What Is Systolic Heart Failure?

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Systolic heart failure, also known as heart failure with reduced ejection fraction (HFrEF), is a type of heart failure in which the main chamber of the heart does not pump as effectively as it should. This can lead to symptoms such as fatigue, leg swelling, and shortness of breath.

This article discusses systolic heart failure and its symptoms, causes, and treatment.

Woman having heart examined

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Understanding Systolic Heart Failure

The heart acts as a pump to supply oxygen and nutrients throughout the body. The left ventricle is the main chamber of the heart that pumps blood to the body. Normally, the left ventricle pumps more than half of the blood it receives in each heartbeat.

Ejection Fraction

The ejection fraction (EF) is a measure of the left ventricle's pumping efficiency and is the proportion of blood pumped out of the heart. An ejection fraction of 55%–60% or higher is normal, and means that 55%–60% of the blood in the left ventricle is pumped out with each heartbeat.

Although an ejection fraction below 55% is abnormal, an ejection fraction ≤40% is considered heart failure with reduced ejection fraction (HFrEF), also known as systolic heart failure.

A low EF can cause reduced cardiac output. Cardiac output is the amount of blood the heart is able to pump out each minute.

Our organs require a certain amount of cardiac output in order to function, and a low cardiac output has negative effects on organs such as the kidneys and brain.

Systolic Heart Failure Symptoms

Symptoms of systolic heart failure are a result of low cardiac output, as well as the backup of blood in the lungs and body. They include:

  • Shortness of breath
  • Exercise intolerance
  • Fatigue
  • Inability to lay flat due to difficulty breathing
  • Waking up at night with spells of breathlessness
  • Rapid heartbeat (palpitations)
  • Decreased appetite and nausea
  • Leg and ankle swelling
  • Abdominal fullness (bloating)

What Causes Systolic Heart Failure?

Systolic heart failure has many causes, including:

Sometimes, the cause of heart failure is not known. This is considered idiopathic.

Diagnosing Systolic Heart Failure

Systolic heart failure is diagnosed with a noninvasive test called transthoracic echocardiography. This test involves an ultrasound that can generate pictures of the heart and evaluate the heart's pumping function (EF), as well as the valves and flow of blood.

Other tests to help determine the cause and complications of heart failure include:


Managing systolic heart failure requires lifestyle changes and medications. Sometimes implantable devices can help.

Lifestyle Changes

In addition to medications, people with systolic heart failure should follow a low-salt diet and monitor their fluid intake. Weighing yourself daily can help you keep track of fluid overload.

Those with systolic heart failure should avoid excessive alcohol intake and stay away from other substances.


Systolic heart failure is a well-studied condition, and several medications have been shown to improve prognosis in people with this condition. Sometimes, the weakened heart muscle can even improve with medication.

The following are medications commonly used to treat systolic heart failure:

  • Diuretics like Lasix (furosemide) or torsemide
  • Beta-blockers, specifically Toprol XL (metoprolol succinate), Coreg (carvedilol), and bisoprolol
  • Ace-inhibitors or angiotensin receptor blockers (ARBs)
  • Neprolysin inhibitors, like in the combination pill Entresto (sacubitril and valsartan)
  • Aldosterone antagonist like Aldactone (spironolactone)
  • Vasodilators like Bidil (isosorbide dinitrate and hydralazine)
  • Sodium-glucose co-transporter-2 (SGLT2) inhibitors like Farxiga (dapagliflozin) and Jardiance (empagliflozin)
  • Procoralan (ivabradine)

Note that treatment is individualized and some medications may not be tolerated in certain people.

Implantable Device Therapy

An implantable cardioverter defibrillator (ICD) is recommended for some people with low EF. An ICD is a small device placed under the skin in the chest, with wires that sit in the heart's chambers. ICDs monitor the heart's rhythm and deliver a "shock" of electricity to stop life-threatening arrhythmias.

Some people who have abnormal electrocardiogram and systolic heart failure can benefit from cardiac resynchronization therapy (CRT). CRT is a special type of ICD with an additional lead that helps it optimize the timing of the heart's contraction. CRT can help improve symptoms, and some people even see an improvement in their EF with this therapy.

Prognosis of Systolic Heart Failure

In general, a diagnosis of heart failure is serious, since it can cause life-threatening arrhythmias and organ failure.

Taking medications as prescribed, monitoring fluid status, and close follow-up with a healthcare provider can help people with heart failure stay out of the hospital and improve quality of life.

Advanced treatments and heart transplant are also options for those with very severe heart failure.

Coping With Heart Failure

Dealing with heart failure symptoms can be difficult, particularly when it impacts daily life. Exercise ability may be significantly limited, with some people having shortness of breath with minimal activity or even while at rest. In addition, leg swelling can become painful, and it can be hard to find shoes that fit.

Staying organized is very important. Consider investing in a pill sorter to keep track of all of the medications you are prescribed. Each morning, write down your weight, blood pressure, and any symptoms on a calendar and bring this to your healthcare provider visits.

For some, cutting back on salt can be a big help. Using other spices can help keep flavor in meals without the added salt.

As with any chronic condition, support from loved ones can help you cope. Many hospitals also offer support groups for people with heart failure.


Systolic heart failure is a serious condition in which the heart's main chamber is not pumping as effectively as it should. This causes symptoms of shortness of breath, fatigue, and leg swelling, and increases the risk of arrhythmias and organ failure. Several medications and devices can improve survival of people with systolic heart failure.

A Word From Verywell

A diagnosis of systolic heart failure is life-changing. It requires monitoring of your diet and remembering to take a handful of medications. Managing the symptoms of heart failure and side effects of medications can be overwhelming. Support from loved ones and healthcare providers can help you cope and live with the condition.

3 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSAGuideline for the Management of Heart Failure: A Report of the American Collegeof Cardiology/American Heart Association Joint Committee on Clinical PracticeGuidelines. J Am Coll Cardiol. 2022;79(17):e263-e421.doi:10.1016/j.jacc.2021.12.012

  2. Cleveland Clinic. Heart failure.

  3. American Heart Association. Implantable cardioverter defibrillator.

By Angela Ryan Lee, MD
Angela Ryan Lee, MD, is board-certified in cardiovascular diseases and internal medicine. She is a fellow of the American College of Cardiology and holds board certifications from the American Society of Nuclear Cardiology and the National Board of Echocardiography. She completed undergraduate studies at the University of Virginia with a B.S. in Biology, medical school at Jefferson Medical College, and internal medicine residency and cardiovascular diseases fellowship at the George Washington University Hospital. Her professional interests include preventive cardiology, medical journalism, and health policy.