What is Heart Failure and Ejection Fraction (Heart Failure)?
Heart failure (HF) is a common medical condition that affects the heart’s capabilities, and it’s a leading cause of heart-related ailments and deaths worldwide. Despite advances in treatment and prevention, it’s estimated by the Centers for Disease Control and Prevention (CDC) that over 6.7 million adults in the United States have heart failure. This number is projected to rise to 8.5 million by 2030.
Heart failure happens when the heart’s ventricles, the chambers responsible for pumping blood, can’t fill with or eject blood efficiently. This can cause a variety of symptoms, making heart failure a complex clinical syndrome.
The American College of Cardiology (ACC) and the American Heart Association (AHA) have established a framework to outline stages of heart failure. This helps recognize the severity and progression of the condition. The stages are categorized as follows:
- Stage A: Individuals are at high risk of developing heart failure but without a structurally damaged heart or symptoms.
- Stage B: The heart’s structure is affected, but there are no symptoms of heart failure.
- Stage C: The heart’s structure is affected, and there are current or past symptoms of heart failure.
- Stage D: A condition of advanced heart failure where persistent symptoms exist despite optimal medical therapy.
Furthermore, the severity of heart failure is also classified by the measurement called left ventricular ejection fraction (LVEF). This system is beneficial for understanding the disease’s progression and the patient’s reaction to treatment. The 2022 AHA/ACC/Heart Failure Society of America (HSFA) Guideline outlines four classes of heart failure based on LVEF readings.
Another prominent classification used by clinicians is the New York Heart Association Classification of Heart Failure. This tool helps professionals evaluate a patient’s functional capacity and the symptoms of those diagnosed with stage C or D heart failure. This subjective assessment is done by a clinican, and it influences the selection of therapeutic interventions for patients. Here’s what the four classes look like:
- Class I (Mild HF): No restrictions in physical activity. Ordinary physical activity does not induce excessive fatigue, palpitations, or difficulty breathing.
- Class II (Mild-to-Moderate HF): Slight limitations in physical activity. The person is comfortable at rest, but normal activities cause fatigue, palpitations, or difficulty breathing.
- Class III (Moderate-to-Severe HF): Physical activity severely limited. The person is comfortable at rest, but activities less than ordinary cause fatigue, palpitations, or shortness of breath.
- Class IV (Severe HF): The person is unable to do any physical activity without discomfort. Symptoms of heart failure are present when resting, and any physical activity increases discomfort.
What Causes Heart Failure and Ejection Fraction (Heart Failure)?
The cause of heart failure can differ based on the type of heart failure and there may be multiple factors that contribute to the condition.
In short, heart failure with reduced ejection fraction (HFrEF) can be caused by certain issues like a heart attack, heart disease that limits blood flow to the heart, an enlarged heart, or viral infections that affect the heart. Additional factors might be high blood pressure, heart valve disease, or genetic factors.
Heart failure with mid-range ejection fraction (HFmrEF) shares similar causes with HFrEF and heart failure with preserved ejection fraction (HFpEF). These could include a heart attack, heart disease that restricts blood flow to the heart, as well as underlying structural heart issues that are somewhere between those seen in HFrEF and HFpEF.
Common causes of HFpEF include high blood pressure, irregular heart rhythms, age-related changes to the heart, and underlying structural problems such as hypertensive heart disease. Other factors that contribute might be diabetes, obesity, and chronic kidney disease.
Other possible causes of heart failure that are not related to lack of blood flow to the heart (nonischemic) can include:
* Some cancer-treatment drugs that can harm the heart
* Immune system disorders or rheumatic diseases
* Endocrine problems, such as thyroid disease, acromegaly, pheochromocytoma, and diabetes
* Obesity
* Genetic heart diseases or diseases that families inherit
* Abnormal heart rhythms, including fast heart rate, right-ventricular pacing, or frequent early heart beats
* Low blood pressure
* Diseases of the heart muscle, including sarcoidosis, Fabry disease, hemochromatosis, and amyloidosis
* Any kind of myocarditis (inflammation of the heart muscle)
* A type of heart failure that can occur during pregnancy (peripartum cardiomyopathy)
* Stress-induced heart disease like Takotsubo and reverse Takotsubo cardiomyopathies
* Substance misuse, including alcohol, cocaine, and methamphetamines
* Birth defects of the heart
* High blood pressure in the lungs (pulmonary hypertension) causing right heart failure
* Blockage of arteries in the lungs (pulmonary embolism) causing right heart failure.
Risk Factors and Frequency for Heart Failure and Ejection Fraction (Heart Failure)
Heart failure (HF) is a major health issue that affects millions of people in the U.S. and around the world. Estimates suggest that by 2030, 8 million people in the United States could have this condition, marking a 46% increase. When you reach 45, the odds of experiencing HF by the time you’re 75-95 varies, with 30-42% in white men, 20-29% in black men, 32-39% in white women, and 24-46% in black women. It’s important to note that having higher blood pressure and BMI at any age increases these lifetime risks.
The rise in HF cases doesn’t necessarily mean more people are getting it. It could be due to people living longer, thanks to improvements in treatments for heart patients. This could result in more people living with HF, even if there’s a decrease in new cases.
Data from the second 25-year period of the Framingham Heart Study indicates that around 19.3% of people may experience Heart Failure with Preserved Ejection Fraction (HFpEF) during their lifetime, which is notably higher than the 11.4% estimated risk for Heart Failure with Reduced Ejection Fraction (HFrEF). This trend is particularly noticeable in women, where the projected lifetime risk for HFpEF is about 10.7%, in contrast to 5.8% for HFrEF. These risks vary based on race. For instance, 13-24% of patients with HF have HFmrEF (Heart Failure with mid-range Ejection Fraction).
Signs and Symptoms of Heart Failure and Ejection Fraction (Heart Failure)
When checking for possible heart failure, a thorough medical history and physical check-up are critical. This is because the diagnosis of heart failure depends largely on specific signs and symptoms. These signs and symptoms are similar regardless of the patient’s ejection fraction (EF), which is a measurement of how much blood the left ventricle pumps out with each contraction. Risk factors and possible causes of heart failure should also be evaluated.
Symptoms of heart failure can include:
- Shortness of breath, difficulty breathing when lying down, and sudden shortness of breath at night
- A persistent cough or wheezing
- Swelling (general or in the lower limbs)
- Feeling tired or fatigued
- Loss of appetite and feeling nauseated
- Confusion and problems with thinking clearly
- Heart palpitations
Physical signs of heart failure might include:
- Pulse alternation
- High neck vein pressure
- Misplaced heart beat
- Extreme mass loss related to heart illness
- Fast heart rate
- Pressure on the right side of the heart
- Creaking sounds in both lungs or a wheezing sound in the heart
- The presence of a third heart sound
- Indentation that stays for some time when skin is pressed (pitting swelling)
- Sensitive enlarged liver
- Accumulation of fluid in the abdomen
Regularly assessing these symptoms and signs during clinic visits is vital to check the effectiveness of treatment and general health condition. Doctors need to measure vital signs and fluid status at each visit to have a complete understanding of the patient’s condition.
Testing for Heart Failure and Ejection Fraction (Heart Failure)
After a thorough exam and health history, doctors often use further tests to understand a patient’s health better. These tests may include an EKG (a test to check the heart’s electrical activity), blood tests looking at complete blood count and kidney, liver, and electrolyte levels, and urine tests. Other tests might involve checking cholesterol levels, blood sugar control, thyroid hormone levels, and iron levels.
To better evaluate heart health, tests may measure substances called NT pro-brain natriuretic peptide and brain natriuretic peptide. These chemical markers can tell doctors how well your heart is working. For example, an NT-pro-brain natriuretic peptide level over 125 pg/ml and a brain natriuretic peptide level of 35 pg/ml or more can indicate heart failure. An echocardiogram (an ultrasound of the heart) is used to assess the portion of blood being pumped out of the heart with each beat, and a chest x-ray may be used to look for signs of fluid buildup in the lungs. If these tests aren’t enough, the doctor may use other imaging technologies like a heart MRI, CT scan, or radionuclide imaging to evaluate the heart’s function better.
Depending on the type of heart failure, the doctor may order additional specialized tests such as stress echocardiogram, exercise treadmill stress test, additional heart imaging or a heart catheterization test, and blood pressure monitoring. Sleep studies may be ordered for suspected sleep apnea, panels for autoimmune diseases, genetic counseling and testing for specific heart diseases that run in families, and heart rhythm monitoring.
Additionally, tests like a transesophageal echocardiogram (an ultrasound probe that is passed into the esophagus to provide clear images of heart structures) can be used for valve diseases, urine drug tests for drug-related heart conditions, and cardiac MRIs for structural heart issues. Tissue samples from the heart might be taken to look for specific diseases, and monitoring of the heart’s pressures might be performed to gather important information in managing heart disease. Overall, there’s a thorough list of tests and scans that can help doctors evaluate heart failure more accurately.
Treatment Options for Heart Failure and Ejection Fraction (Heart Failure)
This list includes medical recommendations for certain medications and their effectiveness on different types of heart failure – HFrEF, HFmrEF and HFpEF.
There are several medications that are very highly recommended for treating HFrEF and HFmrEF. These include Beta-blockers and ARNI. Beta-blockers can decrease mortality and hospitalization rates in patients with HFrEF and HFmrEF, with metoprolol succinate, bisoprolol and carvedilol being the preferred types. ARNI can also reduce mortality and hospitalization rates in these patients.
For HFpEF, there’s not enough hard evidence to support the use of Beta-blockers or readily recommend them, but ARNI is highly recommended.
Other medications like ACE inhibitors and ARB are also very highly recommended for treating HFrEF, and highly recommended for HFmrEF. However, ACE inhibitors don’t have substantial evidence for treating HFpEF.
Then there are other medications like SGLT2i and MRAs, which are very highly recommended for HFrEF, and highly recommended for HFmrEF and HFpEF.
There’s also a group of medications like Hydralazine or Nitrate, Ivabradine, Vericiguat, Digoxin, PUFA, Potassium binders and Diuretics, which are recommended for HFrEF but either don’t have substantial evidence or aren’t recommended for HFmrEF and HFpEF.
Lastly, there are medical treatments for heart failure that revolve around correcting issues, such as Coronary Artery Disease and valvular heart disease, which can contribute to heart failure. Two such treatments are the use of implantable defibrillators and devices that help the heart pump blood more effectively.
In some critical cases, heart transplantation may be needed, while in other cases, medication, lifestyle modifications and management of existing health problems may be sufficient to manage the condition. In other acute cases, an individual might need to undergo procedures such as kidney replacement therapy or ultrafiltration.
The use or withholding of any of these treatments would typically depend on the patient’s specific situation, prognosis and response to other treatments. It is also noted that these decisions should be made in consultation with a multidisciplinary medical and surgical team.
What else can Heart Failure and Ejection Fraction (Heart Failure) be?
Diagnosing heart failure mainly comes down to observing symptoms. However, there are other disorders that can mimic the signs we associate with heart failure. Common conditions that doctors might consider in diagnosing heart failure include:
- Acute kidney injury
- Lung infections like bacterial or viral pneumonia
- Chronic obstructive pulmonary disease (COPD)
- Liver cirrhosis
- Fibrous lung disease, including idiopathic pulmonary fibrosis
- Nephrotic syndrome, a kidney disorder
- Pulmonary embolism, a blockage in one of the arteries in the lungs
- Respiratory failure
- Primary pulmonary hypertension
- Anemia
- Venous insufficiency, a condition where blood doesn’t flow upwards from the legs
Similarly, other conditions which might cause the same symptoms are:
- Acute respiratory distress syndrome
- Pulmonary edema caused by heart issues
- Interstitial (non-idiopathic) pulmonary fibrosis
- Goodpasture syndrome, an autoimmune disease
- Community-acquired pneumonia
- Myocardial infarction, also known as a heart attack
- Neurogenic pulmonary edema, fluid accumulation caused by a neurologic event
- Pneumothorax, collapsed lung
In short, a doctor has to rule out other possible illnesses that might share common symptoms with heart failure to make the most accurate diagnosis.
What to expect with Heart Failure and Ejection Fraction (Heart Failure)
The Seattle Heart Failure Model, CHARM Risk Score, CORONA Risk Score, and MAGGIC Risk Score are all predictive tools most commonly used for all types of chronic heart failure. For heart failure with reduced ejection fraction (HFrEF), which is a specific type of heart failure, risk assessment tools like the PARADIGM-HF, HF-ACTION, GUIDE-IT, and TOPCAT risk scores are popularly used. When it comes to chronic heart failure with preserved ejection fraction (HFpEF), the I-PRESERVE Score and TOPCAT Risk Score are relevant. For situations dealing with acute decompensated heart failure they make use of predictive tools such as the ADHERE Classification and Regression Tree (CART) Model, AHA Get With The Guidelines Score, and EFFECT Risk Score.
Changes in EF, which stands for ejection fraction, over time, are more telling in terms of the prognosis of heart failure rather than the baseline EF. When patients move from mid-range ejection fraction (HFmrEF) to reduced ejection fraction (HFrEF), they have worse prognosis than those who move to preserved ejection fraction (HFpEF) or remain stable in HFmrEF. According to the OPTIMIZE-HF trail, the mortality rate is highest in HFrEF with a rate of 3.9%, followed by HFmrEF at 3%, and finally HFpEF at 2.9%. Also, the mortality rate tends to be higher in patients showing symptoms.
Possible Complications When Diagnosed with Heart Failure and Ejection Fraction (Heart Failure)
Heart failure, also known as HF, can result in several complications:
- Arrhythmias: irregular heartbeats, like atrial fibrillation (Afib), are a common issue in heart failure patients. Afib can be both a cause and result of HF and is often found in 10% to 50% of chronic heart failure patients. Prognosis for these patients is generally poor. More severe heart rhythm disorders such as sustained monomorphic ventricular tachycardia, sustained polymorphic ventricular tachycardia, and torsades de pointes are often found in advanced stages of heart failure, especially when certain other factors are present like electrolyte imbalance, prolonged QT interval, and toxicity due to digoxin, a heart medication. Slow heart rhythms or bradyarrhythmias may also occur.
- Thromboembolism: Heart failure can cause stroke in 9% of patients. Between 10 and 24% of people with stroke also have heart failure. Heart failure patients, particularly those under 60, also have a high risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE).
- Gastrointestinal: In people with heart failure, there is a risk of developing liver shock (ischemic hepatitis), liver cirrhosis, and cardiac cachexia, a weight loss condition due to decreased blood flow to the intestines.
- Renal: Kidney function could worsen for both acute and chronic heart failure patients and that signals a poor prognosis. Even a minor temporary increase in the creatinine levels can have significant clinical relevance.
- Respiratory: Patients with heart failure might experience lung congestion, weakness of respiratory muscles, and in rare cases, pulmonary hypertension.
Preventing Heart Failure and Ejection Fraction (Heart Failure)
Encouraging heart failure patients to stick to their diet and take their medications right is crucial. A common reason for these patients getting readmitted to the hospital is non-compliance to diet or medications. Surprisingly, a research study involving 605 heart failure patients suggested that one teaching session might be just as effective as multiple sessions when it comes to reducing hospital readmissions or death rates.
For more patient-friendly information about heart failure, here are some helpful online resources:
“What is Heart Failure?” offers a simple explanation of different types of heart failure and their symptoms. “Coping With Heart Failure” provides tips on enhancing emotional well-being and seeking help when required.
“Heart Failure: How to be Active” gives advice on safe exercise routines, while “Heart Failure: Assessing Your Heart” reveals the tests used for diagnosing heart failure and elements of treatment plans.
“Heart Failure: Making Changes to Your Diet” discusses how to manage fluid and sodium intake, reading food labels, and when to contact a healthcare provider. “Heart Failure: Procedures That May Help” explains various procedures and devices used in treating heart complications.
“Heart Failure: Tracking Your Weight” offers guidance on tracking weight changes and recognizing when weight gain is a concern that needs a doctor’s attention. “Heart Failure: Warning Signs of a Flare-Up” describes warning signs of heart failure such as swelling, weight gain, and shortness of breath.
“Taking Medicine to Control Heart Failure” explains various heart failure medicines, and tips to manage them. All these resources are free and can be printed out for reference.
Lastly, “Living Well With Heart Failure” is an interactive guide containing quizzes, monitoring tools, videos, animations, and audio instructions. This tool kit is designed to help heart failure patients, their families, and caregivers better manage their heart health. It includes useful sections like monitoring symptoms, following a low-sodium diet, taking medications, living with a chronic condition, and steps for a healthier heart amongst others.
