Managing Fatigue with Heart Failure

Heart failure develops when your heart can't pump enough blood for your body's needs. Your tissues and organs need blood to function properly. Without adequate blood supply, your whole body works harder, and even everyday activities can become more challenging.

One of the most common and often frustrating symptoms of heart failure is fatigue — an overwhelming feeling of tiredness or low energy that doesn’t improve with rest.

Mass General Brigham cardiologist Mandeep Mehra, MD, MSc, FRCP, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital, explains why fatigue often accompanies heart failure and how to seek help for fatigue.

Why does heart failure cause fatigue?

"In heart failure, the heart's pumping capacity can't meet your body's demands," says Dr. Mehra. “This can happen in two main ways. Either the heart is too weak to pump efficiently, or it has become stiff and is unable to relax properly, leading to poor circulation.”

Fatigue in heart failure is more than just feeling tired — it's a complex experience that can include many factors. And as heart failure progresses, fatigue typically worsens.

Dr. Mehra says there are three categories of fatigue-causing factors:

1. Biological fatigue: When a weakened heart pumps less blood, less oxygen reaches organs and muscles. This causes lower energy, which leads to fatigue.
2. Psychological fatigue: Heart failure can be emotionally challenging, leading to more anxiety and depression, which can worsen fatigue. "The mental burden of living with a chronic illness contributes significantly to how tired you feel,” says Dr. Mehra.
3. Social fatigue: Living with heart failure can make participating in social activities more challenging, adding to feelings of isolation and exhaustion. “Many patients describe a sense of withdrawal from their usual activities, which intensifies their feelings of fatigue,” says Dr. Mehra.

Underlying conditions often worsen fatigue

Dr. Mehra says that although fatigue is one of the most common symptoms of heart failure, it's also one of the least evaluated and researched. Doctors do know, however, that the heart’s reduced ability to pump isn’t the only physical cause of heart failure fatigue. Other health conditions often contribute to fatigue, such as:

• Anemia: This blood disorder affects your body’s ability to use oxygen, often leading to tiredness. Dr. Mehra says anemia is one of the most common underlying causes of fatigue in people with heart failure. However, providers may not always check for anemia or iron deficiency states.
• High blood pressure: Blood vessel damage due to high blood pressure (hypertension) can affect blood flow, which can cause fatigue.
• Nocturia: Needing to get up often during the night to urinate (nocturia) can be a side effect of some heart failure medications, such as diuretics. Other health problems, such as bladder or urinary tract infections or enlarged prostate, can also cause nighttime urination. Sleep interrupted by nocturia often leads to fatigue.
• Prior stroke: A stroke can damage different areas of the cardiovascular system, including blood vessels in the brain. This damage can affect blood flow and brain function and cause fatigue.
• Sleep apnea: Brain signals or airway blockages cause interrupted breathing while you're asleep. This disrupted sleep can leave you feeling tired during the day.

Managing underlying conditions, such as treating sleep apnea with CPAP therapy or controlling high blood pressure with medication, can help reduce fatigue.

“Sometimes people attribute the fatigue to the effects of certain medications,” says Dr. Mehra. “But we shouldn’t be too quick to stop lifesaving medications such as beta-blockers because we assume they’re causing fatigue. Before stopping any medications, we need to exclude anything else that might be a problem.”

What to do if you have heart failure and tiredness

Your providers may not ask specifically about fatigue during your visits, so it’s important to speak up if you’re feeling it.

“Don’t shy away from telling your provider about fatigue,” says Dr. Mehra. “We don’t want you to think that you’re just tired and need to deal with it on your own. Seeking and getting help is important.”

If there are no underlying conditions causing fatigue, Dr. Mehra suggests:

• Asking for help if you’re overwhelmed with responsibilities or need assistance
• Cardiac rehabilitation, a supportive, supervised program to improve your overall health that your provider can prescribe
• Exercise training to improve your fitness, which may boost energy levels
• Mindfulness practices such as meditation or yoga

There’s no one fix for fatigue, because there’s not just one cause. Together, you and your provider can understand what’s causing your fatigue and how you can feel better.