What’s the Difference Between HFrEF and HFpEF? Understanding Two Types of Heart Failure
Heart failure is a complex condition that affects millions worldwide. While it may sound like the heart has stopped working entirely, it really means that the heart can’t pump blood as effectively as it should. There are several types of heart failure, each with unique causes, symptoms, and treatment strategies. Two of the most discussed types are heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).
HFrEF vs. HFpEF
The most significant difference between HFrEF and HFpEF lies in how well the heart pumps blood. Ejection fraction (EF) measures the percentage of blood the left ventricle pumps out with each contraction. Normal EF ranges from 50% to 70%.
- HFrEF (Heart Failure with Reduced Ejection Fraction): Also known as systolic heart failure, HFrEF occurs when the heart muscle becomes weak and cannot contract forcefully enough to pump sufficient blood. EF is typically 40% or lower in HFrEF.
- HFpEF (Heart Failure with Preserved Ejection Fraction): Also called diastolic heart failure, HFpEF happens when the heart muscle becomes stiff and doesn’t relax properly between beats. The EF remains in the normal range (above 50%), but the heart’s filling capacity is impaired.
While both conditions lead to similar symptoms, such as fatigue, shortness of breath, and swelling, they stem from different mechanical problems in the heart.
What Are the Four Types of Heart Failure?
Heart failure can be categorized into four main types:
- Left-sided heart failure: This is the most common type and includes both HFrEF and HFpEF. It occurs when the left ventricle fails to pump blood efficiently to the rest of the body.
- Right-sided heart failure: Often caused by left-sided heart failure, this type occurs when the right ventricle has trouble pumping blood to the lungs for oxygenation.
- Systolic heart failure: Equivalent to HFrEF, this type is due to weakened heart muscle contractions.
- Diastolic heart failure: Equivalent to HFpEF, this results from the heart muscle being too stiff to fill correctly.
Which Is Worse: HFpEF or HFrEF?
It’s natural to wonder which condition is more serious, but the answer isn’t straightforward. Both HFrEF and HFpEF carry significant risks and require ongoing treatment.
- HFrEF has traditionally been considered more dangerous due to its association with a lower ejection fraction and more advanced structural heart changes. However, it’s often more responsive to medications like ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.
- HFpEF, on the other hand, can be more challenging to treat. While EF is preserved, patients may experience severe symptoms and frequent hospitalizations. HFpEF is also closely linked to comorbidities like obesity, diabetes, and hypertension.
Left-Sided Heart Failure
Left-sided heart failure affects the heart’s main pumping chamber, the left ventricle. It’s subdivided into:
- Systolic failure (HFrEF): The heart muscle can’t contract properly.
- Diastolic failure (HFpEF): The heart muscle can’t relax properly.
Symptoms often include fatigue, coughing (especially when lying down), and shortness of breath due to fluid backing up into the lungs.
Right-Sided Heart Failure
Right-sided heart failure often follows left-sided failure. As the left ventricle fails, increased pressure backs up into the lungs, which strains the right ventricle. Over time, the right ventricle weakens and struggles to pump blood into the lungs.
Symptoms are more systemic and include:
- Swelling in the legs, ankles, and abdomen
- Weight gain from fluid retention
- Liver congestion and gastrointestinal distress
Right-sided failure is also associated with conditions like pulmonary hypertension or chronic lung disease.
Right vs. Left Heart Failure Symptoms
Understanding the symptom patterns can help in early detection and management:
| Symptom | Left-Sided Heart Failure | Right-Sided Heart Failure |
| Shortness of breath | ✓ | Sometimes |
| Coughing/wheezing | ✓ | Rare |
| Fatigue | ✓ | ✓ |
| Leg/ankle swelling | Sometimes | ✓ |
| Abdominal bloating | Rare | ✓ |
| Weight gain | Sometimes | ✓ |
| Fluid in the lungs | ✓ | Rare |
These symptoms may overlap, especially in cases of congestive heart failure, where both sides of the heart are affected.
Final Thoughts
Understanding the nuances between heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) is essential for accurate diagnosis and effective treatment. While both forms of heart failure share many symptoms, they differ in underlying mechanisms, treatment options, and prognoses.
Whether systolic or diastolic, left- or right-sided, heart failure is a serious condition. Still, with early diagnosis, lifestyle changes, and proper medical care, patients can manage their symptoms and maintain a better quality of life.
If you or a loved one is experiencing symptoms of heart failure, speak with a cardiologist for evaluation and a personalized care plan.
