- Heart failure does not mean the heart has stopped, it means the heart is not pumping as efficiently as it should, and cannot fully keep up with the body’s demands.
- Doctors describe heart failure in two main ways, based on whether the heart’s pumping strength is reduced or whether it is normal but the heart has become stiff. Both cause similar symptoms.
- The term “ejection fraction” refers to the percentage of blood the heart pumps out with each beat. A normal ejection fraction is above 55%. In heart failure with reduced ejection fraction it is below 40%.
- HFrEF, heart failure with reduced ejection fraction, means the heart muscle is pumping less powerfully than normal. HFpEF, heart failure with preserved ejection fraction, means the pumping strength appears normal but the heart has become stiff and does not fill properly between beats.
- Both types are treatable. The specific medications and management approach differ between the two, which is why knowing which type you have matters for your treatment plan.
Being told you have heart failure is frightening enough. Being told you have “HFrEF” or “HFpEF”, or that your ejection fraction is reduced or preserved, adds a layer of medical terminology that can leave patients more confused than informed.
These terms are important, they describe which type of heart failure you have and directly influence which treatments are most appropriate for you. But they are not complicated once they are explained in plain language. This article does exactly that.
What Is Ejection Fraction?
The heart is a pump. With every beat, it squeezes blood out of its main pumping chamber, the left ventricle, and sends it out to the rest of the body. The ejection fraction is simply the percentage of blood in that chamber that gets pumped out with each beat.
It is measured using an echocardiogram, an ultrasound of the heart that shows how the heart muscle is moving and how much blood is being pumped with each beat. It is one of the most important single measurements in cardiology.
In a healthy heart, the left ventricle pumps out roughly 55 to 70% of the blood it contains with each squeeze. This is a normal ejection fraction. The remaining blood stays in the ventricle and is topped up again as the heart relaxes and refills before the next beat.
When the heart muscle is weakened, as happens in certain types of heart failure, it squeezes less powerfully, and a smaller percentage of blood is pumped out with each beat. This is what a reduced ejection fraction means.
The Two Main Types of Heart Failure
HFrEF, Heart Failure with Reduced Ejection Fraction
In HFrEF, pronounced “HF-ref”, the heart muscle has weakened and is not squeezing as powerfully as it should. The ejection fraction is below 40%, meaning less than 40% of the blood in the left ventricle is being pumped out with each beat. The heart is working hard but not achieving enough forward output.
The symptoms this produces, breathlessness, fatigue, ankle swelling, reduced exercise tolerance, reflect the fact that the body’s tissues are not receiving as much blood and oxygen as they need. The heart compensates as best it can, but over time the gap between what the body demands and what the heart can deliver produces the characteristic symptoms of heart failure.
HFrEF has an excellent range of treatments available, in fact the evidence base for treating HFrEF is one of the strongest in all of cardiology. A combination of four medication classes, known as quadruple therapy, including SGLT2 inhibitors, beta-blockers, ACE inhibitors, and mineralocorticoid receptor antagonists has been shown to significantly improve both symptoms and long-term outcomes. We cover this in detail in our dedicated heart failure treatment article.
HFpEF, Heart Failure with Preserved Ejection Fraction
In HFpEF, pronounced “HF-pef”, the heart’s pumping strength appears normal on an echocardiogram. The ejection fraction is above 50%, meaning the heart is squeezing well. But the patient still has heart failure symptoms, breathlessness, fatigue, reduced exercise capacity, because something else is going wrong.
The problem in HFpEF is stiffness. The heart muscle has become less flexible, it does not relax and fill between beats as easily as it should. Think of squeezing a stiff rubber ball compared to a soft one, the stiff ball takes more effort to compress and springs back less readily. When the heart muscle is stiff, it fills less efficiently between beats, pressures rise within the heart, and those elevated pressures back up into the lungs, producing breathlessness and the other symptoms of heart failure despite normal pumping strength.
HFpEF is more common in older patients, women, people with high blood pressure, obesity, and diabetes. Managing the underlying conditions that contribute to cardiac stiffness, blood pressure control, weight management, blood sugar control, is a central part of HFpEF treatment alongside specific medications.
Why Does the Distinction Matter?
The two types of heart failure produce very similar symptoms, which is why an echocardiogram is needed to distinguish them rather than clinical assessment alone. But the treatment approaches differ in important ways.
The medications that have the strongest evidence in HFrEF, particularly certain beta-blockers, ACE inhibitors, and SGLT2 inhibitors, have been studied extensively in that specific population and shown to improve outcomes significantly. HFpEF research has historically lagged behind, but SGLT2 inhibitors have now shown meaningful benefit in HFpEF as well, and the treatment landscape is improving rapidly.
Knowing which type you have means your clinical team can apply the right evidence to your specific situation. Regular follow-up including BNP or NT-proBNP blood tests helps the clinical team monitor how hard the heart is working and whether treatment is achieving the right effect.
When a patient is told they have heart failure, one of the first questions I want answered is which type, because the management pathway differs. An echocardiogram gives us that answer quickly, and it changes the conversation about which treatments are most likely to help.
— Prof. Peter Barlis, Interventional Cardiologist
A Note on Borderline Ejection Fraction
Some patients are told their ejection fraction is “mildly reduced” or “borderline”, typically a reading between 40% and 55%. This sits between the two main categories and is sometimes called HFmrEF, heart failure with mildly reduced ejection fraction. It shares features of both types and is managed on an individualised basis. If you have been given this term and are unsure what it means for your treatment, asking your cardiologist to clarify which treatment approach applies to you is a very reasonable question.
What Both Types Have in Common
Regardless of which type of heart failure you have, the broader management principles are similar, monitoring symptoms, daily weighing to detect fluid accumulation early, appropriate exercise within your limits, salt and fluid awareness, and regular follow-up with your clinical team.
Understanding which type of heart failure you have is the starting point, not the end of the conversation. The most important next step is working with your cardiologist to ensure your treatment is optimised for your specific type, your specific symptoms, and your specific circumstances. We cover all of these management approaches in detail in our heart failure treatment article.
- Which type of heart failure do I have, HFrEF or HFpEF, and what does that mean for my treatment?
- What is my ejection fraction, and has it changed since my last echocardiogram?
- Am I on the right medications for my specific type of heart failure?
- Are there conditions contributing to my heart failure, blood pressure, diabetes, weight, that we should be managing more aggressively?
- What symptoms should prompt me to contact the team between appointments?
Heart Matters Resource
When in Doubt, Get Checked Out
If you have been told you have heart failure and are not sure which type, or if your symptoms have changed, that is a conversation worth having with your cardiologist promptly rather than waiting for the next routine appointment.
Conclusion
HFrEF and HFpEF are not two different diseases, they are two different mechanisms by which the heart fails to meet the body’s demands. One involves a weakened pump, the other a stiff one. Both produce similar symptoms, both are diagnosed with an echocardiogram, and both are treatable, though the specific treatment approaches differ.
Knowing which type you have puts you in a stronger position to understand your treatment and ask the right questions at your appointments. It is not a label to be feared, it is a piece of information that your clinical team uses to make your management as targeted and effective as possible.
Your heart has two ways of struggling, and medicine has effective answers for both.
More from Heart Matters
- Heart Failure and Quadruple Therapy: How the Heart Is Treated Today
- The Echocardiogram: What It Shows and Why It Matters
- BNP and NT-proBNP: What These Heart Failure Markers Tell Your Doctor
- SGLT2 Inhibitors and the Heart
- Shortness of Breath and the Heart
- Breathlessness Lying Flat: What Orthopnoea Means
- Understanding Ankle Swelling
- Fatigue and the Heart
- High Blood Pressure: Why Monitoring Matters
