What Is HFpEF?

It is also important to distinguish a normal ejection fraction from a normal heartbeat. A person can have a preserved ejection fraction while also having an abnormal rhythm, valve disease, conduction problems, or other cardiac conditions, like me.

What Does “Preserved Ejection Fraction” Mean?

Ejection fraction measures the percentage of blood that the left ventricle pumps out with each contraction. In HFpEF, that percentage is generally 50% or higher.

However, a normal percentage does not necessarily mean that the heart is moving a normal total amount of blood.

Imagine a flexible balloon that expands easily and fills completely. Now imagine a thick, stiff balloon that can hold only a smaller amount. Both balloons might empty the same percentage of their contents, but the stiff balloon starts with less inside it.

Something similar can happen with HFpEF. The heart may eject a normal percentage of the blood inside the ventricle, but because the ventricle cannot relax and fill properly, the total amount of blood pumped may still be insufficient—especially during physical activity.

The National Heart, Lung, and Blood Institute describes HFpEF as a condition in which the left side of the heart becomes too stiff to relax fully between beats. That stiffness prevents it from filling with enough blood to meet the body’s needs efficiently.

What Is a “Stiff Heart”?

The heart works in two main phases:

• During systole, the heart contracts and pushes blood forward.
• During diastole, the heart relaxes so its chambers can refill.

With HFpEF, the squeezing phase may remain relatively strong, but the relaxation phase is impaired. The left ventricle does not expand as easily as it should. More pressure is therefore required to push blood into it.

This is why HFpEF was once commonly called diastolic heart failure.

The problem may become more noticeable during exercise or other activity. The body needs more oxygen-rich blood, the heart rate increases, and the ventricle has less time to fill. A stiff heart may not be able to increase its output enough to meet that demand.

This can contribute to symptoms such as mine:

• Fatigue
• Shortness of breath
• Reduced exercise tolerance
• Lightheadedness
• Swelling
• Rapid weight gain
• Difficulty breathing while lying flat

How Does Pressure Build Up?

When the left ventricle cannot fill easily, pressure begins to rise inside it. That increased pressure can travel backward into the left atrium and then into the blood vessels in the lungs.

As pressure rises in those vessels, fluid can move out of the bloodstream and into surrounding tissue. In the lungs, this congestion can cause shortness of breath, coughing, reduced oxygen levels, and difficulty breathing while lying down.

Congestion can also affect the right side of the heart and the veins returning blood from the rest of the body. Fluid may then collect in several places, including:

• Feet and ankles
• Lower legs
• Abdomen
• Lungs
• Tissues around internal organs

Some people first notice tighter shoes, sock marks, swollen ankles, abdominal fullness, or an unexplained increase in weight. Others experience worsening shortness of breath before obvious swelling appears.

How Is Excess Fluid Removed at Home?

For many people with heart failure, fluid management begins at home. The exact plan should be developed with a cardiologist or other healthcare professional and may include:

• Limiting sodium, mine is around 1200mg a day
• Following a prescribed fluid limit, mine is 1.5 liters a day
• Taking an oral diuretic, sometimes called a water pill
• Monitoring weight, blood pressure, symptoms, and swelling daily
• Contacting the healthcare team when warning signs appear

Diuretics help the kidneys remove extra sodium and water through urination. This can reduce congestion and make it easier for the heart to work. It also make you having to use the washroom much more frequently.

A person should not begin taking extra diuretic medication or change the dose unless their clinician has provided specific instructions for doing so. Too much diuretic can cause dehydration, low blood pressure, electrolyte abnormalities, or worsening kidney function. I’ve been in the hospital for this.

What Happens If Home Treatment Does Not Work?

If oral medication is not removing enough fluid—or symptoms are becoming severe—hospital treatment may be necessary.

In the hospital, clinicians can give diuretics intravenously. IV medication enters the bloodstream directly and may work more quickly and reliably than oral medication.

The healthcare team may also:

• Measure urine output
• Monitor daily weight
• Check kidney function
• Check sodium, potassium, and other electrolytes
• Monitor blood pressure and oxygen levels
• Adjust heart failure medications
• Treat the condition that triggered the worsening congestion

In uncommon, severe cases where medications are not effective, a specialized filtration procedure may be considered to remove excess fluid. Most episodes, however, are treated with carefully monitored IV diuretics.

Why Daily Monitoring Matters

Fluid can accumulate before it becomes obvious in the feet or ankles. For that reason, daily weight is one of the most useful early-warning tools for someone living with heart failure.

Weight should generally be checked:

• Every morning
• After using the bathroom
• Before eating or drinking
• On the same scale
• In similar clothing

The American Heart Association advises contacting the healthcare team about a sudden gain of approximately 2–3 pounds in one day or 5 pounds in one week, because it may indicate fluid retention. These are general guidelines; each person should follow the limits established by their own healthcare team. These are the thresholds I have also established with my doctors.

Blood pressure should also be recorded regularly, but there is no single blood-pressure threshold that applies to everyone with HFpEF. Both high and low blood pressure can create problems. The appropriate range depends on medications, kidney function, symptoms, and other medical conditions.

A useful daily record can include:

• Weight
• Blood pressure
• Heart rate
• Swelling in the feet or legs
• Shortness of breath
• Ability to lie flat comfortably
• Fatigue or lightheadedness
• Diuretic use
• Sodium and fluid intake, when directed

The trend often matters more than a single number. A gradual weight increase, falling blood pressure accompanied by dizziness, or steadily worsening breathing deserves attention even when no individual reading appears extreme. I track these daily in an Excel spreadsheet. I will make a post and explain how and what I track.

A Normal Ejection Fraction Does Not Mean a Normal Heart

HFpEF can be confusing because the heart may still appear to squeeze normally on an echocardiogram. But the heart must do more than squeeze—it must also relax, fill, and respond when the body requires additional blood flow.

A stiff ventricle cannot perform those jobs efficiently. Pressure rises, blood backs up, fluid accumulates, and symptoms develop. That is genuine heart failure, even when the ejection fraction remains preserved.

Living with HFpEF means learning to notice small changes before they become emergencies. Daily monitoring, medication, sodium awareness, and communication with the healthcare team all play important roles in keeping fluid and symptoms under control.