Heart failure (manawa ngoikore) is when your heart can’t pump blood properly around your body. It is also known as congestive heart failure.
Key points about heart failure
Heart failure means your heart’s pumping action is getting weaker. It doesn’t mean your heart is about to stop.
There are many conditions that can cause heart failure.
Symptoms develop slowly and can vary. They include shortness of breath, swelling of your ankles, legs or tummy, tiredness and being less able to exercise. Your sleep may be disturbed.
Symptoms can get worse and become particularly severe during a flare-up (exacerbation).
Heart failure can't be cured, but there are treatments to help manage it.
There are many things that you, your family/whānau and your healthcare team can do to help you feel better and stay well for as long as possible.
See your doctor or go to the nearest emergency department if you or someone you care for has heart failure and experiences the following:
sudden chest pain that lasts more than a few minutes
sweating and weakness
more shortness of breath than usual despite following action plan steps
feeling very unwell
dizziness, fainting or blackouts
fever (a high temperature)
increased swelling of ankles or abdomen (tummy)
coughing for no reason.
What is heart failure?
Your heart has 4 chambers with muscular walls. The upper chamber on each side is called an atrium (left and right atrium). The lower chambers are ventricles (left and right ventricle).
Blood that is low in oxygen returns from your body and is collected in the right atrium and then shunted to the right ventricle. The right ventricle then pumps this blood to your lungs to pick up oxygen. Oxygen-rich blood from your lungs returns to your left atrium and passes into the left ventricle. The left ventricle then does the most work, pumping oxygen-rich blood to your entire body.
Every minute your heart pumps 4–6 litres of blood around your body. When you are active, this increases a lot.
Heart failure occurs when your heart can’t pump blood properly around your body. It doesn’t mean your heart is about to stop – it just means your heart’s pumping action is getting weaker.
Heart failure can affect one side or both sides of your heart. The condition gets worse over time as your heart's pumping action becomes weaker. When your heart stops pumping blood properly, fluid starts to build up in different parts of your body, causing symptoms such as swelling of your feet, shortness of breath and tiredness. The term ‘congestive’ means different parts of your body collect too much fluid due to the poor circulation of blood.
Take a tour of the heart and discover how amazing it is with the interactive model below from BioDigital Human.
What are the causes of heart failure?
There are many conditions that can cause heart failure, most of them conditions that affect your heart, including:
Coronary heart disease is the most common cause of heart failure. Coronary heart disease describes the blockage of the blood vessels that supply your heart. Coronary heart disease includes heart attack (where the blockage occurs suddenly) or angina (chest pain due to reduced blood flow to your heart muscles). Coronary heart disease can cause scarring of your heart muscles and weaken your heart’s pumping action.
High blood pressure can put extra strain on your heart, as your heart needs to pump harder. Over time, your heart muscles can be damaged and your heart’s pumping action can get weaker.
Cardiomyopathy is a disease of the heart muscle itself. It commonly refers to an abnormally large, baggy heart that cannot pump well enough. It can be caused by some viral infections or drinking too much alcohol.
Myocarditis isthe inflammation or infection of the heart muscle. This is commonly caused by a virus (including COVID-19) and may lead to heart failure, especially of the left side of your heart.
See your doctor or go to the nearest emergency department if you or someone you care for has heart failure and experiences the following:
sudden chest pain that lasts more than a few minutes
sweating and weakness
more shortness of breath than usual despite following action plan steps
feeling very unwell
dizziness, fainting or blackouts
fever (high temperature)
increased swelling of your ankles or abdomen (tummy)
coughing for no reason.
How are heart failure and its causes diagnosed?
Your doctor or GP will ask you questions about your symptoms and your past medical history. They will also examine you, including checking your pulse and blood pressure and listening to your heart.
Some tests can be done to help diagnose heart failure and its possible causes.
An electrocardiogram (ECG) to check the electrical activity of your heart and for a heart rhythm that can cause heart failure.
An echocardiogram (echo) – an echo is an ultrasound scan of your heart and shows how each part of your heart is functioning, and how much blood is being pumped with each beat.
A chest x-ray – this can find out if there is fluid in your lungs and other lung conditions that can cause the same symptoms as heart failure.
Breathing tests such as spirometry – a spirometry can find out if your breathlessness is caused by another lung condition.
How is heart failure treated?
Heart failure can’t be cured, but there are treatments available to manage your condition.
Treatments of heart failure include:
self-care
medicines
devices for heart failure
surgery, which may include a transplant procedure.
Self-care
You have an important role to play in your heart health. There are things you can do to monitor and improve your symptoms of heart failure, including eating well, stopping smoking, staying active and losing weight if you need to.
Other than self-care and lifestyle changes, medicines are prescribed to control heart failure. These medicines work best if taken regularly. If you get side effects, talk to your doctor before stopping. Sometimes finetuning is needed to find the right dose and combination for you. Many of the pills you need to take to strengthen your heart start with a small dose and are built up gradually, depending on whether you have any side effects.
Medicines used to control heart failure
Diuretics or water pills – these medicines encourage your kidneys to remove excess fluid and salt from your body by increasing the amount of urine (pee) produced. Examples include furosemide and bumetanide.
Digoxin helps your heart beats strongly and regularly.
Beta-blockers help with your heart's pumping action by slowing your heart rate and reducing your blood pressure. Examples include carvedilol and atenolol.
Spironolactone (an aldosterone antagonist) has a diuretic effect and may help in severe heart failure.
Sacubitril with valsartan – this medicine includes a combination of an angiotensin-II receptor antagonist and a neprilysin inhibitor. It is more suitable for people with more severe heart failure, whose symptoms haven’t improved despite trying other medicines.
Blood thinners such as warfarin and dabigatran to help stop blood clots from forming.
Your doctor or nurse will let you know which medicines are suitable for you.
Devices for heart failure
Devices such as pacemakers, cardiac resynchronisation therapy (CRT) and implantable cardioverter defibrillators (ICDs) help manage heart failure in some people. These devices are not suitable for everyone. Your healthcare team will let you know whether these are suitable for you.
Surgery
For some people with heart failure, an operation may help. The type depends on what is causing your heart failure. Your healthcare team will let you know whether surgery may help in your situation.
Coronary bypass surgery may be helpful if you have coronary artery disease as a cause of your heart failure. If you have problems with your heart valves, heart valve surgery may be suitable for you.
Treatment for advanced heart failure
Although treatment can help to control symptoms, heart failure can get worse over time, becoming more severe and getting to a point where treatment isn't that effective any more. If that occurs, your daily life can start to be affected. Read more about advanced heart failure.
How can I care for myself with heart failure?
Managing heart failure well needs the input of your GP, who knows about any other health issues you have that affect health failure. Other healthcare team members that may be involved include a heart specialist, heart failure nurse, dietitian and pharmacist.
There are also things you can do to monitor and improve your symptoms, including:
The Heart Foundation NZ provides resources and support for those living with a heart condition. You can also find a local support group in your area here. Contact them using their online form or visit their website here.
Learn more
The following links provide further information about heart failure. Be aware that websites from other countries may have information that differs from New Zealand recommendations.
After 45 years of GP experience, and 8 years as an examiner and practice assessor, Dr Bryan Frost has completed a Diploma in Editing and is pursuing a new career. He also has a Diploma in Health Administration, with honours in management, and has also completed a paper in Health Care Law.
Credits: Health Navigator Editorial Team. Reviewed By: Dr Bryan Frost, FRNZCGP, Morrinsville
Last reviewed: 20 Apr 2021
How can I care for myself with heart failure?
Managing heart failure well needs the input of your GP, who knows about your other health issues that may affect your heart failure. Other healthcare team members that may be involved in your care include a heart specialist, heart failure nurse, dietitian and pharmacist. Involve your family/whānau in your decision making.
There are also things you can do yourself to monitor and improve your symptoms. On this page you can find out about them:
A heart failure action plan provides you with instructions and information on how to manage your heart failure on a daily basis and also how to recognise and cope with worsening symptoms, such as flare-ups (exacerbations).
You can develop your heart failure action plan with your healthcare provider and fit the plan to suit how severe your heart failure is and your wishes. At each visit with your healthcare provider, you can review the plan and make adjustments as needed.
Your doctor may recommend you do this to check whether you have any extra fluids. If you put on more than 2kg over a few days, your body is retaining fluid, not fat. Your doctor will help you work out your target weight – this is your weight with no extra fluid, and is the weight at which your body and heart work best.
Weigh yourself every morning each day at the same time (after you have been to the toilet, before you eat or drink anything and before you get dressed). Use digital scales, and use these on a firm surface, eg, lino or tiles. Then record your weight on your heart failure action plan and remember to bring it with you to every appointment with your healthcare team.
Other than weighing yourself, you also need to check for swelling. Check whether your rings, waistband, socks or shoes feel tighter. You can also press firmly into the skin of your ankle, shin and knee with your finger. If your finger makes a dent that doesn’t quickly fill, you have swelling.
You should also monitor any changes in your breathing. If you are more short of breath than usual or have more swelling, you are likely to retain more fluid.
Follow the steps in your action plan as discussed with your healthcare team or contact your doctor if you are concerned about any aspect of your health.
Healthy eating
Choosing healthier foods, such as whole grains, smaller portions, healthy fats, low-salt and less processed foods, can help you manage your heart failure or other health issues you may have. Avoiding or limiting salt is particularly important in heart failure as salt makes you retain fluid and makes it difficult to get rid of fluid from your body. Read more about healthy eating.
Limit fluids
You should avoid having too much fluid, but you don’t need to restrict your fluids too much unless your doctor advises you to do so. Drink about the same amount each day. Remember other food may contain fluids, such as yogurts, soups, teas, ice cream or smoothies.
Stop smoking
Smoking makes you even more breathless, continues to damage your heart and dramatically increases your chances of a heart attack. Ask your doctor or nurse to get support to help you quit smoking. Read more about quitting smoking.
Limit alcohol
People with weak hearts don’t cope well with alcohol, even in moderate amounts. Drink only small amounts and don't binge drink. If your heart failure is caused by too much alcohol, you should not drink at all.
Look after your mental health
You also need to look after your mental health. You might have lots of different feelings while coping with your symptoms, such as anxiety, stress or depression.
Try to avoid stressful situations. If you get stressed, use relaxation techniques such as taking 6 slow, deep breaths. Doing something where you feel useful and gain a sense of achievement can help you regain balance in your life.
It also helps to have plenty of rest and get a good night's sleep, as this allows your body and mind to restore. Talking to family/whānau members can also help. If you need more support, ask your healthcare team for a referral to a psychologist or counsellor.
Stay active
Start exercising gently by doing a little, and slowly increase your activity as you manage more. Try walking gently around the house or down the road first. Ask your doctor or nurse about suitable exercises for you or about any exercise programmes available in your area.
Have a healthy body weight
Losing weight if you are overweight helps takes the strain off your heart and can help you feel better. If you are underweight or have a poor appetite, having foods that are higher in calories and protein, or high-energy drinks, can help boost your energy. Ask your doctor, nurse or dietitian for advice on how to reach a healthy weight.
Get vaccinated
Vaccination against the flu and pneumococcal disease is recommended as these infections can worsen your symptoms. Ask your healthcare team about getting these vaccinations, and the COVID-19 one.
Attend regular follow-ups
It is important to attend your follow-up appointments regularly. This allows your doctor or nurse to monitor your health and see how your condition is progressing, as well as review your medicines and answer any questions you may have. Bring your heart failure action plan with you so that your healthcare team can monitor and better understand what is happening for you.
Join a cardiac rehabilitation programme
You may be advised to attend a cardiac rehabilitation group at your local hospital. These are excellent for learning more about ways to strengthen your heart again and supporting you to get more active.
A flare-up is when your heart failure symptoms suddenly get worse. This might include increased shortness of breath, increased swelling of your ankles or tummy or worsening cough. A flare-up might be triggered by an infection, but there may be no apparent reason. A flare-up is also known as an exacerbation.
Each flare-up can make your heart weaker. It's a common cause of admission to hospital. It's important to be prepared and know how to recognise the symptoms of a flare-up and what to do when they happen.
What are the causes of a flare-up?
A heart failure flare-up means you are retaining fluids in your body, such as in your lungs, ankles or tummy. Extra fluids can be due to a number of causes, including:
not taking your diuretics (water tablets) or other heart failure medicines regularly
recent changes in your heart failure medicines
an infection
high blood pressure
a heart attack
a new heart rhythm problem (arrhythmia)
too much alcohol
too much fluid and salt intake.
Any other issue that makes your heart work harder can cause a flare-up.
What are the signs of a flare-up?
Signs you may have a flare-up include:
worsening shortness of breath
worsening swelling of your ankles, legs and tummy
rapid weight gain
worsening cough
confusion
feeling very unwell generally.
What should I do if I have a flare-up?
The best way to manage a heart failure flare-up is to have a heart failure action plan. A heart failure action plan is a written document that provides you with instructions and information on how to manage your heart failure on a daily basis, and how to recognise and cope with worsening symptoms.
You can develop your heart failure action plan with your healthcare provider and fit the plan to suit how severe your heart failure is and your wishes. When you have a flare-up, follow the steps on your action plan as discussed with your healthcare provider.
At each visit, you and your healthcare provider can review your plan and make adjustments as needed.
However, having an action plan doesn't replace your doctor. It means you can respond quickly and recognise symptoms that require you to seek medical attention. You should still see your doctor as soon as possible after a flare-up. Tell your doctor or nurse if your symptoms don't improve after following the steps on your action plan.
You may need to go to hospital for severe flare-ups.
See your doctor or go to the nearest emergency department if you or someone you care for has heart failure and experiences the following:
sudden chest pain that lasts more than a few minutes
sweating and weakness
more shortness of breath than usual despite following the action plan steps
Although treatment can help to control heart failure symptoms, heart failure can get worse over time so that treatment isn't as effective and your daily life is affected.
What are the symptoms of advanced heart failure?
Symptoms of advanced heart failure may include that you:
are very short of breath despite not exerting yourself or even at rest, while you are already on quite a few medicines
need more help with day-to-day chores, such as getting dressed, preparing meals or personal care
lose your appetite
feel weak, with no energy and feel very tired
have repeated hospital admissions due to heart failure or needed to see your doctor multiple times
are losing weight
stay in bed most of the time and move around less.
What happens if I have advanced heart failure?
If you have advanced heart failure, it's likely that you won't get any better. Your doctor will suggest palliative care treatment to make sure you are living in comfort and to improve your quality of life.
Palliative care aims to manage any distressing symptoms you may have and enables you and your whānau to make decisions about how you wish to spend the remainder of your life. Your doctor is likely to refer you to a palliative care team to talk about some of the choices you may want. Read more about palliative care.
It is a good idea to plan your future health care and end-of-life care to help prepare you and your whānau for what the future might hold. This is especially helpful if you can no longer speak for yourself, eg, if you get very sick. It also helps your healthcare team know what health care you want or don't want. This is known as advance care planning.
If you have advanced heart failure and are towards the end of your life, your doctor may stop your heart failure medicines as they are no longer effective in managing your symptoms.
Instead, your doctor may prescribe medicines to relieve your symptoms, such as:
pain relief medicines to control your pain
morphine or benzodiazepines to control your breathlessness
What support is available with advanced heart failure?
The Heart Foundation NZ provides resources and support for those living with a heart condition. You can also find a local support group in your area here. Contact them using their online form or visit their website here.
Extra support is also available if you need it. Talk to your healthcare team to find out how you can access this.
It includes:
equipment to help with your daily chores, such as chair raisers and shower stools
mobility parking and taxi vouchers to help you get around your community
carer support to help support your carer who is looking after you
counselling or mental health support
needs assessment if you want to move into a rest home or other residential care.
Information for healthcare providers on heart failure
The content on this page will be of most use to clinicians, such as nurses, doctors, pharmacists, specialists and other healthcare providers.
The following information on heart failure is taken from Auckland Regional HealthPathways, NZ, accessed March 2021:
Practice point
Check new onset shortness of breath
Unless history and physical examination clearly indicate a non-cardiac cause for their symptoms, evaluate all patients for heart failure who present with new onset shortness of breath on exertion, orthopnoea, or paroxysmal nocturnal shortness of breath.
"Once heart failure has been diagnosed, the goal of treatment is to improve symptoms and signs and avoid or reduce hospital admissions. In the majority of patients with symptomatic heart failure,
a diuretic is used first-line to reduce fluid overload.
An ACE inhibitor and beta-blocker are then added,
followed by spironolactone if the patient is still symptomatic.
An angiotensin-II receptor blocker, digoxin and anticoagulants can be added as appropriate.
Surgical interventions may be considered for some patients."
Management of iron deficiency in chronic heart failure
The following information is taken from a research review education series.
"Anaemia is a frequent finding in patients with chronic heart failure (CHF), being present in approximately one-third of patients with CHF.
Anaemia in CHF increases the risk of hospitalisation and death, and also leads to substantial reductions in exercise tolerance and quality of life (QOL).
The pathophysiology of anaemia in CHF is multifactorial. Iron deficiency is the most common cause of anaemia in patients with CHF, and it is increasingly being recognised that CHF is an iron-deficient state.
Measurement of serum ferritin alone cannot exclude iron deficiency in patients with CHF. Ferritin is an acute phase reactant and levels increase in response to inflammation, which complicates the diagnosis of iron deficiency.
Due to the inflammation associated with CHF, diagnosis of iron deficiency in patients with CHF should be based on both serum ferritin levels and transferrin saturation (TSAT) as follows: 'Ferritin <100 μg/L (absolute iron deficiency); or Ferritin 100–300 μg/L with TSAT <20% (functional iron deficiency)'
Australia and New Zealand 2018 guidelines practice advise that oral iron supplementation is ineffective at normalising iron status or improving QOL in patients with CHF. IV iron should be considered in patients with CHF associated with iron deficiency, with or without anaemia."
Congestive heart failure – management in primary care – Prof. Gerry Devlin (52 minutes)
(PHARMAC Seminars, NZ, 2019)
Heart failure by Dr Patrick Gladding
(The Goodfellow Unit, NZ, 2018)
Congestive heart failure by Dr Hitesh Patel
(Ascot Cardiology Symposium, NZ, 2014)
Regional HealthPathways NZ
Access to the following regional pathways is localised for each region and access is limited to health providers. If you do not know the login details, contact your DHB or PHO for more information:
