Heart failure with reduced ejection fraction (HFrEF): causes, treatment and devices

The NHS describes heart failure as the heart being unable to pump blood properly. It does not mean the heart has stopped or is about to stop. Doctors describe the type by the ejection fraction, which the British Heart Foundation (BHF) explains is the amount of blood squeezed out of the heart's main chamber with each beat, usually given as a percentage and measured from an echocardiogram.

The BHF says that, depending on the percentage and other tests, heart failure may be classed as preserved (50% or more), mildly reduced (40% to 49%) or reduced (40% or less). In HFrEF the ejection fraction is reduced, meaning the heart is squeezing out a smaller proportion of its blood with each beat.

Classification matters because the evidence base for treatment differs. NICE guideline NG106 has separate recommendations for treating heart failure with reduced ejection fraction and for heart failure with mildly reduced or preserved ejection fraction, and a section on starting and monitoring medication.

The BHF says there are many reasons for heart failure and that it can happen suddenly or progress slowly over months or years. The most common causes are a heart attack, which can cause long-term damage to how well the heart pumps; cardiomyopathy, a disease of the heart muscle that can be inherited or caused by infections or pregnancy; and high blood pressure, which strains the heart over time.

Other causes the BHF lists include abnormal heart rhythms, amyloidosis, anaemia, congenital heart conditions, heart valve disease and pulmonary hypertension, and some cancer treatments, an underactive or overactive thyroid and too much alcohol. The NHS adds coronary heart disease, chronic kidney disease and haemochromatosis. Because the cause determines treatment, doctors look for it with tests such as ECG, echocardiogram, MRI and blood tests.

Symptoms the NHS lists include breathlessness during everyday activity or when lying down, feeling weak, light-headed or very tired, swelling in the feet, ankles, legs or tummy, bloating, sudden weight gain, a cough at night and coughing up frothy pink phlegm.

• See a GP if you think you have symptoms of heart failure.

• Ask for an urgent GP appointment or call NHS 111 if you feel breathless when lying down or doing everyday things, are coughing up frothy pink phlegm, or have suddenly gained weight.

• Call 999 for severe difficulty breathing, pale, blue or grey lips or skin, or if someone has passed out and is not responding normally. Do not drive yourself to A&E.

The NHS says treatment depends on the type and stage of heart failure and your overall health. Medicines are used to ease symptoms and help prevent the condition from getting worse. Examples named by the NHS are diuretics to remove excess fluid, such as furosemide; medicines that widen blood vessels so the heart does not have to work as hard, for example candesartan or enalapril; and beta blockers that slow the heart so it needs less oxygen.

The BHF describes medicines used to protect and improve heart function, improve symptoms and reduce fluid build-up. The detail of which combination is used, and how doses are increased and monitored, is set out for clinicians in NICE guideline NG106, which is why specialist heart failure teams usually manage the introduction of medicines and the blood tests that go with them.

The NHS stresses taking medicines as prescribed, weighing yourself regularly because a build-up of fluid can cause sudden weight gain that may need treatment, and having vaccinations you are offered, such as the flu vaccine, since infections can be more serious when you have heart failure.

Some people with heart failure need a device. The BHF describes a pacemaker as helping control the heart rate to reduce the demand on the heart, and an implantable cardioverter defibrillator (ICD) as detecting and treating dangerous, irregular heartbeats. If you are at risk of a dangerous abnormal rhythm you are more likely to have an ICD or a CRT-D.

Cardiac resynchronisation therapy (CRT) pacemakers are used when the pumping chambers of the heart beat out of time with each other; the BHF explains that they help the chambers pump at the same time and help the heart pump better. A CRT device can be combined with defibrillation (CRT-D) or a pacemaker (CRT-P). Pacemakers are fitted in hospital in a procedure that usually takes about an hour under local anaesthetic.

The NHS says surgery may be needed to improve blood flow from blocked or damaged arteries, to repair or replace damaged heart valves, or to fit a pacemaker or ICD. In severe heart failure, a device that helps the heart pump (a left ventricular assist device) or a heart transplant may be offered if treatments are not helping.

The NHS says everyone diagnosed with heart failure should be offered cardiac rehabilitation, which may include an assessment and advice on exercising safely, exercise classes or a personal programme, lifestyle support and peer groups, delivered in hospital, clinics or the community, face to face or online.

The NHS says heart failure is a serious condition that affects everyone differently, with symptoms varying from day to day and week to week, but that treatment and lifestyle changes can help keep it stable for many years. You may need to adjust your job, and if you drive you must tell the DVLA about your condition and check with your insurer. As the condition progresses, you should be referred for palliative care, which focuses on quality of life and symptom control and is for anyone with a lifelong illness that cannot be cured.

It can be hard emotionally. The BHF says it is very difficult to live with uncertainty and suggests learning about your condition, taking part in decisions and talking to family, friends and the heart failure team. The NHS notes you can refer yourself directly to an NHS talking therapies service.

In the NHS, a GP arranges initial tests and refers to a cardiologist or a specialist heart failure team, which manages medicines, devices and rehabilitation. NICE guideline NG106 sets out expected practice, and care is free at the point of use.

Some people use private cardiology for a faster echocardiogram or a second opinion. Because the ejection fraction guides treatment, sharing the report and a list of medicines with your NHS team keeps care coordinated and avoids repeat tests.