Left-Sided Heart Failure: Overview and More - Verywell Health

The signs and symptoms of left-sided heart failure can be confused with another medical condition or even go unnoticed. Edema, fatigue, and shortness of breath—even in the absence of chest pain—can be signs of a failing heart.

The left ventricle (LV) is the chamber that is responsible for pumping blood from the heart to the rest of the body. Dysfunction of the left ventricle leads to two types of heart failure: systolic and diastolic.

Heart failure (HF) is common in the United States with over six million people. Additionally, nearly one million new cases are diagnosed each year. Fortunately, medical advances have made it possible to manage heart failure.

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Types of Left-Sided Heart Failure

The heart has two main pumping chambers: the right ventricle and the left ventricle. The right ventricle receives deoxygenated blood from the body and sends it to the lungs, where it picks up oxygen. The larger and more powerful left ventricle pumps oxygenated blood to the body through the aorta.

Conditions such as hypertension, obesity, and coronary heart disease make the heart have to work harder to pump the same amount of blood. Over time, the heart's main pumping power source is gradually weakened and can no longer handle the blood that it is receiving from the lungs. When this happens, heart failure occurs.

There are two types of left-sided heart failure:

• Heart failure with preserved ejection fraction (HFpEF), also called diastolic heart failure: In this type, the heart muscle contracts normally, but the ventricles do not relax as they should during ventricular filling (or when the ventricles relax).
• Heart failure with reduced ejection fraction (HFrEF), also called systolic heart failure: In this type, the heart muscle does not contract effectively, and less oxygen-rich blood is pumped out to the body.

Left-Sided Heart Failure Symptoms

You may not notice the signs of left-sided heart failure right away. Or you might attribute any mild symptoms you have to something else, such as allergies, congestion, indigestion, or a cold.

As the heart weakens, fluid backs up into the lungs and around the heart. When this happens, your symptoms may get worse and prompt you to seek medical care.

Older adults and people who are obese may have atypical signs and symptoms of heart failure Any sign of chest discomfort or a rapid decline in health should be treated as a medical emergency.

The symptoms of left-sided heart failure include:

• Chest pain
• Fatigue
• Weakness
• Shortness of breath (especially on exertion)
• Orthopnea (shortness of breath when lying down)
• Paroxysmal nocturnal dyspnea (awakening at night with shortness of breath)
• Exercise intolerance
• Fast or irregular heartbeat
• Peripheral edema (swelling of the feet, ankles, and legs)
• Unexplained weight gain
• Nausea
• Persistent coughing or wheezing
• Having to urinate more than usual (polyuria) or at night (nocturia)

As time goes on, your heart may try to compensate by pumping harder to meet your body's blood and oxygen demands. This causes more damage, which can lead to:

• Enlarged heart
• Rapid heart rate
• High blood pressure
• Less blood flow to the arms and legs

Early diagnosis and treatment can help slow the progression of left-sided heart failure and help you learn to adequately manage your symptoms. If undiagnosed and untreated, left-sided heart failure can cause complications like kidney or liver disease and heart attack.

Causes

The most common cause of heart failure is reduced left ventricular myocardial function. There are two types of dysfunction: systolic and diastolic.

Systolic dysfunction (HFrEF) is often due to:

Diastolic dysfunction (HFpEF) is most often due to:

Below is a list of the most common causes of left-sided heart failure and explanations on how these conditions contribute to heart failure.

• High blood pressure: Chronic hypertension is one of the most common causes of diastolic heart failure. High blood pressure over a long time means that the heart has to work harder to pump blood through the body. As a result, the heart gets more muscular and stiffer, which affects its ability to relax during the resting stages of the cardiac cycle when it fills with blood. 
• Diabetes: High blood sugar levels are toxic to blood vessels and may cause them to stiffen. Like high blood pressure, the heart muscle can thicken when it has to work harder against increased pressure.
• Coronary artery disease: Blockages in the heart's blood vessels allow less blood to flow through your heart than usual. Very low blood flow to the heart can lead to the death of heart muscle cells (ischemia), preventing the heart from relaxing and filling as it normally would. 
• Pericardial disease: Fluid around the heart (pericardial tamponade) or a thickened outer covering on the heart (pericardial constriction) can limit the heart's ability to fill with blood.
• Other heart conditions: Several other heart conditions can cause the left ventricle to thicken, compromising its ability to relax and fill with blood. Aortic stenosis (narrowing of the aortic valve) and hypertrophic cardiomyopathy (an inherited heart muscle disorder that leads to a very thickened left ventricular wall) are two examples.
• Obesity: Increased fat padding around the heart causes the heart to have to work harder to pump.
• Sedentary lifestyle: A lack of physical activity can put you at higher risk of high blood pressure, diabetes, coronary artery disease, and obesity—all of which contribute to diastolic heart failure. 
• Obstructive sleep apnea (OSA): OSA is characterized by partial or complete cessation of breathing during sleep. This leads to a complex set of changes in the body, including increases in blood pressure, diminished oxygen delivery to the heart, and increased sympathetic nervous system activity. As a result of these changes, there is a mismatch between oxygen supply and demand, which may predispose you to cardiac ischemia and arrhythmia, left ventricular hypertrophy, left ventricular enlargement, and both systolic and diastolic heart failure.

Hypertension, diabetes, obesity, and a sedentary lifestyle are preventable risk factors that you should be aware of whether you have heart failure or not.

The New York Heart Association classification system is the simplest and most widely used method to gauge symptom severity among people with heart failure.

Class I

• No limitations of physical activity
• No heart failure symptoms

Class II

• Mild limitation of physical activity
• Heart failure symptoms with significant exertion; comfortable at rest or with mild activity

Class III

• Marked limitation of physical activity
• Heart failure symptoms with mild exertion; only comfortable at rest

Class IV

• Discomfort with any activity
• Heart failure symptoms occur at rest

Diagnosis

Heart Failure With Preserved Ejection Fraction

A diagnosis of HFpEF is made based on your clinical history, physical examination, laboratory data, echocardiography, and when necessary, by cardiac catheterization.

To make a diagnosis of heart failure, a doctor needs to assess a patient for:

• The clinical signs and symptoms of heart failure, and
• Evidence of normal, or near-normal, left ventricular systolic heart function with an LV ejection fraction over 50%, and
• An assessment of the heart's diastolic characteristics with an echocardiogram.

An echocardiogram (or cardiac echo) is an ultrasound of the heart that can provide information on how the heart relaxes and fills with blood, also known as diastolic function, cardiac output, and the ejection fraction.

A diagnosis of diastolic heart dysfunction can also be measured invasively, using a catheter to measure the mean pulmonary capillary wedge pressure, or non-invasively, using doppler imaging techniques.

While HFpEF is a heterogeneous syndrome with multiple different conditions that contribute to the syndrome, high blood pressure, diabetes, and coronary artery disease are the biggest culprits.

Heart Failure With Reduced Ejection Fraction

The diagnostic workup for HFrEF includes an assessment of your clinical history, a physical examination, lab work, and an echocardiography assessment of LV structure and function.

If echocardiography is inconclusive, additional imaging tests might be considered, including:

• Radionuclide scan
• Cardiac catheterization
• Magnetic resonance imaging (MRI)
• Computed tomography (CT) scan and endomyocardial biopsy
• Cardiopulmonary exercise testing

HFrEF is a clinical syndrome that is diagnosed based on your symptoms of edema, fatigue, and shortness of breath, plus evidence of reduced left ventricular pumping power and blood delivery, usually documented by a left ventricular ejection fraction (LVEF) equal to or less than 40% on echocardiography.

The signs of HFrEF on physical exam include elevated jugular venous pressure, pulmonary crepitation, and displaced apex beat—but they don't have to be present to make a diagnosis.

Instead, as noted above, the diagnostic hallmark of HFrEF is LVEF equal to or less than 40%, according to both the European Society of Cardiology HF guidelines and the American College of Cardiology Foundation/American Heart Association Task Force on the management of HF.

Treatment

Left-sided heart failure is a progressive condition with no cure, but it can be managed. In most people, heart failure is a chronic condition that requires lifelong treatment. Most treatments are geared toward slowing the progression of heart failure and managing symptoms. 

Treatment of left-sided heart failure depends on the type of heart failure. There is no one-size-fits-all approach to managing the condition. The treatment should take the whole person into account, not just the heart.

A sound treatment plan usually starts with controlling a patient's blood pressure and relieving fluid overload, which can cause swelling or shortness of breath, as well as addressing the anticipated mental, emotional, and physical changes that a patient will experience.

Numerous randomized trials have shown the efficacy of using a diuretic, an ACE inhibitor or an angiotensin receptor blocker, and a beta-blocker. Most patients with HFrEF will benefit from being on these medications.

Treating the root cause of a patient's heart failure is the key to slowing heart disease. Here are a few examples:

• If the cause of your heart failure is a narrowed or leaky heart valve or an abnormal connection between heart chambers, surgery can often correct the problem.
• If it is blockage of a coronary artery, drug treatment, surgery, or angioplasty with a coronary stent may be the answer.
• Antihypertensive drugs can reduce and control high blood pressure.
• Antibiotics can eliminate some infections.

Heart Failure With Preserved Ejection Fraction Treatment

Diuretics are a mainstay of HFpEF treatment, but the medication is only as effective as the changes that a person makes to their diet and overall lifestyle.

If you have HFpEF, your doctor will likely suggest that you follow a treatment regimen that includes a combination of diet and lifestyle changes, medicines, and sometimes a device to protect your heart from abnormal rhythms.

Diet and Lifestyle Changes

If you have heart failure, the following lifestyle changes may help you manage your symptoms:

Reducing your salt intake is especially important. Too much salt in your diet can cause fluid retention, which counteracts the drugs (diuretics) that increase water excretion and relieve fluid accumulation.

The efficacy of medication in the treatment of diastolic heart failure is inconclusive. Therefore, the best way to manage HFpEF is to treat its underlying cause, such as hypertension, diabetes, or coronary artery disease.

Diuretics and beta-blockers are commonly used to manage HF symptoms. They work by removing excess fluid from the body and slowing the heart and giving it more time to fill. The use of diuretics like ACE inhibitors, thiazides, and spironolactone have even been found to increase life expectancy.

Management by Stage

The American College of Cardiology and the American Heart Association (ACC/AHA) recommend that cardiologists manage heart failure by its stage.

• Stage A includes managing heart failure risk factors like high blood pressure and high cholesterol. This may include putting you on a thiazide diuretic or ACE inhibitor and a statin.
• Stage B is diastolic dysfunction without symptoms. In this case, your cardiologist will likely prescribe a thiazide diuretic, ACE inhibitor, or nondihydropyridine calcium channel blockers to help ease the load on your heart.
• Stage C is symptomatic heart failure with or without hypertension. At this stage, your doctor will focus on treating the volume overload on your heart by using diuretics. 

The ACC/AHA also recommends starting or continuing a combined endurance and resistance training program for patients with HFpEF to improve exercise capacity, physical functioning, and diastolic function. Exercise has been proven to help the heart work more efficiently.

Heart Failure With Reduced Ejection Fraction Treatment

Treatment for anyone with heart failure should start with lifestyle modification such as:

• Diet modification, including low sodium and fluid intake
• Smoking cessation
• Decreased alcohol intake
• Increased exercise
• Maintaining a healthy weight

Pharmacotherapy is the cornerstone of the treatment of HFrEF. The main validated heart failure medications are:

• Angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs): Proven to reduce mortality rates and improve kidney function
• Beta-blockers: Proven to reduce mortality rates by decreasing strain on the heart
• Diuretics: Includes drugs like thiazides, which not only reduce mortality, but also reduce congestive symptoms by removing fluid around the heart and lungs. Loop diuretics produce a more intense and shorter diuresis effect than thiazides.
• Mineralocorticoid receptor antagonists (MRAs), such as spironolactone and eplerenone: Used when beta-blockers and ACE inhibitors fail. They should be used cautiously in those with kidney disease, as the medication can exacerbate renal dysfunction.
• Digoxin: Has a high side effect profile and is used as a last-ditch effort to reduce hospitalization
• Ivabradine: Works like a beta-blocker to slow the heart; often prescribed to those who cannot tolerate beta-blockers and used together with ACE inhibitors/ARBs or MRAs/ARBs

Medications are usually added based on how effective they are at managing your symptoms. Your cardiologist will likely start with a combination of an ACE inhibitor, beta-blocker, or diuretics for symptom relief. If you are still symptomatic and your LVEF is equal to or less than 35%, an MRA might be added.

If you are still symptomatic and your LVEF is equal to or less than 35%, your doctor may suggest replacing your ACE inhibitor with an angiotensin receptor-neprilysin inhibitor. Ivabradine or cardiac resynchronization therapy might also be considered.

Finally, if you are still asymptomatic, digoxin, an LV assist device, or heart transplantation should be considered.

Prognosis

There is no cure for left-sided heart failure, but timely management greatly increases your chances of living well with the condition.

Left-sided heart failure, whether HFpEF or HFrEF, is a progressive condition associated with increased mortality, even if you do not have symptoms.

The prognosis of left-sided heart failure depends on many factors, including:

• Age
• The extent of left-sided heart failure: There are four stages of heart failure, with each indicating how serious your condition is.
• Prior medical conditions, like diabetes
• Prior hospitalizations
• How your body responds to medical treatments
• Exercise intolerance

HFpEF Prognosis

The outlook for HFpEF is especially poor if you have been hospitalized, with one-year mortality rates as high as 25% among older patients, and five-year mortality rates of 24% for those over the age of 60 and 54% for those over 80.

Factors associated with a worse prognosis include higher levels of NT-proBNP, older age, diabetes, past history of heart attack or chronic obstructive pulmonary disease (COPD), reduced glomerular filtration rate and diastolic function, and right ventricular remodeling on cardiac echo.

HFrEF Prognosis

Diastolic heart failure tends to have a better short-term prognosis compared to systolic heart failure.

Normal ejection fraction rates range between 50% and 70%. Research shows that the severity of left ventricular dysfunction, measured by the ejection fraction, is proportional to increases in mortality rates.

In other words, the worse the left-sided heart failure, the worse the prognosis. In one trial, 50% of participants with an ejection fraction below 15% did not live for one year.

Survival rates in patients with heart failure are 75.9% at one year, 45.5% at five years, and 24.5% at 10 years, compared to 97%, 85%, and 75% in the general population, respectively.

Despite advances in medical technology, treatment, and widespread heart health campaigns, high mortality rates of 15% to 20% during the first year of diagnosis (and rising to 40% to 50% within five years of diagnosis) have remained relatively consistent in recent decades.

If you are over 65 years old, you are at a particularly high risk of heart disease. This underscores the need to start a heart-healthy life sooner rather than later. Research has shown that older patients hospitalized with congestive heart failure face a grave prognosis, particularly if their heart failure symptoms are caused by LV systolic dysfunction.

Coping

If you have heart failure, feelings of fear, anger, emotional distress, and depression may arise after the initial diagnosis. The physical limitations can be tough to accept, and you may not be ready to make all the changes that are asked of you. All these reactions are natural. Talking to friends and family can help you navigate these challenges.

From adapting to taking daily medication to making adjustments to your social life, living with heart failure is not easy. The key is to make lifestyle changes that lessen the chances of having heart failure exacerbations.

Stay in tune with your symptoms and contact a healthcare professional immediately if you sense that your condition is worsening.

Limiting your stress, quitting smoking, and exercising can benefit both your physical and mental health. Addressing your emotional well-being is key, because depression and anxiety may lead you to turn to ways of coping—like smoking, drinking alcohol, using substances, or making dietary choices that are not the best for your heart health—that could worsen your physical health.

If you are experiencing the following symptoms for two or more weeks, you might be suffering from depression:

• Feeling sad
• Not enjoying normal activities
• Trouble concentrating
• Fatigue
• Withdrawal from friends and family
• Feeling hopeless and worthless
• Excessive sleepiness
• Loss of appetite
• Suicidal thoughts

Recognizing that you might be depressed is the first step to taking action. Talk to your doctor about what options you have for treatment. This might include seeing a mental health provider and working through your stress with methods like cognitive behavioral therapy or medication. Or you might find that staying active and communicating with your loved ones about how you are feeling is enough to manage your mental health.

A Word From Verywell

Learning that you have heart failure is scary, but the better you understand the signs and symptoms of the condition, the better prepared you will be to take steps that can prevent exacerbations.

The once grim prognosis for heart failure can now be well managed with a combination of lifestyle modifications and medical monitoring. For example, you might start following a low-sodium diet, taking medications, and having frequent check-ins with your cardiologist.

While having to make many lifestyle changes in a short time can seem daunting, leaning on your friends and family, reaching out to a mental healthcare professional, and taking part in support groups can help.

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