Compare and contrast the manifestations of left-sided and right sided heart failure.

Left-sided heart failure

The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. The left ventricle supplies most of the heart's pumping power, so it's larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart must work harder to pump the same amount of blood.

There are two types of left-sided heart failure. Drug treatments are different for the two types.

• Heart failure with reduced ejection fraction (HFrEF), also called systolic failure: The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation.
• Heart failure with preserved ejection fraction (HFpEF), also called diastolic failure (or diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can't properly fill with blood during the resting period between each beat.

Right-sided heart failure

The heart's pumping action moves "used" blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to be replenished with oxygen.

Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).

Congestive heart failure

Congestive heart failure (CHF) is a type of heart failure which requires seeking timely medical attention, although sometimes the two terms are used interchangeably.

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the body's tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too.

Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. This is called pulmonary edema and if left untreated can cause respiratory distress.

Heart failure also affects the kidneys' ability to dispose of sodium and water. This retained water also increases swelling in the body's tissues (edema).

Written by American Heart Association editorial staff and reviewed by science and medicine advisers. See our editorial policies and staff.

In heart failure, the heart can no longer pump enough blood around the body. The heart muscle is either too weak or not elastic enough. Different parts of the heart may be affected too. The type of medication people use for the treatment of heart failure will depend on the type of heart failure they have.

Heart failure often only affects the left or right side of the heart, but can affect both. Doctors differentiate between three types of heart failure, accordingly:

• Left-sided heart failure: The left ventricle of the heart no longer pumps enough blood around the body. As a result, blood builds up in the pulmonary veins (the blood vessels that carry blood away from the lungs). This causes shortness of breath, trouble breathing or coughing – especially during physical activity. Left-sided heart failure is the most common type.

• Right-sided heart failure: Here the right ventricle of the heart is too weak to pump enough blood to the lungs. This causes blood to build up in the veins (the blood vessels that carry blood from the organs and tissue back to the heart). The increased pressure inside the veins can push fluid out of the veins into surrounding tissue. This leads to a build-up of fluid in the legs, or less commonly in the genital area, organs or the abdomen (belly).

• Biventricular heart failure: In biventricular heart failure, both sides of the heart are affected. This can cause the same symptoms as both left-sided and right-sided heart failure, such as shortness of breath and a build-up of fluid.

Left-sided heart failure is usually caused by coronary artery disease (CAD), a heart attack or long-term high blood pressure. Right-sided heart failure generally develops as a result of advanced left-sided heart failure, and is then treated in the same way. It is sometimes caused by high blood pressure in the lungs, an embolism in the lungs (pulmonary embolism), or certain lung diseases such as COPD.

Classification based on pumping ability

Nowadays, heart failure is increasingly being classified based on the pumping ability of the heart. This is because the pumping ability plays an important role when choosing the most suitable medication. There are two types of heart failure here:

• Heart failure with reduced pumping ability: The heart muscle has become weaker, and no longer pumps enough blood around the body when it contracts (squeezes). As a result, the organs in the body don’t get enough oxygen. The medical term for this is “heart failure with reduced ejection fraction.”

• Heart failure with preserved pumping ability: Although the heart muscle is still strong, it can no longer relax and widen enough after it has squeezed blood out, so it doesn’t fill up with blood properly. Despite pumping strongly enough, not enough blood is pumped out into the body as a result, especially during physically strenuous activities. Doctors call this “heart failure with preserved ejection fraction.”

Heart failure with reduced pumping ability is sometimes referred to as “systolic” heart failure, and heart failure with preserved pumping ability is also known as “diastolic” heart failure. The systolic phase of the cardiac cycle is the phase when the heart contracts (squeezes), and the diastolic phase is when the heart relaxes and widens.

Classification based on course of the disease

Heart failure can develop suddenly, for instance after a heart attack or due to certain heart rhythm problems. This is known as acute heart failure.

But it usually develops gradually over time as a result of a different medical problem, such as permanently high blood pressure. This is known as chronic heart failure.

Sources

• Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Chronische Herzinsuffizienz. AWMF-Registernr.: nvl-006. October 22, 2019.

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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