Finding the Right Heart Failure Doctor: Diagnosis, Treatment, and Care

Heart failure is a serious condition that affects millions of people worldwide. If you or a loved one has been diagnosed with heart failure, or you suspect you might be experiencing symptoms, finding the right Heart Failure Doctor is crucial. This comprehensive guide will walk you through the diagnosis, treatment options, and lifestyle changes necessary to manage heart failure effectively, ensuring you have the information needed to partner with your healthcare provider for the best possible care.

Understanding Heart Failure Diagnosis

The journey to managing heart failure begins with accurate diagnosis. Your initial step might involve a visit to your primary care physician, but if heart failure is suspected, they will likely refer you to a specialist – a heart failure doctor, also known as a cardiologist specializing in heart failure.

The diagnostic process typically starts with a thorough physical examination and a review of your medical history. Your heart failure doctor will ask detailed questions about your symptoms, including:

• Shortness of breath, especially during exertion or while lying down
• Persistent cough or wheezing
• Fatigue and weakness
• Swelling in the ankles, legs, and abdomen
• Rapid or irregular heartbeat
• Lack of appetite or nausea
• Difficulty concentrating or decreased alertness

Your doctor will also want to know about any existing conditions that are risk factors for heart failure, such as:

• High blood pressure
• Coronary artery disease
• Diabetes
• Valvular heart disease
• Cardiomyopathy
• Congenital heart defects

During the physical exam, your heart failure doctor will use a stethoscope to listen to your heart and lungs. They will be listening for:

• Heart murmurs: Unusual whooshing sounds that can indicate valve problems.
• Lung sounds: Crackling or wheezing sounds that can suggest fluid buildup in the lungs (pulmonary edema), a common sign of heart failure.

They will also check for:

• Jugular vein distention: Swelling of the veins in your neck, indicating increased pressure in the heart.
• Peripheral edema: Swelling in your legs, ankles, and feet due to fluid retention.
• Abdominal distention (ascites): Fluid buildup in the abdomen.

Essential Tests for Diagnosing Heart Failure

To confirm a diagnosis of heart failure and determine its cause and severity, your heart failure doctor will order several tests. These may include:

• Blood Tests: These are crucial for assessing overall health and identifying potential underlying causes or contributing factors to heart failure.

  • B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP): These proteins are released by the heart when it is under stress. Elevated levels are a strong indicator of heart failure.
  • Kidney function tests: To assess kidney health, as kidney problems can both contribute to and be affected by heart failure.
  • Liver function tests: To evaluate liver health.
  • Thyroid function tests: To check for thyroid disorders, which can impact heart function.
  • Complete blood count (CBC): To assess general health and rule out anemia or infection.
  • Electrolytes: To measure levels of potassium, sodium, and other electrolytes, which are important for heart rhythm.

• Chest X-ray: This imaging test provides a picture of your heart and lungs. It can reveal:

  • Heart enlargement (cardiomegaly).
  • Fluid buildup in the lungs (pulmonary congestion).
  • Other lung conditions that might mimic heart failure symptoms.

• Electrocardiogram (ECG or EKG): This painless test records the electrical activity of your heart. It can detect:

  • Abnormal heart rhythms (arrhythmias).
  • Signs of previous heart attack.
  • Enlargement of the heart chambers.
  • Other heart conditions.

• Echocardiogram: This ultrasound of the heart is a primary tool for diagnosing heart failure. It provides detailed images of the heart’s structure and function, showing:

  • Size and shape of the heart.
  • Function of the heart chambers (ventricles and atria).
  • Function of the heart valves.
  • Ejection fraction (EF): The percentage of blood pumped out of the left ventricle with each beat. This is a key measurement in heart failure diagnosis and management.

• Ejection Fraction (EF) Measurement: As mentioned, EF is a critical value assessed during an echocardiogram. A normal EF is generally considered to be 50% or higher. However, heart failure can occur even with a normal EF. Heart failure doctors classify heart failure based on EF:

  • Heart failure with reduced ejection fraction (HFrEF): EF is 40% or less. This is also known as systolic heart failure.
  • Heart failure with preserved ejection fraction (HFpEF): EF is 50% or higher. This is also known as diastolic heart failure.
  • Heart failure with mid-range ejection fraction (HFmrEF): EF is between 41% and 49%.

  Understanding your EF is important as it helps your heart failure doctor tailor your treatment plan.

• Exercise Stress Test: This test assesses how your heart functions during physical activity. It usually involves walking on a treadmill or riding a stationary bike while your heart rhythm, blood pressure, and breathing are monitored. It helps determine:

  • How well your heart responds to exertion.
  • If you experience symptoms like chest pain or shortness of breath during exercise.
  • The severity of your heart failure.
  • If you are unable to exercise, medication can be used to simulate the effect of exercise on your heart (pharmacological stress test).

• Cardiac CT Scan: This advanced X-ray imaging creates detailed cross-sectional images of your heart, providing information about:

  • Heart structure and function.
  • Coronary arteries.
  • Pericardium (the sac surrounding the heart).

• Cardiac MRI (Magnetic Resonance Imaging): Using magnetic fields and radio waves, cardiac MRI produces even more detailed images of the heart than CT scans. It can help assess:

  • Heart muscle damage.
  • Inflammation of the heart muscle (myocarditis).
  • Congenital heart defects.

• Coronary Angiogram: This invasive procedure is used to visualize the coronary arteries and identify blockages. A catheter is inserted into a blood vessel (usually in the groin or wrist) and guided to the heart. Dye is injected through the catheter, making the arteries visible on X-ray images. This test is particularly important if coronary artery disease is suspected as the cause of heart failure.

• Myocardial Biopsy: In rare cases, a myocardial biopsy may be necessary. This involves taking a small sample of heart muscle tissue for microscopic examination. It can help diagnose:

  • Specific types of cardiomyopathy (heart muscle disease).
  • Inflammatory conditions of the heart.
  • Infiltrative diseases affecting the heart.

Staging Heart Failure

Once diagnosed, your heart failure doctor will determine the stage of your heart failure. Staging helps to classify the severity of your condition and guide treatment strategies. Two main classification systems are commonly used:

1. New York Heart Association (NYHA) Functional Classification: This system classifies heart failure based on the severity of symptoms and their impact on physical activity:

• Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, shortness of breath, or palpitations.
• Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or shortness of breath.
• Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or shortness of breath.
• Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest can be present.

2. American College of Cardiology/American Heart Association (ACC/AHA) Staging System: This system focuses on the progression of heart failure, including risk factors and structural heart disease, even before symptoms develop:

• Stage A: At risk for heart failure but without structural heart disease or symptoms of heart failure. This includes patients with conditions like high blood pressure, coronary artery disease, diabetes, or family history of cardiomyopathy.
• Stage B: Structural heart disease is present, but without signs or symptoms of heart failure. Examples include previous heart attack, valvular heart disease, or left ventricular hypertrophy.
• Stage C: Structural heart disease with current or prior symptoms of heart failure.
• Stage D: Advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy, requiring specialized interventions (e.g., heart transplant, mechanical circulatory support).

Heart failure doctors often use both NYHA classification and ACC/AHA staging to comprehensively assess and manage heart failure, allowing for a more personalized and effective treatment approach.

Heart Failure Treatment Options

Treatment for heart failure is multifaceted and aims to:

• Relieve symptoms.
• Improve heart function.
• Slow the progression of the disease.
• Reduce hospitalizations.
• Extend life expectancy.

Your heart failure doctor will develop a personalized treatment plan based on the cause and severity of your heart failure, your overall health, and your individual needs. Treatment typically involves a combination of lifestyle modifications, medications, and, in some cases, surgery or medical devices.

Medications for Heart Failure

Medications are the cornerstone of heart failure management. Several classes of drugs are used, often in combination, to address different aspects of heart failure:

• Angiotensin-Converting Enzyme (ACE) Inhibitors: These medications relax blood vessels, lower blood pressure, improve blood flow, and reduce strain on the heart. Common examples include enalapril, lisinopril, and captopril.

• Angiotensin II Receptor Blockers (ARBs): ARBs have similar effects to ACE inhibitors and are often prescribed to patients who cannot tolerate ACE inhibitors due to side effects like persistent cough. Examples include losartan, valsartan, and candesartan.

• Angiotensin Receptor-Neprilysin Inhibitors (ARNIs): This newer class of drugs combines an ARB with a neprilysin inhibitor. Sacubitril/valsartan (Entresto) is a common ARNI used to treat heart failure with reduced ejection fraction. It has been shown to be more effective than ACE inhibitors or ARBs alone in reducing hospitalizations and improving outcomes.

• Beta-Blockers: These medications slow down the heart rate, lower blood pressure, and reduce the heart’s workload. They can improve heart function and reduce symptoms. Examples include carvedilol, metoprolol, and bisoprolol. It’s important to note that beta-blockers are usually started at low doses and gradually increased, as they may initially worsen symptoms in some patients.

• Diuretics (Water Pills): Diuretics help the body eliminate excess fluid and sodium, reducing fluid buildup and relieving symptoms like swelling and shortness of breath. Common diuretics include furosemide, bumetanide, and torsemide. It’s crucial to monitor electrolyte levels, especially potassium and magnesium, as some diuretics can cause them to be depleted.

• Potassium-Sparing Diuretics (Aldosterone Antagonists): These diuretics, such as spironolactone and eplerenone, not only help remove fluid but also block the effects of aldosterone, a hormone that can worsen heart failure. They have been shown to improve survival in patients with severe heart failure and reduced ejection fraction. Potassium levels need to be monitored closely, as these diuretics can cause potassium to build up to dangerous levels.

• Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors: Initially developed for diabetes, SGLT2 inhibitors like canagliflozin, dapagliflozin, and empagliflozin have become a cornerstone of heart failure treatment, even in patients without diabetes. They reduce hospitalizations and improve outcomes in various types of heart failure.

• Digoxin: This medication, also known as digitalis, strengthens heart contractions and slows down heart rate. It can be helpful in managing symptoms, especially in patients with atrial fibrillation or heart failure with reduced ejection fraction. Digoxin requires careful monitoring due to its potential for toxicity.

• Hydralazine and Isosorbide Dinitrate (BiDil): This combination medication helps relax blood vessels and improve blood flow. It is often used in patients with persistent symptoms despite other treatments, particularly in African Americans with heart failure.

• Vericiguat: This medication is a soluble guanylate cyclase (sGC) stimulator, which helps relax blood vessels and improve heart function. It is used to treat chronic heart failure, particularly after a recent worsening event.

• Positive Inotropes: These medications, such as dobutamine and milrinone, are typically administered intravenously in a hospital setting for patients with severe, decompensated heart failure. They strengthen heart contractions and improve blood pressure but are generally used short-term due to potential risks with long-term use.

Your heart failure doctor will carefully select and adjust your medications based on your specific condition and response to treatment. Regular follow-up appointments and monitoring are essential to optimize medication therapy.

Surgical Procedures and Devices for Heart Failure

In some cases, surgery or implantable devices may be necessary to treat the underlying cause of heart failure or to support heart function:

• Coronary Artery Bypass Graft (CABG) Surgery: If heart failure is caused by severe coronary artery disease, CABG surgery may be recommended to improve blood flow to the heart muscle. This involves grafting healthy blood vessels to bypass blocked arteries.

• Heart Valve Repair or Replacement: Damaged or diseased heart valves can contribute to heart failure. Valve repair or replacement surgery can correct these issues and improve heart function. Procedures can range from open-heart surgery to minimally invasive approaches.

• Implantable Cardioverter-Defibrillator (ICD): An ICD is a device implanted in the chest to monitor heart rhythm. If life-threatening arrhythmias occur, the ICD can deliver an electrical shock to restore a normal rhythm. ICDs are often recommended for patients at risk of sudden cardiac arrest due to heart failure.

• Cardiac Resynchronization Therapy (CRT): CRT, also known as biventricular pacing, is a treatment for patients with heart failure whose heart chambers are not beating in a coordinated manner. A special pacemaker sends electrical signals to synchronize the contractions of the ventricles, improving the heart’s pumping efficiency. CRT devices can also include defibrillator capabilities (CRT-D).

• Ventricular Assist Device (VAD): A VAD is a mechanical pump implanted to support the function of a weakened heart. VADs can be used as a bridge to heart transplantation or as destination therapy for patients who are not candidates for transplant.

• Heart Transplant: For patients with end-stage heart failure who do not respond to other treatments, heart transplantation may be considered. This involves replacing the diseased heart with a healthy donor heart. Heart transplantation is a complex procedure with strict eligibility criteria and requires lifelong immunosuppression medication.

Palliative Care and Hospice for Heart Failure

For individuals with advanced heart failure, palliative care and hospice care can play a vital role in improving quality of life. Palliative care focuses on symptom management, pain relief, and emotional support for patients and their families at any stage of serious illness. Hospice care is a type of palliative care specifically for those with a terminal illness, when life expectancy is limited.

Heart failure doctors specializing in palliative care can help manage symptoms like pain, shortness of breath, fatigue, and anxiety, ensuring comfort and dignity. Hospice care provides comprehensive support, including medical, emotional, and spiritual care, often in the patient’s home or a homelike setting. Discussing advance care planning and end-of-life wishes with your heart failure doctor and family is an important part of managing advanced heart failure.

Lifestyle Modifications for Managing Heart Failure

In addition to medications and procedures, lifestyle changes are essential for managing heart failure and improving overall well-being. Your heart failure doctor will guide you on these modifications:

• Smoking Cessation: Smoking significantly worsens heart failure and overall cardiovascular health. Quitting smoking is crucial. Seek support from your doctor or smoking cessation programs if needed.

• Fluid Management: Fluid retention is a hallmark of heart failure. Your doctor may recommend limiting fluid intake to prevent fluid overload. This includes monitoring daily fluid intake and being mindful of hidden fluids in foods.

• Sodium Restriction: Sodium (salt) causes the body to retain fluid, exacerbating heart failure symptoms. A low-sodium diet is essential. This involves limiting processed foods, restaurant meals, and added salt in cooking and at the table.

• Weight Monitoring: Daily weight monitoring is crucial. Sudden weight gain (2-3 pounds in a day or 5 pounds in a week) can indicate fluid retention and should be reported to your heart failure doctor promptly.

• Healthy Diet: A heart-healthy diet rich in fruits, vegetables, whole grains, and lean proteins is recommended. Limit saturated and trans fats, cholesterol, and refined sugars.

• Alcohol Limitation: Alcohol can worsen heart failure and interfere with medications. Your doctor may advise limiting or abstaining from alcohol.

• Regular Exercise: Moderate physical activity, as tolerated, is beneficial. Your doctor can recommend a safe and effective exercise program, often including cardiac rehabilitation.

• Stress Reduction: Stress can worsen heart failure symptoms. Practice stress-reducing techniques like mindfulness, meditation, yoga, or spending time on hobbies.

• Adequate Sleep: Aim for restful sleep. Elevating your head with pillows can help with shortness of breath at night. Address any sleep disorders like sleep apnea.

• Vaccinations: Get recommended vaccinations, such as annual flu shots, pneumonia vaccines, and COVID-19 vaccines, as infections can be particularly dangerous for people with heart failure.

Coping and Support for Heart Failure Patients

Living with heart failure can be challenging, both physically and emotionally. Building a strong support system and adopting effective coping strategies are crucial:

• Medication Adherence: Take medications exactly as prescribed and do not stop or change doses without consulting your heart failure doctor. Address any concerns about side effects or costs with your doctor.

• Regular Follow-up: Keep all scheduled appointments with your heart failure doctor and other healthcare providers. Regular monitoring and adjustments to your treatment plan are essential.

• Home Monitoring: Monitor your weight, blood pressure, and symptoms at home as instructed by your doctor. Keep a log and share it with your healthcare team.

• Know When to Seek Help: Recognize worsening symptoms and know when to contact your doctor or seek emergency care. Discuss specific warning signs with your heart failure doctor.

• Support Groups: Joining a heart failure support group can provide emotional support, practical advice, and a sense of community.

• Communicate with Your Healthcare Team: Be open and honest with your heart failure doctor and healthcare team about your symptoms, concerns, and challenges.

• Educate Yourself: Learn as much as you can about heart failure to better understand your condition and participate actively in your care.

• Maintain Social Connections: Stay connected with family and friends for emotional support and to combat feelings of isolation.

Preparing for Your Appointment with a Heart Failure Doctor

Being well-prepared for your appointments with a heart failure doctor will ensure you get the most out of your time together:

• Prepare a List of Symptoms: Write down all your symptoms, including when they started, how often they occur, and what makes them better or worse.

• Medical History: Be ready to discuss your medical history, including any past illnesses, surgeries, and family history of heart disease.

• Medication List: Bring a list of all medications, vitamins, and supplements you are taking, including dosages.

• Questions to Ask: Prepare a list of questions you have for your doctor. Prioritize your most important questions to ensure they are addressed during the appointment. Example questions could include:

  • What is the stage and severity of my heart failure?
  • What are my treatment options?
  • What lifestyle changes should I make?
  • What are the potential side effects of my medications?
  • What are the warning signs I should watch out for?
  • How often should I schedule follow-up appointments?

• Bring a Support Person: If possible, bring a family member or friend to your appointment. They can help take notes, remember information, and provide emotional support.

Finding the right heart failure doctor and actively participating in your care are vital steps in managing heart failure effectively. By understanding your diagnosis, treatment options, and lifestyle modifications, and by building a strong partnership with your healthcare team, you can live a fuller, healthier life with heart failure.

References:

1. Heart failure. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/heart-failure. Accessed Nov. 30, 2022.
2. Ferri FF. Heart failure. In: Ferri’s Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Nov. 30, 2022.
3. Colucci WS. Determining the etiology and severity of heart failure or cardiomyopathy. https://www.uptodate.com/contents/search. Accessed Nov. 30, 2022.
4. Colucci WS. Evaluation of the patient with suspected heart failure. https://www.uptodate.com/contents/search. Accessed Nov. 30, 2022.
5. Heart failure (HF). Merck Manual Professional Version. https://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure-hf. Accessed Nov. 28, 2022.
6. Vasan RS, et al. Epidemiology and causes of heart failure. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
7. Goldman L, et al., eds. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 28, 2022.
8. AskMayoExpert. Heart failure with reduced ejection fraction (HFrEF) (adult). Mayo Clinic; 2022.
9. Rakel D, ed. Heart failure. In: Integrative Medicine. 4th ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed Nov. 28, 2022.
10. AskMayoExpert. Heart failure with preserved ejection fraction (HFpEF) (adult). Mayo Clinic; 2022.
11. Allen L. Palliative care for patients with advanced heart failure: Decision support, symptom management, and psychosocial assistance. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
12. The dying patient. Merck Manual Professional Version. http://www.merckmanuals.com/professional/special-subjects/the-dying-patient/the-dying-patient. Accessed Nov. 28, 2022.
13. Nimmagadda R. Allscripts EPSi. Mayo Clinic. Aug. 12, 2024.
14. Mancini D. Heart transplantation in adults: Indications and contraindications. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
15. Sawalha K, et al. Systematic review of COVID-19 related myocarditis: Insights on management and outcome. Cardiovascular Revascularization Medicine. 2021; doi:10.1016/j.carrev.2020.08.028.
16. Armstrong PW, et al. Vericiguat in patients with heart failure and reduced ejection fraction. The New England Journal of Medicine. 2020; doi:10.1056/NEJMoa1915928.
17. Armstrong PW, et al. A multicenter, randomized, double-blind, placebo-controlled trial of the efficacy and safety of the oral soluble guanylate cyclase stimulator. Journal of the American College of Cardiology: Heart Failure. 2018; doi:10.1016/j.jchf.2017.08.013.
18. Verquvo (approval letter). New Drug Application 214377. U.S. Food and Drug Administration. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=214377. Accessed Nov. 28, 2022.
19. Heidenreich PA, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; doi:10.1161/CIR.0000000000001063.
20. Clarke JD, et al. Effect of inotropes on patient-reported health status in end-stage heart failure: A review of published clinical trials. Circulation: Heart Failure. 2021; doi:10.1161/CIRCHEARTFAILURE.120.007759.
21. Lopez-Jimenez F (expert opinion). Mayo Clinic. Dec. 2, 2021.
22. Types of heart failure. American Heart Association. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure. Accessed Nov. 28, 2022.
23. Zannad F, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet. 2020; doi:10.1016/S0140-6736(20)31824-9.
24. Sodium-glucose cotransporter-2 (SGLT2) inhibitors. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sodium-glucose-cotransporter-2-sglt2-inhibitors. Accessed Jan. 10, 2022.
25. Lee MCH, et al. Clinical efficacy of SGLT2 inhibitors with different SGLT1/SGLT2 selectivity in cardiovascular outcomes among patients with and without heart failure: A systematic review and meta-analysis of randomized trials. Medicine (Baltimore). 2022; doi:10.1097/MD.0000000000032489.
26. Mankad R (expert opinion). Mayo Clinic. Jan. 12, 2023.
27. ACC, AHA, HFSA issue heart failure guideline. American Heart Association. https://newsroom.heart.org/news/acc-aha-hfsa-issue-heart-failure-guideline. Accessed Jan. 31, 2023.