, and director of the UCLA Fellowship Program in Cardiovascular Diseases, told Healthline that the big goal is "trying to figure out how to get people to take their medications in the least invasive way possible."
Watson said that, traditionally, you had daily pills people would take or injectables they would have to receive every two weeks. Today, there are more options.
"Now, there is data on the injectables people can do every every six months. Now, there are longer gaps [between injections]. The whole idea is one and done and doing something people will find easier for them. And, it works," Watson explained. "The problem is, these things are not going to be cheap."
The findings of the drug zilebesiran, which showed the potential to lower pressure with an injection every six months, were presented at the American Heart Association's Scientific Sessions 2023.
Watson added that this kind of injectable "makes it easy for people to get the medication they need." She reiterated a big problem persists.
"These [medications] are easy, you have one injection every six months," she said, "but they are not cheap. That is the problem."
Wu pointed back to the 2023 Scientific Statement from the American Heart Association, which offers a summary of cardiovascular-kidney-metabolic (CKM) syndrome. He said this is "an interconnection between obesity, chronic kidney disease, diabetes, and cardiovascular disease, which is linked to premature death and disability."
He said concretely pointing out this relationship is one of the big cardiovascular headlines of the year.
"The statement summarizes what is known about CKM syndrome and how to prevent and manage it. It highlights a new way to calculate risk of the syndrome, as well as gaps in knowledge and needed research," Wu added. "An accompanying Presidential Advisory helps define CKM syndrome and offers guidance on the prevention and treatment of the syndrome across different clinical and community settings."
Wu pointed to research on endovascular thrombectomy, a minimally invasive surgical procedure used to remove a stroke-causing blood clot from an artery in the brain, as another one of 2023's big stories.
This procedure restores blood flow and prevents further brain damage and disability. It's the standard form of treatment for either small or medium-sized strokes.
"Until now, it wasn't clear if endovascular thrombectomy would also benefit people with larger, more severe strokes, which account for up to one-fourth of all strokes.
In a study of people with severe strokes from China and in another trial of people in North America, Europe, Australia, and New Zealand, researchers found endovascular thrombectomy within 24 hours of a stroke was superior to standard medical care," Wu said.
This research showed that these individuals who received this treatment showed signs of experiencing fewer disabilities and "were more functionally independent during the three months after treatment."
He pointed to a third study of those treated for severe stroke in Europe and Canada who showed similar outcomes.
"Those who underwent endovascular thrombectomy were more functionally independent than those who had standard medical treatment, alone. This study also showed that thrombectomy patients were less likely to die," Wu added.
What do these experts see in the year to come? All three cited innovations in gene editing.
Watson said "we are starting to see the era of gene editing."
She pointed to research out of New Zealand that shows, for the first time, gene editing technology can reduce low-density lipoprotein (LDL).
"What we've seen in this small proof of principle study, what we've seen in these first 10 patients, is that [we saw] durable LDL reduction, but of the 10 patients, two of them had very serious adverse events — one died and one had a heart attack, so the questions of safety will always persist," she added.
Watson and Wu said that, even more promising, is the FDA approval of a cure for sickle cell disease that harnessed the same CRISPR gene-editing technology. The approval of Casgevy is a major breakthrough — the first medicine that utilizes CRISPR to receive U.S. Approval, according to NBC News.
Nissen pointed to the number of drugs in development for treating lipoprotein (a), or Lp(a), as a development to keep front and center for the coming year. He said "this is a condition, which is a heart disease risk factor in 20 percent of the population that has never been treatable."
Now, what is known as RNAi, or RNA interference, is being utilized to reduce Lp(a). Nissen said he and his team have published several articles on these new therapies, and one of them involves a clinical trial for a drug called pelacarsen, which he is chairing.
This study has enrolled 8,300 patients and "is now well along toward completion," he said.
"If successful, it will be the first time ever that we can treat this disorder, everyone is waiting for the results of the trial," he said.
Additionally, beyond these innovations, Wu said he's excited about the FDA Modernization Act 2.0, which opens the door for moving beyond mandatory animal testing and toward a new era of using stem cells, organoids, artificial intelligence and machine learning, and in computer models for drug discovery.
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