Heart Failure With Reduced Ejection Fraction

Heart failure with reduced ejection fraction is a condition where the heart’s main pumping chamber cannot push blood forward as effectively as it should, causing blood to back up into the lungs and body, leading to shortness of breath and swelling.

Table of contents

• What is heart failure with reduced ejection fraction?
• Other names for this condition
• Part of the body affected
• How common is this condition?
• Signs and symptoms
• What causes this condition?
• Who is at risk?
• How is it diagnosed?
• Treatment options
• Living with the condition
• Outlook

What is heart failure with reduced ejection fraction?

Heart failure with reduced ejection fraction is a type of heart failure that occurs when the heart’s lower left chamber, called the left ventricle, doesn’t pump blood out to the body as well as it should^[1]. This condition is sometimes called systolic heart failure because the left ventricle doesn’t squeeze forcefully enough during systole, which is the phase of your heartbeat when your heart pumps blood^[1].

To understand this condition, it helps to know about something called ejection fraction. This is a measurement of how much blood inside the left ventricle is pumped out with each contraction. The left ventricle squeezes and pumps some, but not all, of the blood in the ventricle out to your body^[1].

A normal ejection fraction is more than 55 percent. This means that more than 55 percent of the total blood in the left ventricle is pumped out with each heartbeat^[1]. You may be diagnosed with heart failure with reduced ejection fraction when the ejection fraction is 40 percent or less^[1]. If the ejection fraction is between 41 and 49 percent, you may be diagnosed with heart failure with a mid-range ejection fraction^[1].

Heart failure doesn’t mean your heart has stopped working. Instead, it means that your heart can’t pump blood well enough to meet your body’s needs. Because the heart can’t handle the amount of blood it should, blood builds up in other parts of your body. Most of the time, it collects in your lungs, legs, and feet^[7].

Other names for this condition

Systolic heart failure, HFrEF

Part of the body affected

• Heart
• Left ventricle
• Lungs
• Blood vessels

How common is this condition?

Heart failure is one of the most common conditions affecting adults. More than 6 million people in the United States have congestive heart failure^[7]. An estimated 6.7 million individuals aged 20 or older in the United States are affected by heart failure, and it is anticipated that the prevalence will increase to 8.5 million Americans by 2030^[3].

Heart failure is particularly common among older adults. Approximately 14 percent of men and 13 percent of women over 80 years old have heart failure^[6]. It is the leading cause of hospitalization in people older than 65^[7].

Signs and symptoms

If you have heart failure with reduced ejection fraction, your heart can’t supply enough blood to meet your body’s needs. Symptoms may develop slowly, or sometimes they start suddenly^[2].

Common symptoms include^[2][7]:

• Shortness of breath with activity or when lying down
• Waking up short of breath at night
• Fatigue and weakness
• Swelling in your ankles, legs, and abdomen
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Weight gain
• Need to urinate while resting at night
• A dry, hacking cough
• Wheezing
• A full or hard stomach
• Loss of appetite or upset stomach
• Chest pain
• Heart palpitations

Sometimes, you may have mild symptoms or none at all. This doesn’t mean you don’t have heart failure anymore. Symptoms of heart failure can range from mild to severe and may come and go. Unfortunately, congestive heart failure usually gets worse over time. As it worsens, you may have more or different signs or symptoms^[7].

What causes this condition?

There are many different problems that can cause heart failure with reduced ejection fraction^[1][7]:

Coronary artery disease or heart attack. These conditions can limit or block blood flow in your coronary arteries, which bring blood to your heart muscle. This limited or blocked blood flow weakens or damages heart muscle and impairs the muscle’s ability to pump^[1].

Cardiomyopathy. This is a disease of the heart muscle. The heart muscle is weakened, so it can’t pump properly^[1].

High blood pressure. This condition causes elevated pressure in your arteries. The heart works harder to pump against increased pressure, which weakens the muscle^[1].

Diabetes. This condition results in high blood sugar. Over time, diabetes can lead to problems with the heart muscle^[1].

Aortic stenosis. This means that the opening of the aortic valve is narrowed, which impairs blood flow. The heart works harder to pump blood through the narrowed valve, weakening the muscle^[1].

Mitral regurgitation. This means that the mitral valve doesn’t close properly. The increased blood volume stretches and weakens the heart muscle^[1].

Viral myocarditis. This is a viral infection of your heart muscle. The infection causes inflammation in the heart muscle, which affects the heart’s ability to pump^[1].

Arrhythmia. This is an irregular heart rhythm. The irregular rhythm reduces the pumping effectiveness of the heart^[1].

Other causes include heart issues present at birth, kidney disease, a body mass index higher than 30, tobacco and recreational drug use, alcohol use, and medications such as cancer drugs^[7].

Who is at risk?

Several factors can increase your risk of developing congestive heart failure^[7]:

• Being older than 65
• Using tobacco products, cocaine, or alcohol
• Having an inactive lifestyle
• Eating foods that have a lot of salt and fat
• Having high blood pressure
• Having coronary artery disease
• Having a heart attack
• Having a family history of congestive heart failure

How is it diagnosed?

To diagnose heart failure, your healthcare professional examines you and asks questions about your symptoms and medical history. Your care professional checks to see if you have risk factors for heart failure, such as high blood pressure, coronary artery disease, or diabetes^[12].

Your care professional listens to your lungs and heart with a device called a stethoscope. A whooshing sound called a murmur may be heard when listening to your heart. Your care professional may look at the veins in your neck and check for swelling in your legs and belly^[12].

Tests that may be done to diagnose heart failure include^[12]:

Blood tests. Blood tests can help diagnose diseases that can affect the heart. Blood tests also can look for a specific protein made by the heart and blood vessels. In heart failure, the level of this protein goes up^[12].

Chest X-ray. X-ray images can show the condition of the lungs and heart^[12].

Electrocardiogram (ECG or EKG). This quick and painless test records the electrical signals in the heart. It can show how fast or how slowly the heart is beating^[12].

Echocardiogram. Sound waves create images of the beating heart. This test shows the size and structure of the heart and heart valves and blood flow through the heart^[12].

Ejection fraction. Ejection fraction is a measurement of the percentage of blood leaving your heart each time it squeezes. This measurement is taken during an echocardiogram. The result helps classify heart failure and guides treatment^[12].

Exercise tests or stress tests. These tests often involve walking on a treadmill or riding a stationary bike while the heart is monitored^[12].

Treatment options

The goals of treatment for heart failure with reduced ejection fraction are to reduce mortality, hospitalizations, and the severity of symptoms while improving functional status and quality of life^[11]. Proper treatment can help you feel better, stay out of the hospital, and live longer^[16].

Treatments shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction, known as guideline-directed medical therapy, include several types of medications^[11]:

• Renin-angiotensin system/neprilysin inhibitors. These medications help the heart work more efficiently and have been shown to improve the prognosis of patients with this condition^[10]
• Beta blockers. These medicines slow the heart rate and reduce blood pressure
• Mineralocorticoid receptor antagonists. These help remove excess fluid from the body
• Sodium-glucose cotransporter-2 inhibitors. These medications were originally developed for diabetes but have been shown to help heart failure patients

Guidelines recommend initiation with target dose titration within 6 to 12 weeks of diagnosis^[11]. Secondary therapies such as digoxin, hydralazine and isosorbide dinitrate, ivabradine, and vericiguat are indicated in certain patients with persistent or worsening symptoms^[11].

Device and interventional therapies may be indicated in those with prolonged QRS duration to decrease the risk of sudden cardiac death. These include^[11]:

• Implantable cardioverter-defibrillators (ICDs). These devices can detect dangerous heart rhythms and deliver a shock to restore normal rhythm
• Cardiac resynchronization therapy. Special pacemakers help the heart chambers beat in a more coordinated way

In selected patients, catheter-based treatment of secondary mitral regurgitation with a MitraClip has been shown to improve outcomes^[10].

Intravenous iron replacement is recommended in patients with iron deficiency to improve functional status and quality of life^[11].

Living with the condition

If you have heart failure, it’s very important to take good care of yourself^[17].

Have a healthy diet. A balanced diet should include plenty of fruit and vegetables, meals based on starchy foods such as potatoes, bread, rice or pasta, some dairy or dairy alternatives, some beans or pulses, fish, eggs, meat and other sources of protein, and low levels of saturated fat, salt and sugar^[17]. You may also be given advice about dietary changes that can specifically help with heart failure, such as limiting the amount of fluid you drink^[17].

Exercise regularly. Regular physical activity can help improve your symptoms and general health. If you have heart failure, you should be offered an exercise-based cardiac rehabilitation programme^[17]. Before you start, you’ll have an assessment to find out how much exercise you can safely do. A programme of exercise can then be tailored specifically for you^[17].

Stop smoking. If you smoke, stopping smoking can improve your overall health and reduce your risk of many other health problems. Speak to your doctor if you think you’ll need help quitting^[17].

Limit your alcohol consumption. You can usually continue to drink alcohol if you have heart failure, but it’s advisable not to exceed the recommended limits of more than 14 alcohol units a week. If your heart failure is directly related to drinking alcohol, you may be advised to stop entirely^[17].

Get vaccinated. Heart failure can put a significant strain on your body and mean you’re more vulnerable to infections. Everyone with heart failure should be offered the annual flu vaccine and the one-off pneumococcal vaccination^[17].

Monitor your condition. You may be asked to help monitor your condition between appointments. For example, your care team may suggest weighing yourself regularly so any changes in your weight, which could be a sign of a problem, are picked up quickly^[17].

You’ll have regular contact with your doctor or care team to monitor your condition at least every 6 months. Contact your doctor or care team if your symptoms are getting worse or you develop new symptoms^[17].

Outlook

Heart failure can be life-threatening. People with heart failure may have severe symptoms. Some may need a heart transplant or a device to help the heart pump blood^[2].

However, the prognosis of patients with heart failure with reduced ejection fraction has been improved in recent years through the introduction of new drugs and the rigorous implementation of evidence-based recommendations^[10].

Heart failure is the leading cause of a hospital stay for people at age 65 and over. About 20 percent of those who go to the hospital for heart failure have to go back again within 30 days of leaving the hospital due to not feeling better or feeling worse. Up to 50 percent go again within 6 months for the same problem^[6].

Among older adults with heart failure, 60 percent have at least 5 other long-term health conditions. More than half have disability^[6].

Healthcare professionals should begin discussions about symptom relief and end-of-life care early in the treatment of people with heart failure, to understand what matters most to individuals with this condition and be able to honor their wishes and preferences in life. Discussions should occur regularly as the person’s condition changes^[6].