Left-sided heart failure

Left-sided heart failure is a type of heart failure that affects the lower left heart chamber, called the left ventricle. That chamber is the heart's main pumping chamber. In this condition, the chamber cannot pump blood well or cannot fill as it should between heartbeats. When the chamber doesn't work well, pressure can build up behind the left side of the heart and in the lungs.

Some heart conditions slowly leave the heart too weak or stiff to fill and pump blood properly. These conditions include narrowed arteries in the heart and high blood pressure.

Treatment may improve the symptoms of left-sided heart failure and may help some people live longer. Lifestyle changes can improve quality of life. Try to manage your weight, exercise, use less salt and manage stress.

But left-sided heart failure can be life-threatening. It can cause serious symptoms. Some people with left-sided heart failure may need a heart transplant or a device to help the heart pump blood.

Left-sided heart failure is sometimes called left-sided congestive heart failure when it causes fluid buildup known as congestion. Not all left-sided heart failure is congestive heart failure.

Types

In left-sided heart failure, the left ventricle has either trouble pumping blood out or has trouble filling with enough blood between heartbeats. Either type can cause symptoms of left-sided heart failure and may need different treatments.

• Heart failure with reduced ejection fraction (HFrEF), also called systolic heart failure. The left ventricle does not squeeze as hard as it should. The heart isn't strong enough to pump enough blood to the body.
• Heart failure with preserved ejection fraction (HFpEF), also called diastolic heart failure. The left ventricle may squeeze well but be too stiff to fill enough between heartbeats.
• Heart failure with improved ejection fraction (HFimpEF), formerly called heart failure with recovered ejection fraction (HFrecEF). In this subtype of left-sided heart failure, the ejection fraction was reduced in the past but has improved. This means a low ejection fraction is not always permanent. But heart failure can come back, so treatment usually needs to continue.

Left-sided heart failure differs from right-sided heart failure, which affects how the heart pumps blood to the lungs. Over time, left-sided heart failure can lead to right-sided heart failure.

Symptoms of left-sided heart failure can come on slowly or suddenly. They may include:

• Shortness of breath during activity or when lying down.
• Tiredness and weakness.
• Swelling in the feet, ankles or legs. This is more likely if heart failure affects both sides of the heart.
• A fast heartbeat or one that isn't regular.
• Less ability to exercise or do usual activities.
• A cough or wheezing that doesn't go away.
• Quick weight gain due to fluid buildup.

When to see a doctor

See your healthcare professional if you get new symptoms that could be linked to heart failure.

Call your healthcare professional right away if you have heart failure and:

• Your symptoms suddenly get worse.
• You have a new symptom.
• You gain 5 pounds (2.3 kilograms) or more within a few days.

Such changes could mean that existing heart failure is getting worse or that treatment isn't working.

When to seek emergency care

A sudden buildup of fluid in the lungs is called pulmonary edema. Pulmonary edema is a medical emergency. Call 911 or emergency medical help if you have sudden, serious shortness of breath and are coughing up white or pink foamy mucus.

A condition that damages the left ventricle or makes it work harder over time can cause left-sided heart failure. Common causes include:

• Coronary artery disease. Narrowed heart arteries can reduce blood flow to the heart muscle and weaken its pumping ability.
• Heart attack. A heart attack can damage part of the left ventricle and make it harder for the heart to pump blood.
• High blood pressure, also called hypertension. Over time, the left ventricle may thicken or stiffen as it works harder to pump blood against higher pressure.
• Heart valve disease. The valves of the heart keep blood flowing the right way. A narrowed or leaky heart valve can make the left ventricle work harder. This can weaken the heart over time.
• Cardiomyopathy. Diseases of the heart muscle can weaken the heart or make the left ventricle stiff.
• Heart arrhythmias. Heart rhythms that are too fast, too slow or not regular can keep the heart from pumping well.
• Myocarditis. Swelling and irritation of the heart muscle can damage the left ventricle. A virus is most often the cause of myocarditis. This includes the virus that causes COVID-19.
• Congenital heart disease. Heart conditions you're born with can sometimes lead to heart failure later in life.

Certain medicines, some cancer treatments, heavy use of alcohol and use of other substances that are toxic to the heart also can damage the heart muscle and lead to left-sided heart failure.

Besides being older or having obesity, the following may increase your risk of getting heart failure:

• Diabetes.
• Smoking.
• Not being active.
• Sleep apnea.
• Kidney disease.
• Family history of cardiomyopathy or heart failure.
• Heavy alcohol use.

Many risk factors also raise your risk of getting coronary artery disease, high blood pressure or other conditions that can lead to heart failure.

Left-sided heart failure can get worse over time and lead to other health conditions. Possible complications include:

• Pulmonary edema. Increased pressure in the blood vessels of the lungs can cause fluid to collect in lung tissue, making it hard to breathe.
• Pulmonary hypertension. Ongoing pressure buildup on the left side of the heart can increase pressure in the blood vessels that carry blood through the lungs.
• Right-sided heart failure. Increased pressure in the lungs can make the right side of the heart work harder. Over time, the right ventricle may weaken.
• Kidney damage or failure. Less blood flow and fluid buildup can affect how well the kidneys work.
• Heart rhythm issues. Changes in the heart muscle can raise the risk of heartbeats that are too fast, too slow or not regular.

You can't always prevent left-sided heart failure. But managing conditions that damage the heart can lower the risk.

What you can do:

• Manage high blood pressure.
• Manage diabetes and cholesterol levels.
• Don't use tobacco.
• Get to and stay at a healthy weight.
• Get regular physical activity.
• Limit alcohol or don't drink.

To diagnose left-sided heart failure, a healthcare professional asks about symptoms and medical history and does a physical exam. The exam may include listening to the heart and lungs and checking for signs of fluid buildup, such as swelling in the legs or feet.

During an exam, a healthcare professional may hear popping or cracking sounds when listening to the lungs through an instrument called a stethoscope. Fluid buildup in the lungs can cause these sounds, called crackles.

Tests

Tests are done to check your heart and find causes of your symptoms. Tests to help diagnose left-sided heart failure may include:

• Blood tests. Blood tests can look for conditions that may cause heart failure or make it worse.
• Electrocardiogram (ECG or EKG). This test records the heart's electrical activity. It can find issues with heart rhythm and electrical signals.
• Chest X-rays. An X-ray can show whether the heart is larger than usual and whether fluid has built up in the lungs.
• Echocardiogram. Sound waves make pictures of the heart. This test can show how well the left ventricle pumps and fills, measure ejection fraction, and check the heart valves.
• Cardiac MRI. This test uses magnetic fields and radio waves to make detailed pictures of the heart.

Treatment for left-sided heart failure depends on its cause, how well the left ventricle pumps, your symptoms and your other health conditions. Treatment aims to ease symptoms, reduce fluid buildup, slow the advance of heart failure, prevent hospital stays and help you live longer.

Treatment often includes lifestyle changes and medicines. If caught early, left-sided heart failure may get better with treatment for the condition that causes it.

Medicines

Several types of medicines may be used. The mix depends in part on the type of heart failure.

For left-sided heart failure with reduced ejection fraction, medicines may include:

• Angiotensin-converting enzyme (ACE) inhibitors. These medicines help relax blood vessels, improve blood flow and ease strain on the heart. Examples include enalapril (Vasotec, Epaned), lisinopril (Zestril, Qbrelis) and captopril.
• Angiotensin 2 receptor blockers (ARBs). These medicines have many of the same benefits as ACE inhibitors. They may be an option for people who can't tolerate ACE inhibitors. They include losartan (Cozaar), valsartan (Diovan) and candesartan (Aasand).
• Angiotensin receptor plus neprilysin inhibitors (ARNIs). This treatment combines the medicines sacubitril and valsartan (Entresto). It's used to treat some people who have heart failure with reduced ejection fraction. It may help prevent the need for a hospital stay in those people.
• Beta blockers. These medicines slow the heart rate and lower blood pressure. They ease the symptoms of left-sided heart failure and help the heart work better. Examples include carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL, Kapspargo Sprinkle) and bisoprolol.
• Mineralocorticoid receptor antagonists. These medicines can help ease fluid retention and the effects of hormones that can worsen heart failure.
• Diuretics. Often called water pills, these medicines make you urinate more often. This helps prevent fluid buildup in the body. Diuretics, such as furosemide (Lasix, Furoscix), also lessen fluid in the lungs, so it's easier to breathe.

  Some diuretics make the body lose potassium and magnesium. Your healthcare professional may advise you to take supplements to treat this. If you take a diuretic, you may have regular blood tests to check your potassium and magnesium levels.

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors. These medicines can lower blood sugar. They are often prescribed with diet and exercise to treat type 2 diabetes. But they're also one of the first treatments for heart failure. Several studies have shown that the medicines lower the risk of hospital stays and death in people with certain types of heart failure — even if they don't have diabetes. These medicines include canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin (Jardiance).

Your healthcare professional may need to change your medicine doses often. This is more common when you've just started a new medicine or when your condition is getting worse.

Surgery or other procedures

Some people may need surgery or a heart device to treat left-sided heart failure. Treatments may include:

• Coronary artery bypass graft surgery. You may need this surgery if blocked arteries are causing your heart failure. The surgery involves taking a healthy blood vessel from the leg, arm or chest to make a new route for blood to flow around the blocked artery. The new pathway improves blood flow to the heart muscle.
• Heart valve repair or replacement. If a damaged heart valve causes heart failure, your health professional may advise repairing or replacing the valve. The type of heart surgery you need depends on the cause of the heart valve disease.

  Heart valve repair or replacement may be done as open-heart or minimally invasive surgery.

• Implantable cardioverter-defibrillator (ICD). An ICD is used to prevent complications of heart failure. It doesn't treat heart failure itself. An ICD is a device like a pacemaker. It's implanted under the skin in the chest with wires leading through the veins and into the heart.

  The ICD checks the heartbeat. If the heart starts beating at a dangerous rhythm, the ICD tries to correct the beat. An ICD also can work as a pacemaker and speed up a slow heartbeat.

• Left ventricular assist device (LVAD). An LVAD helps pump blood from the left ventricle of the heart to the rest of the body. It's also called a mechanical circulatory support device. Your healthcare professional may advise you to get an LVAD if you're waiting for a heart transplant. Or it may be treatment for left-sided heart failure for people who can't have a heart transplant.
• Cardiac resynchronization therapy (CRT). Also called biventricular pacing, CRT is a treatment for heart failure in people whose lower heart chambers aren't pumping in sync with each other. A device sends electrical signals to the lower heart chambers. The signals tell the chambers to work together. This improves the pumping of blood out of the heart. CRT may be used with an ICD.
• Heart transplant. Some people have heart failure that surgery or medicines don't help. These people may need to have their hearts replaced with donor hearts.

  A heart transplant isn't right for everyone. A team of healthcare professionals at a transplant center helps decide whether the procedure may be a safe choice that helps you.

Symptom care and end-of-life care

Your healthcare team may suggest special medical care to ease symptoms and improve quality of life. This is called palliative care. This type of care is for anyone who has a serious or life-threatening illness. It can treat symptoms or ease side effects of treatment.

In some people with heart failure, medicines no longer work and a heart transplant or device isn't an option. Then the healthcare team may advise special end-of-life care. This is called hospice care.

Hospice care allows people who care about you to help care for and comfort you with the aid of nurses, social workers and trained volunteers. You can get hospice care in your home or in a nursing home or assisted living center.

Hospice care provides the following to you and those who care for you:

• Emotional support.
• Psychological support.
• Spiritual support.

Although it can be hard, discussing end-of-life issues with people who care for you and your medical team is important. This may involve an advance care directive. This is a general term for spoken and written instructions you give about your medical care if you can't speak for yourself.

If you have an ICD, also discuss whether and when to turn off the device so that it can't give shocks near the end of life.

Some people with heart failure may be told to take omega-3 fatty acid supplements. Some research shows that the supplements may help reduce the need for hospital stays.

Making certain lifestyle changes often improves heart failure symptoms. It may even slow the condition from getting worse.

The following changes are recommended to improve heart health:

• Don't smoke. Smoking damages blood vessels and raises blood pressure. It lowers blood oxygen levels and speeds up the heartbeat. Quitting is the best thing you can do to help your heart health. If you need help quitting, talk with your health professional. You can't have a heart transplant if you smoke. Also stay away from other people's smoke.
• Check your legs, ankles and feet for swelling. Do this every day. Call your healthcare professional if the swelling gets worse.
• Weigh yourself. Ask your healthcare professional how often you should do this. Weight gain may mean your body is holding onto fluid. You may need a change in treatment. Call your health professional if you gain 5 pounds (2.3 kilograms) or more within a few days.
• Manage weight. Being overweight increases the risk of heart disease. Ask your health professional what weight is best for you. Even losing a small amount of weight can help improve heart health.
• Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains, fat-free or low-fat dairy products, and lean proteins. Limit saturated and trans fats.

• Ask about salt. Too much salt, also called sodium, can make the body hold onto water. This is called water retention. It makes the heart work harder. Symptoms include shortness of breath and swollen legs, ankles and feet.

  Ask your health professional whether you should follow a no-salt or low-salt diet. Keep in mind that salt has been added to many prepared foods. Read labels.

• Ask how much fluid you can have. If you have serious heart failure, your health professional may suggest that you limit the amount of fluid you drink.
• Limit or don't drink alcohol. Alcohol can interfere with certain medicines. It also weakens the heart and raises the risk of heartbeats that aren't regular. If you have heart failure, your health professional may advise you not to drink any alcohol.
• Stay as active as you can. Moderate exercise helps keep the heart and body healthy. But be sure to talk with your health professional about an exercise program that's right for you. If you have heart failure, your health professional may suggest a walking program or a cardiac rehabilitation program at your local hospital.
• Lower stress. Strong feelings such as worry or anger can make the heart beat faster. Breathing becomes heavier and blood pressure goes up. These changes can make heart failure worse.

  Find ways to lower stress. Practicing mindfulness and connecting with others in support groups are some ways to lower and manage stress.

• Get better sleep. Heart failure can cause shortness of breath, especially when lying down. Try sleeping with your head propped up using a pillow or a wedge. If you snore or have had other sleep issues, get tested for sleep apnea.
• Get recommended vaccinations. Ask your health professional about getting influenza, pneumonia and COVID-19 vaccinations.

Managing heart failure requires open communication between you and your health professional. Be honest about any challenges with your diet, lifestyle and medicine use. Notice how you feel. Tell your health professional when you feel better or worse. This helps guide your treatment.

If you worry about your heart failure risk, make an appointment with your healthcare professional. You may be sent to a doctor trained in heart diseases, called a cardiologist. Finding heart failure early may make treatment easier and work better.

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do before you go. This may include fasting before certain tests. If possible, take someone with you to the appointment to help you remember what you learn.

Make a list of:

• Your symptoms and when they began. Include any that may not seem related to heart failure.
• Key personal information, including a family history of heart disease, stroke, high blood pressure or diabetes, and major stresses or recent life changes. Find out if anyone in your family has had heart failure.
• All medicines, vitamins and supplements you take. Include doses. Take the list with you to all health checkups.

For heart failure, questions may include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What tests do I need? How do I prepare for the tests?
• What treatments are there? Which do you suggest for me?
• How often should I be screened for changes in my condition?
• I have other health conditions. How can I best manage these conditions together?
• When is it safe for my partner and me to have sex?

Be sure to ask all the questions you have.

What to expect from your doctor

Your health professional is likely to ask many questions, such as:

• Do you have symptoms all the time, or do they come and go?
• How bad are your symptoms?
• What, if anything, seems to make your symptoms better?
• Does anything make your symptoms worse?

What you can do in the meantime

It's never too early to make healthy-lifestyle changes, such as quitting smoking, cutting down on salt and eating healthy foods. These changes can help prevent heart failure or keep it from getting worse.

During or after testing for heart failure, your healthcare professional may tell you the stage of disease. Staging helps determine the treatment. There are two main ways to determine the stage or class of heart failure:

New York Heart Association classification

The New York Heart Association (NYHA) classification system groups heart failure into four categories by number. You may see Roman numerals used for these categories.

• Class 1 heart failure. There are no heart failure symptoms during daily activities or low-intensity exercise.
• Class 2 heart failure. Everyday activities can be done without difficulty. But exertion causes shortness of breath or tiredness.
• Class 3 heart failure. It's hard to complete everyday activities.
• Class 4 heart failure. Shortness of breath happens even at rest. This category includes the most serious heart failure.

American College of Cardiology/American Heart Association classification

This stage-based classification system uses letters A to D. It includes a category for people who are at risk of developing heart failure.

• Stage A. There are risk factors for heart failure but no signs or symptoms.
• Stage B. There is heart disease but no signs or symptoms of heart failure.
• Stage C. There is heart disease and current or previous signs or symptoms of heart failure.
• Stage D. This is advanced heart failure that needs specialized treatments.

Healthcare professionals often use the classification systems together to help decide the right treatment options. Your health professional can help you understand your stage.