Topic Overview
Heart failure with reduced ejection fraction (HFrEF) happens when the left side of your heart doesn't pump blood out to the body as well as normal.
It's sometimes called systolic heart failure. This is because your left ventricle doesn't squeeze forcefully enough during systole, which
is the phase of your heartbeat when your heart pumps blood.
What does reduced ejection fraction mean?
The types of heart failure are based on a measurement called the ejection fraction. The ejection fraction measures how much blood inside the 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. A normal ejection fraction is more than 55%. This means that 55% of the total blood in the left ventricle is pumped out with each heartbeat.
Heart failure with reduced ejection fraction happens when the muscle of the left ventricle is not pumping as well as normal. The ejection fraction is 40% or less.footnote 1
The amount of blood being pumped out of the heart is less than the body needs. A reduced ejection fraction can happen because the left ventricle is enlarged and cannot pump normally.
Examples of ejection fractions of a healthy heart and a heart with reduced ejection fraction:
- A healthy heart with a total blood volume of 100 mL that pumps 60 mL has an ejection fraction of 60%.
- A heart with an enlarged left ventricle that has a total blood volume of 140 mL and pumps 60 mL has an ejection fraction of 43%.
What causes it?
There are many different problems that can cause heart failure with reduced ejection fraction.
Causes of heart failure with reduced ejection fractionCause | What is it? | How it causes heart failure |
|---|
| Coronary artery disease or heart attack | Blockages in your coronary arteries that limit blood
flow to your heart muscle | It weakens or damages heart muscle and impairs the muscle's
ability to pump. |
|---|
| Cardiomyopathy | A disease of the heart muscle | The heart muscle is weakened, which affects its ability
to pump properly. |
|---|
| High blood pressure | Elevated pressure in your arteries | The heart works harder to pump against increased
pressure, which weakens the muscle. |
|---|
| Aortic stenosis | Opening of aortic valve is narrowed, impairing blood
flow | The heart works harder to pump blood through the
narrowed valve, weakening the muscle. |
|---|
| Mitral regurgitation | Mitral valve doesn't close properly, causing leakage
on left side of the heart | Increased blood volume stretches and weakens heart
muscle. |
|---|
| Viral myocarditis | Viral infection of your heart muscle | Inflammation in the heart muscle affects the heart's
ability to pump. |
|---|
| Arrhythmia | Irregular heart rhythm | Irregular rhythm reduces the pumping effectiveness
of the heart. |
|---|
Gradual heart damage
Coronary artery disease causes gradual heart damage over time. Ischemia is the medical term for what happens when your heart muscle doesn't
get enough oxygen. Ischemia may happen only once in a while, such as when you
are exercising and your heart muscle needs more oxygen than it normally does.
Ischemia can also be ongoing
(chronic) if your coronary arteries are so narrowed that they limit blood flow
to your heart all the time. This chronic lack of oxygen can gradually damage
portions of your heart muscle. Your heart can slowly lose its ability to pump blood to your body.
Chronic ischemia can allow your heart muscle to get just enough
oxygen to stay alive but not enough oxygen to work normally. Ongoing poor blood flow to the heart muscle reduces the heart's ability
to contract and causes it to pump less blood during each beat. The less blood
your heart pumps out to your body, the less blood it is actually pumping back
to itself through the coronary arteries. The end result is that heart failure
makes ischemia worse, which in turn makes heart failure worse.
Mitral valve regurgitation can gradually lead to heart failure. With this problem, the mitral valve doesn't close properly, and blood leaks back into the left atrium when the left
ventricle contracts. Over time, the left ventricle pumps harder to move the
extra blood that has returned to it from the left atrium. The
ventricle stretches and gets bigger to hold the larger volume of
blood. Gradual weakening of the left ventricle may cause
heart failure.
High blood pressure can also gradually lead to heart failure. To pump against your high blood pressure, your heart has to
increase the pressure inside your left ventricle when it pumps. After years of
working harder to pump blood, your ventricle may begin to weaken. When this
happens, the pressure inside the weakened left ventricle will cause the
ventricle to expand, stretching out the heart muscle. This damaging process is
called dilation, and it impairs your heart's ability to squeeze forcefully. The
result is heart failure.
Sudden heart damage
A heart attack damages heart muscle suddenly. A heart attack can cut off the flow of blood to
your heart muscle so that your heart muscle doesn't get any oxygen. If your
heart muscle goes without oxygen for long enough, heart muscle can die. If a heart attack damages a very large area of heart muscle, it
is possible that the ability of your heart to pump blood will be suddenly
limited to such a degree that you develop heart failure. But this sudden complication isn't common.
If you have a substantial heart attack that injures a large
area of the heart muscle, you may eventually develop heart failure, even if it
doesn't occur suddenly. This happens most commonly after you have had a heart
attack involving the anterior wall of the heart. After a large area of the
anterior wall is destroyed, the percentage of blood pumped with each beat
(ejection fraction) can be significantly less. As a result, the heart attempts
to change its shape to maximize its pumping efficiency, a process referred to
as left ventricular remodeling. Initially, the changes made to the heart wall
(myocardium) are beneficial. Over time though, the left ventricle dilates and
increases in size, which makes the heart less able to pump.