Signs of Left-Sided Heart Failure

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The symptoms of left-sided heart failure can be similar to other medical conditions. Sometimes they can even go unnoticed.

Heart failure (HF) affects over 6 million people in the United States. Nearly 1 million new cases are diagnosed each year. Fortunately, medical advances have made it possible to manage heart failure.

This article discusses the two types of left-sided heart failure, and what some of the symptoms are. It also looks at the causes, diagnosis, and treatment of this common heart condition.

An older white woman in a light blue shirt standing outside with her hand on her chest

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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 sends blood to the lungs, where it picks up oxygen. The larger and more powerful left ventricle pumps the oxygen-rich blood to the body.

Certain medical conditions make it so your heart has to work harder to pump blood. Examples include:

Over time, this can cause the heart to weaken so it can no longer handle the blood it receives from the lungs. This is called heart failure.

Reduced function of the left ventricle is the most common cause of heart failure. There are two types of left-sided heart failure:

  • Heart failure with preserved ejection fraction (HFpEF): This type is also called diastolic heart failure. When you have this type of heart failure, your heart muscle contracts normally, but it doesn't relax as well between beats. This causes it to not fill all the way up with blood.
  • Heart failure with reduced ejection fraction (HFrEF): This type is also called systolic heart failure. With this type of heart failure, the heart muscle does not contract effectively. This means less oxygen-rich blood gets pumped out into your body.

Left-Sided Heart Failure Symptoms

You may not notice the signs of left-sided heart failure right away. Or you might attribute mild symptoms 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 symptoms of heart failure. Any sign of chest discomfort or a rapid decline in health should always be treated as a medical emergency.

The symptoms of left-sided heart failure include:

  • Chest pain
  • Fatigue
  • Weakness
  • Shortness of breath, especially when exerting yourself
  • Shortness of breath when lying down (orthopnea)
  • Awakening at night with shortness of breath (paroxysmal nocturnal dyspnea)
  • Exercise intolerance
  • Fast or irregular heartbeat
  • Swelling of the feet, ankles, and legs (peripheral edema)
  • 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. 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. With the right care, you can learn to manage your symptoms. If undiagnosed and untreated, however, left-sided heart failure can cause complications. These can include:

Causes of Left-Sided Heart Failure

Left-sided heart failure can have many potential causes, including:

  • High blood pressure: Chronic hypertension is one of the most common causes of diastolic heart failure. When you have high blood pressure over a long time, your heart has to work harder to pump blood through your body. As a result, your heart gets more muscular and stiffer. This affects its ability to relax between beats. 
  • Diabetes: High blood sugar levels may cause stiffening of blood vessels. This makes the heart have to work harder, which can cause the muscle to thicken.
  • Coronary artery disease: Blockages permit less blood to flow through your heart. Very low blood flow to the heart can lead to the death of heart muscle cells (ischemia). This can stop the heart from relaxing and filling as it should. 
  • Pericardial disease: Fluid around the heart is called pericardial tamponade. A thickened outer covering on the heart is called pericardial constriction. Both can limit the heart’s ability to fill with blood.
  • Obesity: Increased fat padding around the heart makes it have to work harder.
  • Sedentary lifestyle: A lack of physical activity can put you at higher risk of high blood pressure, diabetes, coronary artery disease, and obesity. All these conditions can contribute to diastolic heart failure. 
  • Obstructive sleep apnea (OSA): When you have OSA, you stop breathing while you sleep. This leads to a complex set of changes in the body. Some of these changes include increases in blood pressure, reduced oxygen delivery to the heart, and increased nervous system activity. These changes cause a mismatch between oxygen supply and demand. When this happens, it puts you at higher risk for both systolic and diastolic heart failure as well as other heart conditions.
  • Other heart conditions: Several other heart conditions can cause the left ventricle to thicken. 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.

Systolic and diastolic heart failure can have different root causes. Systolic dysfunction (HFrEF) is often due to:

Diastolic dysfunction (HFpEF) is most often due to:

Hypertension, diabetes, obesity, smoking, 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 on physical activity
  • No heart failure symptoms

Class II

  • Mild limitation on 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


The diagnosis of left-sided heart failure begins with an assessment of your clinical history. Your healthcare provider will also do a physical examination and order lab work. An echocardiogram will help your healthcare provider assess the structure and function of your left ventricle.

An echocardiogram (or cardiac echo) is an ultrasound of the heart that can provide information on how the heart relaxes and fills with blood (diastolic function), cardiac output, and the ejection fraction. The ejection fraction is a measurement of how much blood is pumped out of your heart with each beat.

Heart Failure With Preserved Ejection Fraction

To make a diagnosis of HFpEF, your healthcare provider looks for:

  • The clinical signs and symptoms of heart failure, and
  • Evidence that the left ventricle contracts normally, or near normally, and that it pumps out greater than 50% of the blood it contains with each beat, and
  • Evidence of reduced diastolic function seen on an echocardiogram

A diagnosis of diastolic heart dysfunction can also be measured invasively, using a catheter, or non-invasively, using doppler imaging techniques. Exercise tests can also help your healthcare provider diagnose your condition.

There are multiple conditions that can contribute to HFpEF, but the most common are:

  • High blood pressure
  • Diabetes
  • Coronary artery disease

Heart Failure With Reduced Ejection Fraction

Symptoms of HFrEF include:

  • Edema (swelling of tissues)
  • Fatigue
  • Shortness of breath

Your healthcare provider will also look for evidence that your left ventricle has reduced pumping power and isn't able to deliver as much blood as it should. This is usually seen on an echocardiogram.

With HFrEF, the left ventricular ejection fraction (LVEF) is equal to or less than 40%. This means your heart is only pumping 40% or less of the blood it contains out into the body with each beat. This is considered the diagnostic hallmark of HFrEF.

If your echocardiography is inconclusive, your healthcare provider might order more tests. These may include:


Left-sided heart failure is a progressive condition, which means it gets worse over time. It can't be cured, 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 your blood pressure and relieving fluid overload. Fluid overload can cause swelling or shortness of breath. Your healthcare provider will also address the anticipated mental, emotional, and physical changes that you might experience.

Research has shown that the condition can be effectively treated with a combination of drugs, which may include:

Most patients with HFrEF will benefit from being on a combination of these medications.

Jardiance, a medication used to help improve blood sugar control in those with type 2 diabetes, is also prescribed to reduce the risk of heart-related death in people with type 2 diabetes and those with heart failure and reduced ejection fraction.

Jardiance can interact with diuretics and increase the risk of dehydration, so careful monitoring and/or adjustment of other medications may be needed if Jardiance is added as part of your combination therapy.

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, or 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. For these medications to be helpful, however, you need to also make changes to your diet and overall lifestyle.

If you have HFpEF, your doctor will likely suggest you follow a treatment regimen that includes a combination of:

  • Diet and lifestyle changes
  • Medicines
  • For some patients, a device to protect the heart from abnormal rhythms

Diet and Lifestyle Changes

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

  • Regular low-intensity aerobic exercise to strengthen the heart
  • Eating a heart-healthy diet
  • Cutting back on salt (sodium)
  • Limiting your alcohol consumption
  • Quitting smoking

Reducing your salt intake is especially important. Too much salt in your diet can cause fluid retention. This will counteract the drugs (diuretics) that help relieve fluid accumulation.

The effectiveness 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.

SGLT2 inhibitor medications are antidiabetic drugs that may be used to treat HFpEF in people with or without diabetes. In people with heart failure, taking this medication can help prevent heart failure episodes. Your doctor can determine whether you are able to use an SGLT2 inhibitor.

Diuretics and beta-blockers are commonly used to manage HF symptoms. They work by removing excess fluid from the body and slowing the heart to give 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 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 healthcare provider will focus on treating the volume overload on your heart by using diuretics. 
  • Stage D is severe heart failure. In this stage you may not get much relief from medication. Treatment may include heart surgery, transplant, or a device that helps your heart pump. Palliative or hospice care may also be offered in this stage.

The ACC/AHA also recommends starting or continuing a combined endurance and resistance training program for patients with HFpEF. The goal is 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
  • Quitting smoking
  • Drinking less alcohol
  • Increasing 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.
  • Lanoxin (digoxin): Has a high side effect profile and is used as a last-ditch effort to reduce hospitalization
  • Corlanor (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
  • Jardiance (empagliflozin): This medication has been shown to reduce the risk of hospitalization and death for patients with HFrEF by up to 30%. It can also significantly slow the decline of kidney function. Jardiance may interact with diuretics and may cause hypoglycemia (low blood sugar) in people taking insulin. Discuss all your medications with your healthcare provider before taking Jardiance.

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. Corlanor 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.


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
  • Which stage of heart failure you are in
  • 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. For people in this group, the one-year mortality rates are as high as 25% among older patients. For people over the age of 60, the five-year mortality rate is 24%. For those over the age of 80, the five-year mortality rate is 54%.

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
  • Right ventricular remodeling on cardiac echo

HFrEF Prognosis

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 mortality rates have remained high. During the first year after diagnosis, they are 15% to 20%, and they rise to 40% to 50% within five years of diagnosis. These numbers 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.


After you've been diagnosed with heart failure, you may have feelings of fear, anger, emotional distress, and depression. 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 stress, quitting smoking, and exercising can benefit both your physical and mental health. It's very important to address your emotional well-being, because depression and anxiety may lead to coping strategies like drinking and eating unhealthy foods that could make things worse.

If you have 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 depression is the first step to getting treatment. Talk to your healthcare provider about your options. This might include seeing a mental health provider and working through your stress with things like cognitive behavioral therapy or medication. You might also find that staying active and communicating with your loved ones about how you feel is enough to manage your mental health.


There are two types of left-sided heart failure: heart failure with preserved ejection fraction and heart failure with reduced ejection fraction. Both can cause symptoms like chest pain, fatigue, and shortness of breath.

Certain medical conditions like diabetes, high blood pressure, and coronary artery disease put you at higher risk for developing heart failure. Your healthcare provider can diagnose which type of heart failure you have based on a physical exam and tests such as an echocardiogram.

Treatment for left sided heart failure includes lifestyle changes and medications. There is no cure, but the condition can be managed.

A Word From Verywell

Learning that you have heart failure is scary. The better you understand the signs and symptoms of the condition, however, 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.

Making 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 you cope and learn how to live with your condition.

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By Shamard Charles, MD, MPH
Shamard Charles, MD, MPH is a public health physician and journalist. He has held positions with major news networks like NBC reporting on health policy, public health initiatives, diversity in medicine, and new developments in health care research and medical treatments.