Heart Failure: Symptoms, Causes, Types, and the Link With Irregular Heartbeat

Heart failure does not mean your heart has stopped or is about to stop [1][14]. It means the heart cannot pump enough blood to meet the body's needs, either because it cannot fill properly or because it is too weak to pump well [1]. It is still a serious condition that needs medical care [1]. Heart failure can come on suddenly or develop over time, and it can affect one or both sides of the heart [1].

When to Get Help

In the UK, the NHS says call 999 if someone has severe difficulty breathing, such as gasping, choking or being unable to get words out. It also says call 999 if their lips or skin are pale, blue or grey, or if they have passed out and are not responding normally [14]. On brown or black skin, colour changes may be easier to see on the palms, soles of the feet or gums [14]. The NHS advises not driving yourself to A&E [14].

The NHS says to ask for an urgent GP appointment or contact NHS 111 if you feel breathless when lying down or during everyday activities, are coughing up frothy pink phlegm, or have suddenly gained weight [14]. For a fast or irregular heartbeat with symptoms such as chest pain, fainting or confusion, the NHS has separate 999 guidance [15]. Rhythm warning signs are explained in Irregular Heartbeat: Causes, Symptoms, and Treatment Options.

In the US, the American Heart Association (AHA) says heart failure with fluid build-up requires quick medical care, and that untreated fluid in the lungs can cause breathing distress [9]. The National Heart, Lung, and Blood Institute (NHLBI) notes that symptoms can suddenly get worse, and that weight gain, ankle swelling or increasing shortness of breath may mean fluid is building up. It advises asking your provider when to book a visit and when to get emergency care [5].

Symptoms of Heart Failure

Most heart failure symptoms come from two problems: the body not getting enough blood, and fluid backing up into the lungs and tissues [10]. Common signs include [2][7][10][14][18]:

• Breathlessness. At first it may come only with activity such as climbing stairs. As the heart weakens it can come with getting dressed, walking across a room, or lying flat [2]. The AHA notes it can wake people at night and they may need several pillows to sleep [10].
• Coughing. The NHS lists coughing at night and coughing up frothy pink phlegm [14]. The AHA describes a persistent cough or wheezing with white or pink, blood-tinged mucus [10].
• Swelling. Feet, ankles, legs or tummy may swell, and some people feel bloated or full [14][18].
• Sudden weight gain, often from fluid [7][14].
• Tiredness and weakness, especially after moving, and feeling light-headed or dizzy [14].
• Loss of appetite or nausea [10].
• Confusion or memory problems, which a relative or carer may notice first [10].

The NHS says symptoms can vary from day to day and week to week [14]. The NHLBI notes that mild heart failure may cause no symptoms except during hard physical work, and that symptoms usually worsen as the heart weakens [2]. The AHA advises reporting any of these symptoms to a healthcare professional and asking for a heart check, even if you have never been told you have a heart problem [10].

Symptoms by Side of the Heart

The NHLBI links breathing trouble, cough, extreme tiredness, bluish fingers and lips, sleepiness and trouble concentrating, and being unable to sleep flat to the left side [2]. When the right side is affected, it adds nausea, belly pain, swelling that can reach the abdomen and neck veins, needing to pee often, and weight gain [2]. People can have symptoms of both [2].

Older Adults

The NHLBI says older adults who are not very active may not notice shortness of breath, but may feel tired and confused instead [2].

Types of Heart Failure

Ejection Fraction

Doctors often describe heart failure by ejection fraction, the share of blood the main pumping chamber pushes out with each beat. The AHA gives a normal figure of about 55% to 60% [9]. US and UK bodies use similar bands [4][9][16]:

• Reduced ejection fraction: 40% or less. The left side is weak and cannot pump enough blood [3][9].
• Mildly reduced ejection fraction: 41% to 49%, the term used by NICE and the AHA. The NHLBI calls this band "borderline" [4][9][16].
• Preserved ejection fraction: 50% or more. The left side is too stiff to relax and fill properly between beats [3][9]. NICE also requires signs of a structural problem in the heart for this diagnosis, so it is confirmed by an echo and other findings, not the number alone [16].

The NHLBI notes that women more often have the preserved type and men the reduced type, that men tend to develop heart failure younger, and that women often have worse symptoms [3].

Left, Right, or Both Sides

The NHLBI says left-sided heart failure is more common, and is the main cause of right-sided failure [3]. Other causes of right-sided failure include congenital heart defects, valve problems and lung diseases such as COPD [3]. When the right side loses pumping power, blood backs up in the veins [9]. When both sides are affected, the AHA notes symptoms of each can appear [9].

What "Congestive" Means

The term is used differently. The NHLBI treats congestive heart failure as another name for heart failure [1]. The AHA uses it for heart failure that includes fluid build-up in the body [9].

Causes and Risk Factors

The AHA says most people who develop heart failure have, or have had, another heart condition first, and that having more than one risk factor greatly increases risk [11]. Heart failure can follow a sudden event, such as a heart attack or infection, or long-term strain from conditions like high blood pressure [14].

Main Conditions

Common conditions behind heart failure include [3][7][11][14][18]:

• Coronary heart disease and heart attack. A heart attack damages muscle so it does not contract as well [11].
• High blood pressure. It makes the heart pump harder, and over time the chambers can become larger and weaker [11].
• Heart valve disease, which makes the muscle work harder [11].
• Cardiomyopathy, or disease of the heart muscle [14].
• Diabetes and obesity, which the NHLBI links to stiffer heart chambers [3]. See Diabetes and Heart Disease: The Cardiovascular Connection.

Other Conditions

Heart failure is also linked to chronic kidney disease, anaemia, too much iron in the body, thyroid problems, sleep apnea, serious lung disease, myocarditis, congenital heart defects, and infections including HIV and the virus that causes COVID-19 [3][11][14]. Some cancer treatments, including radiation and chemotherapy, can injure the heart [3][11].

The NHLBI notes that certain medicines can worsen heart failure symptoms, and advises telling your provider and pharmacist about everything you take [5].

Lifestyle, Age, and Family History

Smoking, heavy alcohol use, cocaine or other illegal drugs, being overweight, inactivity and diets high in saturated fat, cholesterol or salt can all raise risk [3][7][11][14]. The World Health Organization (WHO) notes that these habits show up as raised blood pressure, blood sugar, blood fats and weight, which signal a higher risk of heart failure, heart attack and stroke [17].

Risk rises from age 65, according to the NHS, NHLBI and AHA [3][11][14]. The NHS also lists pregnancy [14]. The NHLBI says a family history of heart failure raises risk, and some gene changes can make heart tissue weaker or less flexible [3].

In US data, the NHLBI says Black and African American people are more likely to develop heart failure, often at a younger age and more severely [3]. The AHA puts their risk at about 19% higher than white people's, and says research on Hispanic people suggests increased risk [11].

Heart Failure and Irregular Heartbeat

Heart failure and heart rhythm problems are closely tied, and each can lead to the other.

A rhythm problem can cause heart failure. The NHS lists heart rhythm problems as a possible cause [14], and the NHLBI says that most often, heart failure is caused by another medical condition that damages your heart, which includes an irregular heartbeat [1]. The NHLBI names atrial fibrillation (AFib), a common irregular rhythm, as one cause [3], and warns that untreated AFib can lead to heart failure [6]. The AHA explains that in AFib the heart may beat so fast or unevenly that it never fills properly, so blood can back up into the lungs and fluid can collect in the legs [12]. It also notes that, less commonly, a rhythm that is too fast, too slow or irregular can leave an otherwise healthy heart temporarily unable to keep up, until the rhythm problem is found and treated [11].

Heart failure can cause a rhythm problem. The NHLBI lists irregular heartbeat among the heart conditions heart failure can lead to [1], and the NHS lists heart failure as a possible cause of AFib [15].

The symptoms overlap. The NHS lists tiredness, finding exercise harder and breathlessness for both conditions [14][15]. The AHA notes that a faster heartbeat, felt as palpitations, can itself be a heart failure symptom, as the heart speeds up to make up for weaker pumping [10]. So if you already have an irregular heartbeat, new or worsening breathlessness, swelling or tiredness is worth reporting to your doctor [10].

For rhythm types, tests and treatment, see Irregular Heartbeat: Causes, Symptoms, and Treatment Options, Atrial Fibrillation (AFib): Symptoms, Causes, Stroke Risk, Diagnosis, and Advanced Treatment and Heart Palpitations: Causes, Symptoms, and When to Worry.

Complications

The NHLBI says heart failure can damage the liver or kidneys, cause fluid to build up in or around the lungs, and lead to malnutrition, high blood pressure in the lungs, leaking valves and sudden cardiac arrest [1][2]. It also notes that heart failure often gets worse over time, even with treatment [5].

Heart Failure in Children and Teens

The AHA says heart failure in children is very rare and has different causes than in adults [13]. It is most often due to a heart defect present from birth. Other causes include infections that damage the heart muscle, some treatments for other conditions such as cancer, irregular heartbeats, valve defects, muscular dystrophy, Kawasaki disease and some genetic disorders [13].

The AHA lists signs in babies as breathing trouble, poor feeding, poor growth, heavy sweating, swelling, and fast or laboured breathing [13]. Older children and teens may tire quickly, pee more at night, lose their appetite, cough, gain weight or become short of breath [13]. If you notice these signs, see your child's doctor. The AHA says many causes can be fixed or managed, and that with proper care most children with heart failure grow up to lead active lives [13]. NICE's heart failure guideline covers adults only [16].

Outlook and Lowering Risk

There is no cure, but the NHS says treatment can ease symptoms and help keep heart failure stable for many years [14], and the NHLBI says lifestyle changes, medicines, devices and procedures help many people have a better quality of life [1]. The AHA says some people may reach remission with treatment and healthy lifestyle changes [8]. The CDC adds that early diagnosis and treatment can improve quality and length of life [7]. In the UK, the NHS says everyone diagnosed should be offered cardiac rehabilitation [14].

To lower risk, the NHLBI recommends heart-healthy eating, a healthy weight, regular activity, not smoking, limiting alcohol and managing diabetes, high blood pressure and obesity with your provider. It notes that the sooner you start, the better your chances of preventing or delaying heart failure [3]. A JAMA patient page also lists treating high cholesterol, abnormal heart rhythms and sleep apnea [18].

Conclusion

Breathlessness that is new or getting worse, swelling that does not go away, or weight that goes up suddenly are worth raising with a doctor rather than putting down to age or being out of shape. If you already live with a heart condition, keeping a simple record of your weight and symptoms gives your care team something concrete to work with.

Medical Disclaimer

This article is for general information and does not replace advice from a qualified health professional. If you or someone with you is struggling to breathe, get emergency help straight away.