Top Triggers of Heart Failure Exacerbations

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A sudden worsening of heart failure, known as an exacerbation, usually occurs when some change places an increased demand on the weakened heart, which can't compensate by beating harder or faster. Heart failure exacerbations can be life-threatening, so it's important to recognize the signs of an exacerbation and know what to do.

When heart failure (sometimes called congestive heart failure is stabilized with good medication control and dietary management, it should be possible to prevent frequent exacerbations. Over time, however, the number of heart failure exacerbations is likely to rise as heart failure progresses and the heart is less able to handle increased loads. Often an exacerbation will require hospitalization until the doctor is convinced that the heart has stabilized. In severe cases, someone may need breathing support or IV medication, administered in an intensive care unit (ICU), to help the heart beat more strongly. The mechanical support of a ventilator may be needed until the acute symptoms have resolved.

Some triggers are within your control, and others are underlying conditions that can't be avoided. Here are the most frequent causes of exacerbations, along with how to avoid those that can be controlled.

Not taking medications correctly

Over time, many people with heart failure fail to follow the medication regimen the doctor has prescribed. One study found that nearly one-third of exacerbations occurred because patients failed to comply with their prescribed treatment. This happens for many reasons, including confusion and misreading labels, concern over side effects, and the high cost of medications. Often the medication regimen to control heart failure is complicated, requiring many medication doses throughout the day. Sometimes people with heart failure mistakenly think that because they feel better, they don't need the medications anymore.

How to avoid this trigger: The medications prescribed for heart failure treat the symptoms of the condition and rebuild the strength of the heart muscle. Careful medication management is key to preventing exacerbations and gives the best chance for recovery. Bring in all your loved one's medication bottles when you visit your doctor, so he or she can determine if any changes need to be made. Bringing in the bottles is always better then bringing in a list.


Pneumonia and the respiratory infections that lead to it -- such as colds, the flu, and sinus infections -- are the top cause of hospitalization for a heart failure exacerbation. Other common infections that can trigger exacerbations include urinary tract infections, shingles, and food-borne illnesses.

How to avoid this trigger: Make sure your loved one gets all the vaccinations recommended by the doctor, including a yearly flu shot and a pneumococcal vaccine every five years to prevent pneumonia. Help him or her avoid being in close quarters with people who are sick. Also, remind your loved one to wash his or her hands frequently, and make sure everyone in the family knows not to touch their eyes and nose with unwashed hands.

More triggers of heart failure exacerbations

Excessive salt intake

Eating too much salt causes fluid retention and puts pressure on the heart.

How to avoid this trigger: Follow suggestions for a low-sodium diet, and be careful to avoid hidden salt in canned soups, prepared foods, some juices, and other items.

Excessive fluid intake

Treatment for heart failure aims to eliminate extra water from your body, so drinking large amounts of fluid isn't recommended and may trigger an exacerbation. If you're drinking a lot of fluids and eating a diet high in sodium, you're at particular risk for exacerbation. Even though in general, health experts urge people to drink many glasses of water a day, this advice doesn't apply to those with heart failure.

How to avoid this trigger: Encourage your loved one to drink when thirsty but not to drink extra water. Drinking a lot of fluids to "flush your system" isn't necessary. Avoid beverages that contain sodium, such as some flavored waters, carbonated waters, and juice-water combinations.

Medication side effects

Some medications can make heart failure worse. For example, over-the-counter medications such as ibuprofen and naproxen (known as nonsteroidal anti-inflammatory drugs) can cause fluid retention, increase blood pressure, and worsen kidney function. Those with heart failure should avoid these medications. Other drugs, such as thiazolidinediones used to treat diabetes, cause fluid retention, which worsens heart failure. Calcium channel blockers can cause exacerbations for those with systolic failure but may be prescribed for patients with preserved systolic failure, though they can cause fluid retention. Beta-blockers, which are an important part of heart failure treatment, can cause exacerbations when first started or when the dose is increased. Beta-blockers are known to be beneficial over the long term, though, so be sure to discuss the risk of exacerbation with the doctor.

How to avoid this trigger: Any time the doctor prescribes a medication for another condition, make sure he or she knows your loved one has heart failure; ask if there's a risk that the new drug will worsen heart failure. If a medication prescribed for heart failure is making your loved one feel worse, tell the doctor immediately. Also, ask the doctor if there are over-the-counter medicines your loved one should avoid. For example, both prescription and over-the-counter nonsteroidal anti-inflammatories (NSAIDs), such as ibuprofen (Advil, Motrin), are harmful for heart failure patients and can lead to an exacerbation.

Alcohol consumption

Alcohol of all types (beer, wine, liquor) can be harmful to heart failure patients. Alcohol can be the actual cause of heart failure for those with systolic failure, and it should be avoided. Alcohol can also increase blood pressure, which can be detrimental in both types of heart failure, systolic or preserved systolic heart failure. Although a glass or two of red wine is considered healthful -- and can even help prevent coronary artery disease (CAD) -- this isn't true for those with heart failure. There's also significant risk that alcohol might interact with medications prescribed for heart failure.

How to avoid this trigger: Be sure your loved one doesn't drink alcohol, not even a glass. If he or she wants to celebrate, encourage him or her to limit it to a sip or two just for the experience. Some people, particularly heavy drinkers and alcoholics, may find their heart muscle strength improves when they stop all alcohol intake.

More triggers of heart failure exacerbations

Uncontrolled hypertension

Uncontrolled high blood pressure weakens the heart muscle and affects the heart's pumping strength. High blood pressure can also cause fluid retention. Over time, failure to control cardiac risk factors, such as hypertension and high cholesterol, can lead to a heart attack, which can initiate heart failure.

How to avoid this trigger: Check blood pressure regularly and be sure your loved one takes all medications prescribed to control blood pressure. Bring in a log of blood pressure measurements when you visit the doctor and ask what his or her blood pressure goal is. If medications aren't working adequately, tell the doctor; dosages may need to be increased or a different medication prescribed.


When your loved one is anemic, there may not be enough oxygen delivered to his or her heart, and this adds to the strain on the heart muscle. Over time, this can lead to an exacerbation.

How to avoid this trigger: Make sure your loved one is getting enough iron, either from diet or in the form of supplements. If there's a concern, ask the doctor to test for anemia. If your loved one has been told to take iron but stopped because it's hard on his or her digestive system, talk to the doctor about other forms of iron he or she can take. Recognizing the role that anemia plays in worsening outcomes for heart failure, the doctor may have alternatives for your loved one's specific cause of anemia.

Other conditions that can trigger a heart failure exacerbation

  • Heart attack

  • Arrhythmia

  • Worsening kidney function

These heart failure triggers aren't necessarily under your control, so there isn't any action required to manage them, but it's important to be aware of the role they play in heart failure exacerbations. If kidney function is worsening or arrhythmia is an ongoing problem, these are reasons to be even more alert for sudden worsening of heart failure.