Editing Heart failure (section)

==Management==
{{main|Management of heart failure}}
Treatment focuses on improving the symptoms and preventing the progression of the disease. Reversible causes of heart failure also need to be addressed (e.g. [[infection]], alcohol ingestion, anemia, [[thyrotoxicosis]], [[Heart arrhythmia|arrhythmia]], and hypertension). Treatments include lifestyle and pharmacological modalities, and occasionally various forms of device therapy. Rarely, cardiac transplantation is used as an effective treatment when heart failure has reached the end stage.<ref name="pmid33069454">{{cite journal | vauthors = Cebeci F, Arikan B, Catal E, Bayezid O | title = A bridge to transplantation: The life experiences of patients with a left ventricular assist device | journal = Heart & Lung | volume = 50 | issue = 1 | pages = 106–112 | date = 2021 | pmid = 33069454 | doi = 10.1016/j.hrtlng.2020.09.020 | s2cid = 224780668 }}</ref>

===Acute decompensation===
{{main|Acute decompensated heart failure}}
In [[acute decompensated heart failure]], the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that [[ABC (medicine)|airway, breathing, and circulation]] are adequate. Immediate treatments usually involve some combination of vasodilators such as [[Nitroglycerin (medication)|nitroglycerin]], diuretics such as [[furosemide]], and possibly [[noninvasive positive pressure ventilation]]. [[Oxygen therapy|Supplemental oxygen]] is indicated in those with oxygen saturation levels below 90%, but is not recommended in those with normal oxygen levels in the normal atmosphere.<ref name=Pre2018>{{cite journal |title=Acute heart failure with dyspnoea. First-choice treatments |journal=Prescrire International |date=2018 |volume=27 |issue=194 |pages=160–162}}</ref>

===Chronic management===

The goals of treatment for people with chronic heart failure are prolonging life, preventing acute decompensation, and reducing symptoms, allowing for greater activity.

Heart failure can result from a variety of conditions. In considering therapeutic options, excluding reversible causes is of primary importance, including [[thyroid disease]], [[anemia]], chronic [[tachycardia]], [[alcohol use disorder]], [[hypertension]], and dysfunction of one or more [[heart valves]]. Treatment of the underlying cause is usually the first approach to treating heart failure. In most cases, though, either no primary cause is found or treatment of the primary cause does not restore normal heart function. In these cases, [[behavioral treatments|behavioral]], [[Medical treatment|medical]] and [[medical device|device]] treatment strategies exist that can provide a significant improvement in outcomes, including the relief of symptoms, exercise tolerance, and a decrease in the likelihood of [[hospitalization]] or death. Breathlessness rehabilitation for [[chronic obstructive pulmonary disease]] and heart failure has been proposed with exercise training as a core component. Rehabilitation should also include other interventions to address shortness of breath including the psychological and educational needs of people and the needs of caregivers.<ref>{{cite journal | vauthors = Man WD, Chowdhury F, Taylor RS, Evans RA, Doherty P, Singh SJ, Booth S, Thomason D, Andrews D, Lee C, Hanna J, Morgan MD, Bell D, Cowie MR | title = Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure | journal = Chronic Respiratory Disease | volume = 13 | issue = 3 | pages = 229–39 | date = August 2016 | pmid = 27072018 | pmc = 5029782 | doi = 10.1177/1479972316642363 }}</ref> [[Iron supplementation]] appears to reduce hospitalization but not all-cause mortality in patients with iron deficiency and heart
failure.<ref>{{cite journal | vauthors = Zhou X, Xu W, Xu Y, Qian Z | title = Iron Supplementation Improves Cardiovascular Outcomes in Patients with Heart Failure | journal = The American Journal of Medicine | volume = 132 | issue = 8 | pages = 955–963 | date = August 2019 | pmid = 30853478 | doi = 10.1016/j.amjmed.2019.02.018 | s2cid = 73725232 }}</ref>

==== Advance care planning ====
The latest evidence indicates that advance care planning (ACP) may help to increase documentation by medical staff regarding discussions with participants and improve an individual's depression.<ref name="Nishikawa2020">{{cite journal | vauthors = Nishikawa Y, Hiroyama N, Fukahori H, Ota E, Mizuno A, Miyashita M, Yoneoka D, Kwong JS | title = Advance care planning for adults with heart failure | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | pages = CD013022 | date = February 2020 | issue = 2 | pmid = 32104908 | pmc = 7045766 | doi = 10.1002/14651858.CD013022.pub2 | collaboration = Cochrane Heart Group }}</ref> This involves discussing an individual's future care plan, preferences, and values. The findings are, however, based on low-quality evidence.<ref name="Nishikawa2020" />

====Monitoring====
The various measures often used to assess the progress of people being treated for heart failure include [[fluid balance]] (calculation of fluid intake and excretion) and monitoring [[body weight]] (which in the shorter term reflects fluid shifts).<ref>{{cite journal | vauthors = Yu CM, Wang L, Chau E, Chan RH, Kong SL, Tang MO, Christensen J, Stadler RW, Lau CP | title = Intrathoracic impedance monitoring in patients with heart failure: correlation with fluid status and feasibility of early warning preceding hospitalization | journal = Circulation | volume = 112 | issue = 6 | pages = 841–848 | date = August 2005 | pmid = 16061743 | doi = 10.1161/CIRCULATIONAHA.104.492207 | doi-access = free }}</ref> Remote monitoring can be effective to reduce complications for people with heart failure.<ref>{{cite journal | vauthors = Bashi N, Karunanithi M, Fatehi F, Ding H, Walters D | title = Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews | journal = Journal of Medical Internet Research | volume = 19 | issue = 1 | pages = e18 | date = January 2017 | pmid = 28108430 | pmc = 5291866 | doi = 10.2196/jmir.6571 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG | title = Structured telephone support or non-invasive telemonitoring for patients with heart failure | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 10 | pages = CD007228 | date = October 2015 | pmid = 26517969 | pmc = 8482064 | doi = 10.1002/14651858.CD007228.pub3 | url = https://dspace.flinders.edu.au/xmlui/bitstream/2328/35732/1/Inglis%20Structured%202015.pdf | access-date = 25 September 2019 | url-status = live | archive-date = 28 August 2021 | archive-url = https://web.archive.org/web/20210828103110/https://dspace.flinders.edu.au/xmlui/bitstream/handle/2328/35732/Inglis%20Structured%202015.pdf;jsessionid=B2254F0FEBB8F13B06AFE621E018A88A?sequence=1 | hdl = 2328/35732 }}</ref>

====Lifestyle====
Behavior modification is a primary consideration in chronic heart failure management programs, with [[dietary guidelines]] regarding [[Drinking water|fluid]] and [[Sodium chloride|salt]] intake.<ref name="hf-prevention lifestyle">{{cite web |url=http://www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp |title=Lifestyle Changes for Heart Failure |publisher=[[American Heart Association]] |url-status=live |archive-url=https://web.archive.org/web/20150503123439/http://www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp |archive-date=3 May 2015 }}</ref> Fluid restriction is important to reduce fluid retention in the body and to correct the hyponatremic status of the body.<ref name="US cardiology 2008"/> The evidence of the benefit of reducing salt, however, is poor as of 2018.<ref>{{cite journal | vauthors = Mahtani KR, Heneghan C, Onakpoya I, Tierney S, Aronson JK, Roberts N, Hobbs FD, Nunan D | title = Reduced Salt Intake for Heart Failure: A Systematic Review | journal = JAMA Internal Medicine | volume = 178 | issue = 12 | pages = 1693–1700 | date = November 2018 | pmid = 30398532 | doi = 10.1001/jamainternmed.2018.4673 | s2cid = 53241717 | pmc = 6422065 }}</ref> Thirst is a common and burdensome symptom for patients to cope with. Chewing gum is an effective intervention to relieve thirst in patients experiencing heart failure, although patient acceptability remains an issue.<ref>{{Cite journal |last1=Allida |first1=Sabine M. |last2=Shehab |first2=Sajad |last3=Inglis |first3=Sally C. |last4=Davidson |first4=Patricia M. |last5=Hayward |first5=Christopher S. |last6=Newton |first6=Phillip J. |date=April 2021 |title=A RandomisEd ControLled TrIal of ChEwing Gum to RelieVE Thirst in Chronic Heart Failure (RELIEVE-CHF) |url=https://www.heartlungcirc.org/article/S1443-9506(20)30480-7/fulltext |journal=Heart, Lung and Circulation |language=English |volume=30 |issue=4 |pages=516–524 |doi=10.1016/j.hlc.2020.09.004 |pmid=33032897 |hdl=10453/146390 |issn=1443-9506 |archive-url=https://web.archive.org/web/20231115093428/https://www.heartlungcirc.org/article/S1443-9506(20)30480-7/fulltext |archive-date=15 November 2023 |access-date=15 November 2023 |url-status=live |hdl-access=free }}</ref>

====Exercise and physical activity====
Exercise should be encouraged and tailored to suit an individual's capabilities. A meta-analysis found that center-based group interventions delivered by a physiotherapist help promote physical activity in HF.<ref>{{cite journal | vauthors = Amirova A, Fteropoulli T, Williams P, Haddad M | title = Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis | language = English | journal = Open Heart | volume = 8 | issue = 1 | pages = e001687 | date = June 2021 | pmid = 34108272 | pmc = 8191629 | doi = 10.1136/openhrt-2021-001687 | oclc = 9066065537 }}</ref> There is a need for additional training for physiotherapists in delivering behavior change intervention alongside an exercise program. An intervention is expected to be more efficacious in encouraging physical activity than the usual care if it includes ''Prompts and cues'' to walk or exercise, like a phone call or a text message. It is helpful if a trusted clinician provides explicit advice to engage in physical activity (''Credible source''). Another highly effective strategy is to place objects that will serve as a cue to engage in physical activity in the person's everyday environment (''Adding object to the environment''; e.g., exercise step or treadmill). Encouragement to walk or exercise in various settings beyond CR (e.g., home, neighborhood, parks) is also promising (''Generalisation of target behavior''). Additional promising strategies are ''Graded tasks'' (e.g., gradual increase in intensity and duration of exercise training), ''Self-monitoring'', ''Monitoring of physical activity by others without feedback'', ''Action planning'', and ''Goal-setting''.<ref>{{cite journal | vauthors = Amirova A, Fteropoulli T, Williams P, Haddad M | title = Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis | journal = Open Heart | volume = 8 | issue = 1 | pages = e001687 | date = June 2021 | pmid = 34108272 | pmc = 8191629 | doi = 10.1136/openhrt-2021-001687 | doi-access = free }}</ref> The inclusion of regular physical conditioning as part of a [[cardiac rehabilitation]] program can significantly improve [[quality of life]] and reduce the risk of hospital admission for worsening symptoms, but no evidence shows a reduction in mortality rates as a result of exercise.

Home visits and regular monitoring at heart-failure clinics reduce the need for hospitalization and improve [[life expectancy]].<ref name="Feltner 2014">{{cite journal | vauthors = Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, Arvanitis M, Lohr KN, Middleton JC, Jonas DE | title = Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis | journal = Annals of Internal Medicine | volume = 160 | issue = 11 | pages = 774–84 | date = June 2014 | pmid = 24862840 | doi = 10.7326/M14-0083 | doi-access =  | s2cid = 262525144 | hdl = 11250/2485759 | hdl-access = free }}</ref>

====Medication====
Quadruple medical therapy using a combination of [[sacubitril/valsartan|angiotensin receptor-neprilysin inhibitors (ARNI)]], [[beta blocker]]s, [[Antimineralocorticoid|mineralocorticoid receptor antagonists (MRA)]], and [[SGLT2 inhibitor|sodium/glucose cotransporter 2 inhibitors (SGLT2 inhibitors)]] is the standard of care as of 2021 for heart failure with reduced ejection fraction (HFrEF).<ref>{{cite journal | vauthors= Greene S, Khan M, et al. |title=Quadruple Medical Therapy for Heart Failure |journal = J Am Coll Cardiol |date= March 2021 |volume= 77 |issue=11 |pages=1408–1411  |doi=10.1016/j.jacc.2021.02.006 |pmid=33736822 |s2cid=232299815 |doi-access=free }}</ref><ref>{{cite journal |vauthors=Straw S, McGinlay M, Witte KK  |title= Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction |journal=[[Open Heart (journal)|Open Heart]] |date= 2021  |volume= 8 |issue= 1 |page=e001585 |doi= 10.1136/openhrt-2021-001585|pmid= 33653703 |pmc= 7929859 }}</ref>

There is no convincing evidence for pharmacological treatment of heart failure with preserved ejection fraction (HFpEF).<ref name="ESC2021">{{cite journal | vauthors = McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JG, Coats AJ, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CS, Lyon AR, McMurray JJ, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GM, Ruschitzka F, Kathrine Skibelund A | title = 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure | journal = European Heart Journal | volume = 42 | issue = 36 | pages = 3599–3726 | date = September 2021 | pmid = 34447992 | doi = 10.1093/eurheartj/ehab368 | url = https://academic.oup.com/eurheartj/article-pdf/42/36/3599/40594787/ehab368.pdf | access-date = 7 February 2023 | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20220908043625/https://academic.oup.com/eurheartj/article-pdf/42/36/3599/40594787/ehab368.pdf | archive-date = 8 September 2022 }}</ref> Medication for HFpEF is symptomatic treatment with diuretics to treat congestion.<ref name="ESC2021"/> Managing risk factors and comorbidities such as [[hypertension]] is recommended in HFpEF.<ref name="ESC2021"/>

Inhibitors of the [[renin–angiotensin system]] (RAS) are recommended for heart failure. The [[sacubitril/valsartan|angiotensin receptor-neprilysin inhibitors (ARNI) sacubitril/valsartan]] is recommended as the first choice of RAS inhibitors in American guidelines published by AHA/ACC in 2022.<ref name="AHA2022"/> Use of [[ACE inhibitor]], or [[angiotensin receptor blockers]] (ARBs) if the person develops a long-term cough as a side effect of the ACE-I,<ref>{{cite book | vauthors = Goljan EF |title=Rapid Review Pathology |edition = 4th |location=Philadelphia, PA |publisher=Saunders/Elsevier |date=2014 |isbn=978-0-323-08787-2 }}</ref> is associated with improved survival, fewer hospitalizations for heart failure exacerbations, and improved quality of life in people with heart failure.<ref name=NICECG108>{{NICE|108|Chronic heart failure – managements (ARBs) of chronic heart failure in adults in primary and secondary care | August 2010}}</ref> European guidelines published by ESC in 2021 recommends that [[sacubitril/valsartan|ARNI]] should be used in those who still have symptoms while on an [[ACE inhibitor|ACE-I]] or [[angiotensin receptor blocker|ARB]], [[beta blocker]], and a [[mineralocorticoid receptor antagonist]]. Use of the combination agent ARNI requires the cessation of ACE-I or ARB therapy at least 36 hours before its initiation.<ref name="AHA2022"/>

[[Beta blockers|Beta-adrenergic blocking agents (beta blockers)]] add to the improvement in symptoms and [[Case fatality rate|mortality]] provided by ACE-I/ARB.<ref name=NICECG108 /><ref>{{cite journal | vauthors = Kotecha D, Manzano L, Krum H, Rosano G, Holmes J, Altman DG, Collins PD, Packer M, Wikstrand J, Coats AJ, Cleland JG, Kirchhof P, von Lueder TG, Rigby AS, Andersson B, Lip GY, van Veldhuisen DJ, Shibata MC, Wedel H, Böhm M, Flather MD | title = Effect of age and sex on efficacy and tolerability of β blockers in patients with heart failure with reduced ejection fraction: individual patient data meta-analysis | journal = BMJ | volume = 353 | pages = i1855 | date = April 2016 | pmid = 27098105 | pmc = 4849174 | doi = 10.1136/bmj.i1855 }}</ref> The mortality benefits of beta blockers in people with systolic dysfunction who also have [[atrial fibrillation]] is more limited than in those who do not have it.<ref name="Kotecha 2014">{{cite journal | vauthors = Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, Lip GY, Coats AJ, Andersson B, Kirchhof P, von Lueder TG, Wedel H, Rosano G, Shibata MC, Rigby A, Flather MD | title = Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis | journal = Lancet | volume = 384 | issue = 9961 | pages = 2235–43 | date = December 2014 | pmid = 25193873 | doi = 10.1016/S0140-6736(14)61373-8 | s2cid = 25660815 | url = http://pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf | access-date = 27 May 2019 | archive-date = 28 September 2020 | archive-url = https://web.archive.org/web/20200928221341/http://pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf | url-status = live }}</ref> If the ejection fraction is not diminished (HFpEF), the benefits of beta blockers are more modest; a decrease in mortality has been observed, but reduction in hospital admission for uncontrolled symptoms has not been observed.<ref>{{cite journal | vauthors = Liu F, Chen Y, Feng X, Teng Z, Yuan Y, Bin J | title = Effects of beta-blockers on heart failure with preserved ejection fraction: a meta-analysis | journal = PLOS ONE | volume = 9 | issue = 3 | pages = e90555 | date = 5 March 2014 | pmid = 24599093 | pmc = 3944014 | doi = 10.1371/journal.pone.0090555 | bibcode = 2014PLoSO...990555L | doi-access = free }}</ref>

In people who are intolerant of ACE-I and ARB or who have significant kidney dysfunction, the use of combined [[hydralazine]] and a long-acting nitrate, such as [[isosorbide dinitrate]], is an effective alternate strategy. This regimen has been shown to reduce mortality in people with moderate heart failure.<ref name="NatClinGuide CHF">{{cite book | chapter = Chapter 5: Treating heart failure | title = Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care | edition = Partial Update [Internet]. | author = National Clinical Guideline Centre (UK) | publisher = Royal College of Physicians | location = London (UK) | date = August 2010 | chapter-url = https://www.ncbi.nlm.nih.gov/books/NBK65330/ | access-date = 31 August 2017 | archive-date = 6 September 2017 | archive-url = https://web.archive.org/web/20170906120901/https://www.ncbi.nlm.nih.gov/books/NBK65330/ | url-status = live }}</ref> It is especially beneficial in the black population.{{efn|Specifically, in one randomized control trial the patients self-identified as black (defined as of African descent), and in one randomized control trial the patients were defined as ''black'', without further details given.<ref name="NatClinGuide CHF" />}}<ref name="NatClinGuide CHF" />

Use of a [[mineralocorticoid antagonist]], such as [[spironolactone]] or [[eplerenone]], in addition to beta blockers and ACE-I, can improve symptoms and reduce mortality in people with symptomatic heart failure with reduced ejection fraction (HFrEF).<ref name="NICE2018ch6"/>

[[SGLT2 inhibitor]]s are used for heart failure with reduced ejection fraction as they have demonstrated benefits in reducing hospitalizations and mortality, regardless of whether an individual has comorbid Type 2 Diabetes or not.<ref name="AHA2022">{{cite journal | vauthors = Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW | title = 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 | journal = Journal of the American College of Cardiology | volume = 79 | issue = 17 | pages = e263–e421 | date = May 2022 | pmid = 35379503 | doi = 10.1016/j.jacc.2021.12.012 | s2cid = 247882156 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Zannad F, Ferreira JP, Pocock SJ, Anker SD, Butler J, Filippatos G, Brueckmann M, Ofstad AP, Pfarr E, Jamal W, Packer M | title = SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials | journal = Lancet | volume = 396 | issue = 10254 | pages = 819–829 | date = September 2020 | pmid = 32877652 | doi = 10.1016/S0140-6736(20)31824-9 }}</ref>

=====Other medications=====
Second-line medications for CHF do not confer a mortality benefit. [[Digoxin]] is one such medication. Its narrow therapeutic window, a high degree of toxicity, and the failure of multiple trials to show a mortality benefit have reduced its role in clinical practice. It is now used in only a small number of people with refractory symptoms, who are in atrial fibrillation, and/or who have chronic hypotension.<ref>{{cite web| url=https://www.lecturio.com/concepts/congestive-heart-failure/| title=Congestive Heart Failure| website=The Lecturio Medical Concept Library| date=7 August 2020| access-date=10 July 2021| archive-date=10 July 2021| archive-url=https://web.archive.org/web/20210710035402/https://www.lecturio.com/concepts/congestive-heart-failure/| url-status=live}}</ref><ref>{{cite web|title=Digoxin|url=https://www.drugs.com/monograph/digoxin.html|publisher=The American Society of Health-System Pharmacists|access-date=8 December 2016|url-status=live|archive-url=https://web.archive.org/web/20161221004328/https://www.drugs.com/monograph/digoxin.html|archive-date=21 December 2016}}</ref>

Diuretics have been a mainstay of treatment against symptoms of fluid accumulation, and include diuretics classes such as [[loop diuretic]]s (such as [[furosemide]]), [[thiazide-like diuretic]]s, and [[potassium-sparing diuretic]]s. Although widely used, evidence on their efficacy and safety is limited, except for [[mineralocorticoid antagonist]]s such as [[spironolactone]].<ref name="NICE2018ch6"/><ref name=vonLueder>{{cite journal | vauthors = von Lueder TG, Atar D, Krum H | title = Diuretic use in heart failure and outcomes | journal = Clinical Pharmacology and Therapeutics | volume = 94 | issue = 4 | pages = 490–8 | date = October 2013 | pmid = 23852396 | doi = 10.1038/clpt.2013.140 | s2cid = 7441258 }}</ref>

Anemia is an independent factor in mortality in people with chronic heart failure. Treatment of anemia significantly improves the quality of life for those with heart failure, often with a reduction in severity of the NYHA classification, and also improves mortality rates.<ref name=He2009>{{cite journal | vauthors = He SW, Wang LX | title = The impact of anemia on the prognosis of chronic heart failure: a meta-analysis and systemic review | journal = Congestive Heart Failure | volume = 15 | issue = 3 | pages = 123–30 | year = 2009 | pmid = 19522961 | doi = 10.1111/j.1751-7133.2008.00030.x | doi-access = free }}</ref><ref>{{cite journal | vauthors = Nunez-Gil MI, Peraira-Moral MJ |title=Anaemia in heart failure: intravenous iron therapy |journal=e-Journal of the ESC Council for Cardiology Practice |volume=10 |issue=16 |date=19 January 2012 |url=http://www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx |url-status=dead |archive-url=https://web.archive.org/web/20130603124155/http://www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx |archive-date=3 June 2013 |df=dmy-all |access-date=3 October 2012 }}</ref> The [[European Society of Cardiology]] recommends screening for iron deficiency and treating with [[parenteral iron|intravenous iron]] if deficiency is found.<ref name="ESC2021"/>{{rp|pages=3668–3669}}

The decision to anticoagulate people with HF, typically with left ventricular ejection fractions <35% is debated, but generally, people with coexisting atrial fibrillation, a prior embolic event, or conditions that increase the risk of an embolic event such as amyloidosis, left ventricular noncompaction, familial dilated cardiomyopathy, or a thromboembolic event in a first-degree relative.<ref name="Hunt-2005" />

[[Vasopressin receptor antagonist]]s can also treat heart failure. [[Conivaptan]] is the first medication approved by the US [[Food and Drug Administration]] for the treatment of euvolemic hyponatremia in those with heart failure.<ref name="US cardiology 2008"/> In rare cases hypertonic 3% saline together with diuretics may be used to correct hyponatremia.<ref name="US cardiology 2008"/>

[[Ivabradine]] is recommended for people with symptomatic heart failure with reduced left ventricular ejection fraction who are receiving optimized guideline-directed therapy (as above) including the maximum tolerated dose of beta-blocker, have a normal heart rhythm and continue to have a resting heart rate above 70 beats per minute.<ref name=ACC2017/> Ivabradine has been found to reduce the risk of hospitalization for heart failure exacerbations in this subgroup of people with heart failure.<ref name=ACC2017>{{cite journal | vauthors = Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C | title = 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America | journal = Circulation | volume = 136 | issue = 6 | pages = e137–e161 | date = August 2017 | pmid = 28455343 | doi = 10.1161/CIR.0000000000000509 | doi-access = free }}</ref>

====Implanted devices====
In people with severe cardiomyopathy (left ventricular ejection fraction below 35%), or in those with recurrent VT or malignant arrhythmias, treatment with an automatic implantable cardioverter-defibrillator (AICD) is indicated to reduce the risk of severe life-threatening arrhythmias. The AICD does not improve symptoms or reduce the incidence of malignant arrhythmias but does reduce mortality from those arrhythmias, often in conjunction with antiarrhythmic medications. In people with left ventricular ejection (LVEF) below 35%, the incidence of [[ventricular tachycardia]] or [[sudden cardiac death]] is high enough to warrant AICD placement. Its use is therefore recommended in [[American Hospital Association|AHA]]/[[American College of Cardiology|ACC]] guidelines.<ref name="Guidelines rhythm-abnormalities" />

[[Cardiac contractility modulation]] (CCM) is a [[Therapy|treatment]] for people with moderate to severe [[Heart#Chambers|left ventricular]] systolic heart failure (NYHA classes II–IV), which enhances both the strength of ventricular [[Muscle contraction|contraction]] and the heart's pumping capacity. The CCM mechanism is based on stimulation of the cardiac muscle by [[Action potential#Refractory period|nonexcitatory electrical signals]], which are delivered by a [[Artificial cardiac pacemaker|pacemaker]]-like device. CCM is particularly suitable for the treatment of heart failure with normal [[QRS complex]] duration (120 ms or less) and has been demonstrated to improve the symptoms, quality of life, and exercise tolerance.<ref name="Kuck 2013" /><ref name="Abraham 2013">{{cite journal | vauthors = Abraham WT, Smith SA | title = Devices in the management of advanced, chronic heart failure | journal = Nature Reviews. Cardiology | volume = 10 | issue = 2 | pages = 98–110 | date = February 2013 | pmid = 23229137 | pmc = 3753073 | doi = 10.1038/nrcardio.2012.178 }}</ref><ref name="Giallauria 2014">{{cite journal|vauthors=Giallauria F, Vigorito C, Piepoli MF, Stewart Coats AJ|date=August 2014|title=Effects of cardiac contractility modulation by non-excitatory electrical stimulation on exercise capacity and quality of life: an individual patient's data meta-analysis of randomized controlled trials|journal=International Journal of Cardiology|volume=175|issue=2|pages=352–7|doi=10.1016/j.ijcard.2014.06.005|pmid=24975782}}<!--| access-date = Oct 10, 2014--></ref><ref name="Borggrefe 2012">{{cite journal|vauthors=Borggrefe M, Burkhoff D|date=July 2012|title=Clinical effects of cardiac contractility modulation (CCM) as a treatment for chronic heart failure|journal=European Journal of Heart Failure|volume=14|issue=7|pages=703–12|doi=10.1093/eurjhf/hfs078|pmid=22696514|s2cid=10484257|doi-access=free}}<!--| access-date = Oct 11, 2014--></ref><ref name="Kuschyk 2015">{{cite journal | vauthors = Kuschyk J, Roeger S, Schneider R, Streitner F, Stach K, Rudic B, Weiß C, Schimpf R, Papavasilliu T, Rousso B, Burkhoff D, Borggrefe M | title = Efficacy and survival in patients with cardiac contractility modulation: long-term single center experience in 81 patients | journal = International Journal of Cardiology | volume = 183 | issue = 183C | pages = 76–81 | date = March 2015 | pmid = 25662055 | doi = 10.1016/j.ijcard.2014.12.178 }}</ref> CCM is approved for use in Europe, and was approved by the Food and Drug Administration for use in the United States in 2019.<ref name="Kuschyk 2014a">{{cite journal | title = Der Besondere Stellenwert der Kardialen Kontraktilitätsmodulation in der Devicetherapie | journal = Herzmedizin | date = 2014 | vauthors = Kuschyk J | url = http://cme.medlearning.de/herzmedizin/kardialen_kontraktilitaetsmodulation/cme.htm | access-date = Jun 6, 2014 | url-status = live | archive-url = https://web.archive.org/web/20150705113329/http://cme.medlearning.de/herzmedizin/kardialen_kontraktilitaetsmodulation/cme.htm | archive-date = 5 July 2015 | df = dmy-all }}</ref><ref name="clinicaltrials">{{ClinicalTrialsGov|NCT01381172|Evaluate Safety and Efficacy of the OPTIMIZER System in Subjects With Moderate-to-Severe Heart Failure: FIX-HF-5C (FIX-HF-5C)}}</ref><ref name="DAIC 2019">{{cite web | title=FDA Approves Optimizer Smart System for Heart Failure Patients | website=Diagnostic and Interventional Cardiology (DAIC) | date=2019-03-21 | url=http://www.dicardiology.com/product/fda-approves-optimizer-smart-system-heart-failure-patients | access-date=2022-06-25 | archive-date=19 March 2023 | archive-url=https://web.archive.org/web/20230319124802/https://www.dicardiology.com/product/fda-approves-optimizer-smart-system-heart-failure-patients | url-status=live }}</ref>

About one-third of people with an [[LVEF]] below 35% have markedly altered conduction to the ventricles, resulting in dyssynchronous depolarization of the right and left ventricles. This is especially problematic in people with left bundle branch block (blockage of one of the two primary conducting fiber bundles that originate at the base of the heart and carry depolarizing impulses to the left ventricle). Using a special pacing algorithm, biventricular [[cardiac resynchronization therapy]] (CRT) can initiate a normal sequence of ventricular depolarization. In people with LVEF below 35% and prolonged QRS duration on ECG (LBBB or QRS of 150 ms or more), an improvement in symptoms and mortality occurs when CRT is added to standard medical therapy.<ref name=ACCFAHA2013>{{cite journal | vauthors = Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL | title = 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines | journal = Circulation | volume = 128 | issue = 16 | pages = e240–327 | date = October 2013 | pmid = 23741058 | doi = 10.1161/CIR.0b013e31829e8776 | doi-access = free }}</ref> However, in the two-thirds of people without prolonged QRS duration, CRT may be harmful.<ref name="Guidelines rhythm-abnormalities" /><ref name="Kuck 2013" /><ref name="Ruschitzka 2013">{{cite journal | vauthors = Ruschitzka F, Abraham WT, Singh JP, Bax JJ, Borer JS, Brugada J, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J | title = Cardiac-resynchronization therapy in heart failure with a narrow QRS complex | journal = The New England Journal of Medicine | volume = 369 | issue = 15 | pages = 1395–405 | date = October 2013 | pmid = 23998714 | doi = 10.1056/NEJMoa1306687 | s2cid = 205095941 | url = https://www.zora.uzh.ch/id/eprint/84125/1/Ruschitzka_NEJMechoCRT.pdf | access-date = 24 November 2018 | archive-date = 28 July 2020 | archive-url = https://web.archive.org/web/20200728222046/https://www.zora.uzh.ch/id/eprint/84125/1/Ruschitzka_NEJMechoCRT.pdf | url-status = live }}</ref>

====Surgical therapies====
People with the most severe heart failure may be candidates for [[ventricular assist device]]s, which have commonly been used as a bridge to heart transplantation but have been used more recently as a destination treatment for advanced heart failure.<ref name="Carrel 2012">{{cite journal | vauthors = Carrel T, Englberger L, Martinelli MV, Takala J, Boesch C, Sigurdadottir V, Gygax E, Kadner A, Mohacsi P | title = Continuous flow left ventricular assist devices: a valid option for heart failure patients | journal = [[Swiss Medical Weekly]] | volume = 142 | pages = w13701 | date = Oct 18, 2012 | pmid = 23135811 | doi = 10.4414/smw.2012.13701 | doi-access = free }}</ref>

In select cases, heart transplantation can be considered. While this may resolve the problems associated with heart failure, the person must generally remain on an immunosuppressive regimen to prevent rejection, which has its own significant downsides.<ref name="Lindenfeld 2004">{{cite journal | vauthors = Lindenfeld J, Miller GG, Shakar SF, Zolty R, Lowes BD, Wolfel EE, Mestroni L, Page RL, Kobashigawa J | title = Drug therapy in the heart transplant recipient: part I: cardiac rejection and immunosuppressive drugs | journal = Circulation | volume = 110 | issue = 24 | pages = 3734–40 | date = December 2004 | pmid = 15596559 | doi = 10.1161/01.cir.0000149745.83186.89 | doi-access = free }}</ref> A major limitation of this treatment option is the scarcity of hearts available for transplantation.

===Palliative care===
People with heart failure often have significant symptoms, such as shortness of breath and chest pain. Palliative care should be initiated early in the HF trajectory, and should not be an option of last resort.<ref name="Kavalieratos2017">{{cite journal | vauthors = Kavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ, Goldstein N, Kimmel SE, Bakitas MA, Arnold RM | title = Palliative Care in Heart&nbsp;Failure: Rationale, Evidence, and Future Priorities | journal = Journal of the American College of Cardiology | volume = 70 | issue = 15 | pages = 1919–1930 | date = October 2017 | pmid = 28982506 | pmc = 5731659 | doi = 10.1016/j.jacc.2017.08.036 }}</ref> Palliative care can not only provide symptom management, but also assist with advanced care planning, goals of care in the case of a significant decline, and making sure the person has a medical [[power of attorney]] and discussed his or her wishes with this individual.<ref name=AHAJournPallaiative>{{cite journal | vauthors = Adler ED, Goldfinger JZ, Kalman J, Park ME, Meier DE | title = Palliative care in the treatment of advanced heart failure | journal = Circulation | volume = 120 | issue = 25 | pages = 2597–606 | date = December 2009 | pmid = 20026792 | doi = 10.1161/CIRCULATIONAHA.109.869123 | doi-access = free }}</ref> A 2016 and 2017 review found that palliative care is associated with improved outcomes, such as quality of life, symptom burden, and satisfaction with care.<ref name="Kavalieratos2017"/><ref name="Kavalieratos2016">{{cite journal | vauthors = Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, Hoydich ZP, Ikejiani DZ, Klein-Fedyshin M, Zimmermann C, Morton SC, Arnold RM, Heller L, Schenker Y | title = Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis | journal = JAMA | volume = 316 | issue = 20 | pages = 2104–2114 | date = November 2016 | pmid = 27893131 | pmc = 5226373 | doi = 10.1001/jama.2016.16840 }}</ref>

Without transplantation, heart failure may not be reversible and heart function typically deteriorates with time. The growing number of people with stage IV heart failure (intractable symptoms of fatigue, shortness of breath, or chest pain at rest despite optimal medical therapy) should be considered for palliative care or [[hospice]], according to American College of Cardiology/American Heart Association guidelines.<ref name=AHAJournPallaiative/>