Heart failure is treated with a combination of medications, lifestyle changes, and in some cases implanted devices or surgery. The specific approach depends largely on how well your heart pumps, measured by a number called ejection fraction. For the most common form of heart failure with reduced pumping ability, four classes of medications form the foundation of treatment and can cut the risk of death by 30% or more.
The Four Core Medications
When the heart’s pumping strength is reduced (a condition doctors call HFrEF), treatment centers on four types of medication that work together. Each one targets a different mechanism that drives heart failure, and the combination is significantly more effective than any single drug alone.
The first is a combination pill that pairs two compounds: one blocks hormones that constrict blood vessels, and the other prevents the breakdown of a protein that helps the heart relax and shed excess fluid. In clinical trials, this combination reduced the risk of cardiovascular death or hospitalization by 20% compared to older blood pressure medications. A real-world study found it was associated with a 15% reduction in death from any cause, with the strongest benefit seen in patients who had recently been hospitalized.
The second is a beta-blocker, which slows the heart rate and reduces the workload on the heart muscle. Beta-blockers have some of the most dramatic survival data of any heart failure drug. In major trials, specific beta-blockers reduced death by 34% to 65%, depending on the study and the severity of heart failure being treated.
The third is a type of drug that blocks a hormone called aldosterone, which causes the body to retain salt and water. Blocking it reduced death by 30% in a landmark trial. These medications require periodic blood tests because they can raise potassium levels.
The fourth and most recently added class was originally developed for diabetes. These drugs help the kidneys excrete excess sugar and fluid, reducing strain on the heart. They lower the risk of cardiovascular death and worsening heart failure even in people without diabetes, which is why they’re now standard for heart failure regardless of blood sugar status.
The goal is to get all four medications started and gradually increased to their target doses. In practice, many patients can’t tolerate the full dose of every drug due to low blood pressure, kidney changes, or side effects. Doctors typically start one or two at a time and adjust over weeks to months.
Treatment When Pumping Strength Is Normal
About half of people with heart failure have a normal ejection fraction, meaning the heart squeezes adequately but doesn’t relax and fill properly. This form, called HFpEF, has historically had fewer proven treatments. That changed recently.
The kidney-protective drugs originally designed for diabetes (the same fourth-pillar class used in reduced pumping) are now recommended as a first-line treatment for this type of heart failure too. Aldosterone-blocking drugs and the combination blood-pressure/heart-relaxation pill may also help some patients in this group, though the evidence is less definitive. A 2023 expert consensus pathway from the American College of Cardiology lists all three of these drug classes as options, with the diabetes-origin drugs having the strongest supporting data.
Beyond medication, managing blood pressure, body weight, and conditions like sleep apnea and atrial fibrillation plays an outsized role in this form of heart failure.
Lifestyle Changes That Make a Measurable Difference
Medications do the heavy lifting, but daily habits determine whether you stay stable or end up back in the hospital. Sodium restriction is the single most impactful dietary change. The Heart Failure Society of America recommends keeping sodium between 2,000 and 3,000 milligrams per day for most people with heart failure, and under 2,000 milligrams for moderate to severe cases. For context, a single fast-food meal can contain 2,000 milligrams on its own.
Practical strategies include eliminating canned foods (which are high in sodium preservatives), choosing frozen foods only if they’re preservative-free, and checking salt substitutes with your doctor since many contain potassium, which can interact with heart failure medications. Fluid intake may also need to be limited to around 50 ounces per day, including water-rich foods like fruit. This matters most for people who retain fluid easily.
Daily weigh-ins are one of the simplest and most effective monitoring tools. Weigh yourself every morning, after using the bathroom but before eating. A gain of more than two to three pounds in 24 hours, or more than five pounds in a week, is a warning sign of fluid buildup and warrants an immediate call to your doctor. The American Heart Association considers this level of sudden weight gain a medical alert that needs same-day evaluation.
Regular physical activity, even moderate walking, improves exercise tolerance, quality of life, and long-term outcomes. Cardiac rehabilitation programs are structured to help you build activity safely after a hospitalization or new diagnosis.
Implanted Devices
When medications alone aren’t enough, two types of implanted devices can help. Both are placed under the skin near the collarbone during a procedure that typically takes one to three hours.
The first is a defibrillator, a small device that continuously monitors heart rhythm and delivers a shock if it detects a life-threatening arrhythmia. Heart failure increases the risk of sudden cardiac death, and a defibrillator serves as a safety net. It’s generally considered when the ejection fraction remains at or below 35% despite optimal medication.
The second is a cardiac resynchronization device, which sends timed electrical signals to both sides of the heart so they contract together. In some people with heart failure, the left and right ventricles beat slightly out of sync, which makes pumping less efficient. This device corrects that timing. It’s recommended for patients with an ejection fraction of 35% or less whose heart’s electrical signal is delayed, specifically when the QRS duration on an EKG is 130 milliseconds or longer. The benefit is greatest when the delay is 150 milliseconds or more and follows a particular electrical pattern. Many patients receive a combination device that includes both resynchronization and defibrillator functions.
Valve Repair and Replacement
Heart valve problems can both cause and worsen heart failure. The mitral valve, which sits between the left atrium and left ventricle, is the most commonly involved. When it leaks significantly (a condition called regurgitation), blood flows backward with each heartbeat, forcing the heart to work harder. Severe leaking that causes shortness of breath or other symptoms is an indication for repair or replacement.
Repair is preferred over replacement when the valve’s structure allows it, because it preserves more of the heart’s natural anatomy. Some repairs can now be done through a catheter threaded through a blood vessel rather than open-heart surgery, which means a shorter recovery. Aortic valve disease, particularly narrowing that restricts blood flow out of the heart, can also drive heart failure and may require valve replacement.
Advanced Options for End-Stage Heart Failure
When heart failure progresses despite medications, lifestyle changes, and device therapy, two options remain: a mechanical pump or a heart transplant.
A left ventricular assist device, or LVAD, is a surgically implanted pump that helps the weakened left ventricle push blood to the rest of the body. It connects to an external battery pack worn outside the body, typically on a belt or harness. LVADs serve two roles. For people on the transplant waiting list, the device keeps them alive and functional until a donor heart becomes available. For people who aren’t candidates for transplant due to age, other medical conditions, or personal preference, the device becomes a permanent treatment, known as destination therapy.
Heart transplantation remains the most effective treatment for end-stage heart failure, with median survival exceeding 12 years. The limiting factor is organ availability. Roughly 3,500 heart transplants are performed in the United States each year, while far more patients could benefit. The evaluation process is extensive and considers overall health, other organ function, social support, and the ability to adhere to lifelong immunosuppressive medication.
Add-On Therapies for Worsening Symptoms
For patients whose heart failure worsens despite the four core medications, a newer class of drug that stimulates a signaling pathway involved in blood vessel relaxation can be added. European and American guidelines recommend considering it for people who have been hospitalized for heart failure within the past six months or needed intravenous fluid-removing drugs within the past three months. In the pivotal trial of over 5,000 patients, this drug reduced the combined risk of cardiovascular death and heart failure hospitalization when added to standard therapy.
This drug is particularly useful for patients who can’t tolerate full doses of the foundational medications due to low blood pressure or kidney problems. It works through a different mechanism, so it doesn’t compound the blood-pressure-lowering effects as much as increasing doses of the core drugs would. Doctors typically start it once a patient is clinically stable, with systolic blood pressure reliably above 100 mmHg.