Heart failure with reduced ejection fraction (HFrEF) is a chronic condition where the heart muscle is weakened. This means the heart cannot pump blood effectively because its main pumping chamber, the left ventricle, doesn’t contract with enough force.
Doctors measure this pumping ability using ejection fraction (EF), which is the percentage of blood the left ventricle pumps out with each beat. A healthy heart has an EF of 50% or higher. In HFrEF, the EF is 40% or less, indicating the heart circulates less oxygen-rich blood than the body needs.
Foundational Medical Therapies
Guideline-directed medical therapy (GDMT) is the standard for treating HFrEF, involving a combination of medications from four main classes. These drugs work together to address different aspects of heart function and improve outcomes. The goal is to use these therapies simultaneously and reach the highest tolerated dose of each medication to maximize benefits.
One group of drugs relaxes blood vessels and lowers blood pressure to lessen the heart’s workload. This includes Angiotensin-Converting Enzyme (ACE) Inhibitors, Angiotensin II Receptor Blockers (ARBs), or an Angiotensin Receptor-Neprilysin Inhibitor (ARNI). ARNIs both relax blood vessels and help reduce the overall strain on the heart.
Beta-blockers are another class of medication that slows the heart rate and reduces the effects of stress hormones on the heart muscle. This allows the heart to beat more efficiently and helps protect it from further damage. This action gives the heart time to recover and strengthen.
Mineralocorticoid Receptor Antagonists (MRAs) are a third medication group. MRAs block the hormone aldosterone, which causes the body to retain salt and water, increasing strain on the heart. By inhibiting this hormone, MRAs also help prevent stiff, scar-like tissue from forming in the heart muscle.
The fourth foundational therapy is a class of drugs called Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors. Though originally for diabetes, they have shown significant benefits for heart failure. SGLT2 inhibitors help the body remove excess sugar and fluid through urine, reducing the blood volume the heart must pump and decreasing its workload.
Lifestyle and Self-Care Management
Beyond medication, daily habits and self-care are fundamental to managing HFrEF. Lifestyle adjustments can lessen symptoms and slow the progression of the disease, allowing individuals to take an active role in their health.
Dietary changes are a primary focus, particularly restricting sodium. Consuming too much salt leads to fluid retention, which increases blood volume and forces the heart to work harder. Doctors may also advise limiting daily fluid intake to prevent the body from holding onto excess water.
Regular physical activity, approved by a healthcare provider, is another component of self-care. Moderate exercise strengthens the heart muscle and improves cardiovascular health. A structured cardiac rehabilitation program may be recommended to create a safe and effective activity plan.
Self-monitoring is a proactive way to manage the condition. Daily weight checks are recommended to detect fluid retention early, as sudden weight gain can be a first sign of worsening fluid buildup. Reporting any changes in symptoms, such as increased fatigue or shortness of breath, to a healthcare provider is also necessary.
Device and Procedural Interventions
When medications and lifestyle changes are not enough, device-based therapies and procedural interventions can offer support. These options are considered when specific criteria are met, such as dangerous heart rhythms or persistent symptoms despite optimal medical therapy.
An Implantable Cardioverter-Defibrillator (ICD) is a small device surgically placed in the chest to monitor heart rhythm. It protects against life-threatening arrhythmias (irregular heartbeats). If an ICD detects a dangerous rhythm, it delivers an electrical shock to restore a normal heartbeat.
Cardiac Resynchronization Therapy (CRT) uses a specialized pacemaker. In some people with HFrEF, the heart’s lower chambers (ventricles) do not beat in a coordinated way. A CRT device sends small electrical impulses to both ventricles to make them contract simultaneously, improving the heart’s pumping efficiency and reducing symptoms.
For advanced heart failure, a Left Ventricular Assist Device (LVAD) may be an option. An LVAD is a surgically implanted mechanical pump that helps the weakened left ventricle pump blood. It can be a long-term treatment or a temporary measure for a patient awaiting a heart transplant, the definitive treatment for eligible individuals with end-stage heart failure.
Managing Fluid Overload and Other Conditions
Managing HFrEF involves controlling symptoms and addressing related health issues. Fluid retention (congestion) is a common problem that leads to symptoms like shortness of breath and swelling (edema) in the legs and abdomen. Managing this fluid buildup improves daily comfort and function.
To combat fluid overload, doctors prescribe diuretics, or “water pills.” These medications help the kidneys remove excess salt and water through urination, reducing fluid volume in the bloodstream. This alleviates swelling and makes breathing easier. While diuretics are effective for symptom relief, they do not treat the underlying heart muscle weakness like the four foundational therapies.
Comprehensive care also includes addressing co-existing conditions. Iron deficiency is common and can worsen fatigue and reduce exercise capacity; treatment with intravenous iron can improve quality of life. Atrial fibrillation, an irregular and rapid heart rate, is another frequent condition that requires management with medications like blood thinners to prevent complications such as stroke.