1.  Previous heart attack(s) or Ischemic heart disease
2.  Valvular heart disease (marked obstruction or leaking of a heart valve)
3.  Persistent high blood pressure or Hypertensive heart disease
4.  Viral or Idiopathic (unknown)
5.  Alcoholic abuse (long-term heavy alcohol consumption)
6.  Genetic diseases

Symptoms
A.  Exercise intolerance, fatigue, cool hands and feet - known as “Forward failure”
B.  Shortness of breath, swelling of abdomen and legs/feet - known as “Backward failure”

Physical examination
Swollen veins in neck, crackling in lungs, swelling of legs/feet, and abnormal heart sounds

Laboratory Tests
A.  Elevated B-type natriuretic peptide (BNP)
B.  Electrocardiogram: evidence of heart attack

Electrocardiogram - Normal ST SegmentsElectrocardiogram – ST Segment Elevation

Imaging
A.  Chest X-ray: enlarged heart and fluid in lungs

B.  Echocardiogram (ultrasound of heart): decreased pumping function, abnormal heart chamber size or wall thickness, valvular disease

C.  CT angiogram

D.  MRI

E.  Heart catheterization and coronary angiogram

Class I (Mild):
You have no limits to your daily activities. You are able to do all of your normal daily activities without becoming tired, short of breath or having heart palpitations.

Class II (Mild):
You have some limits to your daily activities. You are comfortable at rest, but normal activities may cause you to be tired, short of breath or have heart palpitations.

Class III (Moderate):
Your daily activities are greatly limited. You are comfortable at rest, but are unable to do daily activities without becoming tired, short of breath or having heart palpitations.

Class IV (Severe):
You are unable to do any physical activity without discomfort. You become tired, short of breath and possibly have heart palpitations even when you are at rest. Any physical activity makes your discomfort worse.

1.  Discontinuing smoking and alcohol use
2.  Regular aerobic exercise
3.  Weight loss
4.  Low sodium diet

Coronary revascularization
This therapy is for patients with significant coronary artery disease. These patients may or may not have had a previous heart attack. Treatment can be via heart catheterization with balloon angioplasty or stent placement. Alternatively, coronary artery bypass surgery can be performed.

Implantable cardioverter defibrillator (ICD) placement
This therapy typically involves implanting a generator in the upper chest with one or more leads (wires) running through veins into the heart. The heart rhythm can be monitored, and the heart can be shocked if there is a dangerous or life-threatening abnormal heart rhythm detected. Dangerous heart rhythm abnormalities include bradycardia (slow heart rate) or tachycardia (fast heart rate).

Biventricular pacemaker placement (also called cardiac resynchronization therapy: CRT)
This therapy involves implanting a generator in the upper chest and three leads into the heart. The leads are placed putting one in the right atrium, one in the right ventricle and one in the coronary sinus overlying the left ventricle. This therapy is often combined with a defibrillator in a single device. Standard indications for this therapy include: 

• Left ventricular ejection fraction < 35%
• Wide (> 120 ms) QRS complex on ECG
• Advanced symptoms of heart failure on good medical therapy

Left ventricular assist devices (LVAD)

This therapy has recently been approved for patients with very advanced heart failure. A number of different devices are being studied and used in patients. These devices act to support the failing heart by assisting in improving blood output from the left ventricle to the body. An example of one type of LVAD is shown.

From Medscape^® (www.medscape.com)

Heart transplantation
Heart transplantation is a surgery that involves removing a seriously damaged heart from a patient with heart failure and replacing it with a healthy heart from an individual who has recently died. Heart transplantation is a therapy reserved for very sick heart failure patients who have severe symptoms of heart failure despite aggressive drug and/or device therapy. Survival following heart transplantation is about 85% at 1 year and 70% at 5 years. Approximately 4,000 people are on waiting lists for heart transplantation but only about 2,000 heart transplants are performed each year due to the limited number of donor hearts.

Primary Care Physicians:
These physicians often manage the overall care of the heart failure patient and work with other specialists in collaboration to care for the patient.

General Cardiologists:
Many heart failure patients are seen and managed by General Cardiologists.

Heart Failure Cardiologists:
Some Cardiologists specialize in the care of heart failure patients. These physicians often see patients with more complex or advanced disease.

Heart Failure Nurse Clinicians or Nurse Practitioners:
These individuals are specially trained in heart failure and perform services such as patient education, drug monitoring and titration and disease management. They usually work in close collaboration with a Cardiologist.

Electrophysiologists:
These Cardiology physicians specialize in electrical abnormalities of the heart. They treat abnormal heart rhythms, and implant pacemakers and defibrillators (devices which can electrically shock the heart out of dangerous rhythms).

Cardiac Surgeons:
These specialists perform surgeries on patients with heart failure such as coronary artery bypass surgery, valve surgery and heart transplantation, among other things.