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Heart Failure Overview
Types, Symptoms, Causes, Prevention and Treatment
Important Information You Should Know

Illustration of a normal heart versus a heart with congestive heart failure.

What is Heart Failure?

Heart failure is a chronic condition that does not go away. If you have heart failure, the lower chambers of your heart (ventricles) can't pump blood and/or relax like they should.

How Common is Heart Failure?

More than 6 million Americans have heart failure. One million people are diagnosed with the condition each year. You are more likely to have heart failure when you are older — about 12% to 13% of people older than 80 have the condition. Heart failure is the most common cause of hospitalization among people over age 65.

Heart failure affects men and women alike➜ Women tend to develop the condition later in life, have heart failure caused by high blood pressure, have more shortness of breath than men do, and have heart failure with a normal/ preserved ejection fraction (EF).

Types of Heart Failure

Heart failure is generally broken down into two types:

➜ Heart failure with reduced ejection fraction (HF-rEF)/Systolic failure: The lower left chamber of the heart (left ventricle) gets bigger and cannot squeeze (contract) hard enough to pump the right amount of oxygen rich blood to the rest of the body.

➜ Heart failure with preserved ejection fraction (HF-pEF)/Diastolic failure: The heart contracts and pumps normally, but the ventricles are thicker and stiffer than normal. Because of this, they can't relax enough to completely fill with blood. So, less blood is pumped out to the rest of the body when the heart contracts.

What is Ejection Fraction?

Ejection fraction is a measurement (percentage) of how much blood pumps out of your heart each time it contracts. For example, if your EF is 65%, your heart pumps out 65% of the blood in it each time it contracts. Your EF can go up and down depending on your heart's condition and how well your treatment plan is working.

➜ The left ventricle is your heart's main pumping chamber.

➜ A left ventricle EF that is below normal can be a sign of a heart problem, including heart failure.

➜ If you have HF-rEF, your healthcare provider may check your EF after you start treatment and when your condition changes.

How is EF measured?

Ejection fraction can be measured using:

➜ Echocardiogram (echo) - this is the most common way to check your EF.

➜ Magnetic resonance imaging (MRI) - scan of the heart.

➜ Nuclear medicine scan (multiple gated acquisition [MUGA]) of the heart; also called a nuclear stress test.

➜ Cardiac Catheterization

Why is it important to know my EF?

➜ Your EF can help determine how bad your heart failure is.

➜ Your EF can improve when you follow your treatment plan, including taking all of your heart failure medications as directed.

What Do EF Numbers Mean?

Visual representation of what EF numbers mean for the heart.

Normal Heart. A normal left ventricular EF (LVEF) ranges from 55% to 70%.

HF-pEF. If you have HF-pEF, your EF is in the normal range. Your heart is still pumping well, but the ventricles can't fully relax to fill with blood➜ Your healthcare provider will measure your EF and may check your heart valves and muscle to see how severe your heart failure is.

HF-rEF. If you have an EF of less than 40%, your left ventricle may be larger than normal (dilated) and not pumping enough blood to meet your body's needs. If you have severe heart failure or have a very poor quality of life, your healthcare provider may talk to you about special treatment options, such as a heart transplant or a ventricular assist device (VAD).

Some patients have both HF-rEF (with an EF below 40%) and HF-pEF, with problems such as a stiff left ventricle that cannot fill with blood like it should. This combination of problems is more common in older patients.

Left Ventricular Ejection Fraction (LVEF) % Pumping Ability of the Heart Level of Heart Failure/Effect on Pumping
55% to 70% Normal Heart function may be normal or you may have heart failure with preserved EF (HF-pEF).
50% to 54% Low normal or borderline. Heart function may be normal or you may have heart failure with preserved EF (HFpEF).
40% to 49% Slightly below normal. Left ventricle can't pump well, so the amount of oxygenrich blood going to the rest of the body is below normal➜ You may not have symptoms.
30% to 39% Moderately below normal. Heart function is moderately decreased➜ If you have symptoms, you have heart failure with reduced EF (HF-rEF).
Less than 30% Severely below normal. If you have severe HF-rEF, you have a higher risk of lifethreatening abnormal “extra” heartbeats, and your ventricles may not be able to pump together as they should.

What Causes Heart Failure?

Heart failure can be caused by many problems that damage the heart muscle. Common conditions that cause heart failure are:

Coronary artery disease. The coronary arteries carry blood oxygen to your heart. Coronary artery disease is the narrowing or blockage of the coronary arteries. This condition is usually caused by atherosclerosis. Atherosclerosis is the build-up of cholesterol and fatty deposits (plaques) on the inner walls of the arteries. These plaques can limit or stop blood flow to the heart muscle by clogging the artery or by causing damage to the arteries. This can lead to chest pain (angina) and/or a heart attack.

A frowning heart wears a bandaid.

Heart attack. A heart attack happens when a coronary artery suddenly becomes blocked and blood cannot flow to all areas of the heart muscle. The heart muscle becomes permanently damaged and muscle cells may die. As a result, normal heart muscle cells may work harder.

Cardiomyopathy. Cardiomyopathy is a disease of the heart muscle. It makes it harder for the heart to fill with blood and to pump blood. It can be caused by many things, including viruses, alcohol and drug abuse, smoking, genetics and pregnancy.

Heart defects present at birth (congenital heart disease)


A blood pressure monitor measures heart rate.

High blood pressure (hypertension). Blood pressure is the force of blood pushing against the walls of your blood vessels (arteries). When blood pressure is high, your heart has to pump harder to move blood to the body. This can cause the left ventricle to become thick or stiff, and you can develop HF-pEF. High blood pressure also increases your risk of coronary artery disease.

Abnormal heart rhythms (arrhythmias), including atrial fibrillation

What Causes Heart Failure

Frowning kidneys with bandaids. A body weight scale. And a cigarette.

➜ Kidney disease

➜ Being overweight/obese

➜ Smoking

➜ Alcohol and drug abuse

➜ Amyloidosis

➜ Sarcoidosis

➜ Some chemotherapy medications

What are the Symptoms of Heart Failure?

Shortness of breath or trouble breathing. This may happen when you are exercising, doing your daily activities or even when you are resting or lying in bed. You may get short of breath if fluid backs up into your lungs (congestion) or if your body isn't getting enough oxygen-rich blood. If you wake up suddenly at night to catch your breath, the problem is severe and you need medical treatment. Call your healthcare provider in the morning.

Body diagram of heart failure symptoms.

➜ Feeling tired (fatigue) and leg weakness. When your heart does not pump enough oxygen-rich blood to major organs and muscles, you get tired and your legs may feel weak.

➜ Swelling in your ankles, legs and abdomen; weight gain. When your kidneys do not filter enough blood, your body holds onto extra fluid.

➜ Need to urinate during the night. There is more blood flow to the kidneys when you are lying down, and they make more urine.

➜ Dizziness, confusion, trouble concentrating, fainting. These symptoms happen because your heart is not pumping enough oxygen-rich blood to your brain.

➜ Rapid or irregular heartbeats (palpitations). When your heart does not pump with enough force, your heart may beat faster to try and get enough oxygen-rich blood to major organs and muscles. You may have an irregular heartbeat if your heart muscle is damaged or if the electrical cells in your heart are active when they should be at rest.

➜ A dry, hacking cough. This is caused by lying flat and having extra fluid in your lungs.

➜ A full (bloated) or hard stomach, loss of appetite, upset stomach. (nausea). These symptoms happen when you have extra fluid in the tissues around the organs in your abdomen.

Symptoms of heart failure can range from mild to severe, and they may come and go. If they get better or go away, it does not mean you no longer have heart failure.

In general, heart failure gets worse over time. As it does, your symptoms may change. It is important to let your healthcare provider know if you have new symptoms or if your symptoms get worse. It is also important to manage other health problems you have. Some conditions have symptoms similar to those of heart failure.

How is Heart Failure Diagnosed?

If you have signs of symptoms of heart failure, your healthcare provider will do a complete exam, order tests and ask you about your symptoms and medical history, including:

➜ Other health conditions you have

➜ If you have a family history of heart disease or sudden death

➜ If you smoke or use tobacco products

➜ How much alcohol you drink

➜ If you have chemotherapy or radiation treatment

➜ The medications you take

➜ Activities that make your symptoms worse

Common Tests Used to Diagnose Heart Failure

A vial of blood. Blood tests to see how well your kidneys, liver and thyroid are working. We will also check your cholesterol levels and blood counts.

NT-pro B-type Natriuretic Peptide (BNP) blood test. If you have too much NT-pro BNP (a type of protein made by your heart) in your blood, it means your heart is working harder than normal to pump blood. Low levels of NT-pro BNP mean your heart failure is stable. If you have shortness of breath, your NT-pro BNP level can help your healthcare provider know if it is caused by heart failure.
Illustration of a heart. Cardiac catheterization. A catheterization lets your doctor check your heart from the inside. A long, thin tube called a catheter is inserted into an artery in your arm or leg. The doctor uses a special X-ray machine to guide the catheter to your heart. There are two types of cardiac catheterization - left and right. If you have a left heart catheterization, your doctor may inject dye to record videos of your heart valves, coronary arteries and heart chambers (atria and ventricles). A right heart catheterization does not use dye; it shows how well your heart is pumping blood.
Chest X-Ray. Chest X-ray shows the size of your heart and any fluid build-up in your lungs.
Echocardiogram (echo). Echocardiogram (echo). Used to see how well your heart can pump and relax, check your heart valves and measure the size of your heart's chambers and the pressure in your arteries. Images are captured using an ultrasound wand that is moved around on the skin of your chest. An echo is often done with a Doppler test to see changes in pressure inside your heart and blood flow across your heart valves.
Electrocardiograph (EKG or ECG). Electrocardiograph (EKG or ECG). This test records the electrical activity in your heart by using small, sticky patches (electrodes) placed on your body that are connected with wires to a monitor. The wires carry information to the monitor, which creates a graph to show electrical activity.
A heart and a video camera. Multigated acquisition scan (MUGA scan). This test measures how well your ventricles are pumping blood. A small amount of a radioactive dye is injected into a vein. A special camera (gamma camera) is used to create video of your heart as it beats.
Person walking on a treadmill. Stress test. This test shows how your heart reacts to stress. You will exercise on a treadmill or stationary bike. The intensity of the test will increase to see how your heart reacts. Your heart rate, electrocardiograph and blood pressure are recorded during the test. If you cannot exercise, you may get medication to create the same effect as exercise on your heart.

You may need other tests, depending on your condition, medical history and symptoms.

What are the Stages of Heart Failure?

There are four stages of heart failure — A, B, C and D. They range from a high risk of developing heart failure to advanced heart failure. Once you have symptoms of heart failure, even if they are controlled/go away, you are at Stage C.

Ask your healthcare provider which stage of heart failure you are in. Stages of heart failure are different from the New York Heart Association (NYHA) clinical classifications of heart failure (Class I, II, III, IV).

The goal of treatment is to keep you from reaching Stage D heart failure. Treatment changes are made as heart failure gets worse. Your treatment plan may be different from those listed here, depending on your needs. Please talk to your healthcare provider if you have any questions or concerns.

Stage A

Stage A is considered pre-heart failure. It means you have a high risk of developing heart failure because you have a family history of heart failure or you have one or more of these medical conditions:

➜ High blood pressure (hypertension)

➜ Diabetes

➜ Coronary artery disease

➜ Metabolic syndrome

➜ History of alcohol abuse

➜ History of rheumatic fever

➜ Family history of cardiomyopathy

➜ History of taking drugs that can damage heart muscle, such as some chemotherapy drugs

Stage A Treatment

The usual treatment plan for patients with Stage A heart failure includes:

➜ Regular exercise, being active, walking every day

➜ Not smoking

➜ Treatment for high blood pressure (medication, low-sodium diet, active lifestyle)

➜ Treatment for high cholesterol

➜ Not drinking alcohol or using recreational drugs

➜ Medications:

➜ Angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor (ARB) if you have coronary artery disease, diabetes, high blood pressure, or other vascular or cardiac conditions.

➜ Beta-blocker if you have high blood pressure

Stage B

Stage B heart failure means there are changes in your heart's structure (such as a valve problem), but you do not yet have signs or symptoms of heart failure.

Stage B Treatment

The usual treatment plan for patients with Stage B heart failure includes:

➜ Angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) (if you aren't already taking one)

➜ Beta-blocker if you have had a heart attack and your EF is 40% or lower (if you aren't already taking one)

➜ Aldosterone antagonist if you have had a heart attack or if you have diabetes and an EF of 35% or lower

➜ Medications for other medical conditions that can cause heart failure or make it worse, such as atrial fibrillation, high blood pressure, diabetes, obesity, coronary artery disease, chronic lung disease, high cholesterol and kidney disease

➜ Possible surgery or intervention as treatment for coronary artery blockage, heart attack, valve disease (you may need valve repair or replacement surgery) or congenital heart disease Stage C and reduced EF treatment Patients with Stage C heart failure have been diagnosed with heart failure and have or had (previously) signs and symptoms of the condition.

Stage C and Reduced EF Treatment

Patients with Stage C heart failure have been diagnosed with heart failure and have or had (previously) signs and symptoms of the condition.

Stage C and Reduced EF Treatment

➜ Treatments listed in Stages A and B

➜ ARB + neprilysin inhibitor (ARN-i)

➜ Sodium-glucose cotransporter 2 Inhibitor (SGLT2-i)

➜ Beta-blocker (if you aren't taking one)

➜ Aldosterone antagonist (if you aren't taking one) if a vasodilator medicine (ACE-i, ARB or ARN-i) and betablocker don't help your symptoms

➜ Hydralazine/nitrate combination if other treatments do not help your symptoms

➜ African-American patients should take these medications if they have moderate-to-severe symptoms, even if they are taking other vasodilator medications.

➜ Medications to slow your heart rate if it is faster than 70 beats per minute and you still have symptoms

➜ Diuretic (“water pill”) if you have symptoms caused by extra fluid in your body

➜ Limit sodium in your diet

➜ Keep track of your weight every day

➜ May need to limit fluids

➜ Possible cardiac resynchronization therapy (biventricular pacemaker)

➜ Possible implantable cardiac defibrillator (ICD)

If your symptoms get better or stop with treatment, you still need to continue treatment to keep your heart working the best it can.

Stage D and Reduced EF

Patients with Stage D HF-rEF have advanced symptoms that do not get better with treatment. This is the final stage of heart failure.

Stage D Treatment

The usual plan for patients with Stage D heart failure includes:

➜ Treatments listed in Stages A, B and C

➜ Evaluation for:

➜ Implantable hemodynamic monitor

➜ Heart transplant

➜ Ventricular assist device (VAD)

➜ Heart surgery

➜ Continuous infusion of intravenous (IV) medication to help your heart pump better

➜ Palliative or hospice care

➜ Research therapies

Stages C and D with Reduced EF

Patients with Stage C or D heart failure with preserved EF have the same symptoms as those with Stage C or D with reduced EF.

Treatment for patients with Stage C and Stage D heart failure and preserved EF (HF-pEF) includes:

➜ Treatments listed in Stages A and B

➜ Diuretic ("water pill") if you have symptoms caused by extra fluid in your body

➜ An aldosterone antagonist to help relieve symptoms and prevent hospitalization

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional health information, please contact the Center for Consumer Health Information at the Cleveland Clinic (216) 444-3771 ☎ or toll-free (800) 223-2273 ☎ extension 43771. If you prefer, you may visit or http://www.clevelandclinic

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