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Signs Your Heart Failure is Getting Worse

Written by Todd Neff on behalf of National Jewish Health
In a perfect world, heart failure would always be diagnosed before the first hint of symptoms. This can happen, usually when a patient with a family history of heart problems asks to see a cardiologist.

Physicians reviewing test results
More often, though, heart failure symptoms emerge quietly and, with time, get worse. There are two main ways of classifying heart failure. One from the New York Heart Association, the other from the American College of Cardiology and the American Heart Association. While they differ in focus, both use a four-tiered system that shows ways to tell if your heart failure is getting worse.

Classifying Heart Failure

The first stage involves no signs of heart failure at all, but recognizes a family history or chronic conditions that stress the heart such as high blood pressure.

The second stage involves feeling fine at rest, but noting symptoms such as:

  • Fatigue

  • Shortness of breath

  • Chest pain

  • Discomfort during normal physical activity

In the third stage, those symptoms appear with little physical activity. The fourth stage is serious heart failure with nonstop symptoms.

How to Know When Symptoms Get Worse

Ankie Amos, MD, a National Jewish Health cardiologist specializing in heart failure, stresses the importance of recognizing the subtle slide from one heart failure stage into the next. Worsening symptoms are an obvious warning sign, and so is retaining fluid, she says.

“Let’s say they have swelling in their ankles, or their pants are tighter, or they’re trying to sleep and are waking up gasping for air, or they feel suffocated or short of breath when lying flat and have to sleep with pillows – those are all signs that they’re collecting fluid,” explained Dr. Amos.

Sleep apnea also can be a concern. Roughly 80% of heart failure patients have sleep apnea, a condition where you stop breathing during sleep. Apnea can put pressure on the heart and make heart failure worse.

Changes in medication doses are warning signs for those who have been diagnosed with heart failure, said Dr. Amos. Patients should note if they’re having to lower their doses of heart failure medications because of low blood pressure. Having to boost their doses of diuretics (water pills) also can be a concern.

With advanced heart failure, worsening kidney function and more frequent hospital admissions are red flags.
“Each heart failure hospitalization takes over a year off your life,” said Dr. Amos. “Frequent hospitalizations are a sign that something is drastically wrong.”

Depending on your heart failure symptoms, heart failure doctors order a variety of tests to understand the cause of heart failure and to determine how well the heart is pumping blood. This information helps tailor treatment to each patient’s needs.

Heart Failure Tests & Procedures

The first goal of heart failure testing is to determine the underlying cause.

Blood tests can spot abnormal proteins that can lead to cardiac amyloidosis. That’s a major cause of heart failure with preserved ejection fraction (HFpEF, pronounced “hef-pef”), which makes up about half of heart failure cases. HFpEF happens when a heart stiffened or thickened from scarring, amyloidosis, or other causes can’t fill up properly and then pumps out too little blood with each beat.

Cardiac MRIs can see HFpEF scarring patterns, as well as structural problems and damage caused by coronary artery disease.

PET scans can provide deeper insights into the type of scarring and heart-muscle damage seen on a cardiac MRI.

The second goal of heart failure testing is to understand how well the heart is performing.

Cardiopulmonary stress tests see how much blood the heart can pump at by speeding up heart rate through exercise. Cardiopulmonary stress tests are important because patients often slide into worse and worse heart failure without noticing. Comparing recent tests with past ones also can quantify in a standard way how heart failure is getting worse.

“They’re not conscious of it, but they learn to adjust their lifestyles for their disease,” said Dr. Amos. “I’ve had so many people who say, ‘Yeah, I can do all my daily living, no problem,’ but then I do a cardiopulmonary stress test that standardizes effort, and I show them that, compared to their peers, they’re doing really poorly.”

Electrocardiograms (EKGs) measure the heart’s electrical activity and if there’s an irregular heartbeat.

Right-heart catheterization is considered the gold standard in measuring blood flow and blood pressure in the heart to show how well your heart is working.

How you feel can tell you a lot about whether your heart failure is getting worse. But heart failure specialists – not to mention other experts they bring in such as electrophysiologists, blood specialists (hematologists), kidney specialists (nephrologists) – use information gleaned from a wide variety of tests to establish the state of your heart. That’s essential to receiving timely treatment, slowing the progression of the disease and improving quality of life.
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