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Q: I was recently diagnosed with mild heart failure. But my echocardiogram showed a normal ejection fraction. Why would I still have heart failure? 

A: Heart failure conjures up the image of your heart suddenly stopping. But it actually means the heart is not pumping as it should. 

Impairments in pumping action can develop in the entire heart or just the left or right side. Most heart failure is caused by left-sided problems: the left ventricle (the heart’s largest chamber) is either too weak or too stiff to pump normally. 

To figure out what is happening, doctors usually order an echocardiogram to measure the heart’s ejection fraction (EF). EF is a percentage of how much of the blood inside the left ventricle gets pumped out with each contraction. 

The left ventricle never pushes out 100% of its blood when it contracts. A normal heart’s EF is 50% to 70%. An EF of 40% to 49% is considered borderline low. Less than 40% is deemed a low or reduced EF.  

This indicates the left ventricle is too weak to push out enough blood — a problem known as heart failure with reduced ejection fraction (HFrEF). 

But when older adults develop heart failure, they more often have a normal EF of 50% or greater, called heart failure with preserved ejection fraction (HFpEF).  

In that situation, the left ventricle muscle is too stiff to relax. Ejection fraction is normal, but less blood can enter the chamber in the first place, so less total amount of blood gets pumped out. 

What puts you at risk for HFpEF? The usual factors are high blood pressure, coronary artery disease, obesity and diabetes. Less common causes are inherited or acquired heart muscle diseases. 

Both types of left-sided heart failure have similar symptoms. At first, you might only notice that you’re more tired or that you can’t walk as fast as you used to.  

Other symptoms include: 

• shortness of breath with exertion or when you’re lying flat
• swelling in the legs, ankles or both
• persistent cough
• waking up in the middle of the night short of breath

The treatment for HFpEF starts with the same lifestyle changes that help prevent heart failure. This means striving for a healthy weight, reducing salt intake, eating a Mediterranean-style diet, exercising regularly and limiting alcohol to no more than one drink per day. 

The mainstays of HFpEF drug treatment are to reduce fluid in the body with diuretics (“water pills”) and to aggressively lower blood pressure with a variety of medications, such as ACE inhibitors, angiotensin-receptor blockers, beta blockers and calcium-channel blockers.  

In addition, new research has shown that drugs called SGLT2 inhibitors can lower risks for dying from heart problems or being hospitalized for heart failure. 

Q: My father’s doctor told him he may need a pacemaker. But he didn’t know why. What are the reasons why a person might need a pacemaker, and what can he expect? 

A: A pacemaker monitors the heart’s rhythm and, when necessary, generates a painless electrical impulse that triggers a heartbeat. 

The most common use for a pacemaker is when the heart beats too slowly or pauses, which can trigger dizziness, shortness of breath or fainting.  

A pacemaker also can help your heart chambers beat in sync and improve blood flow if your heart isn’t pumping enough blood. In some cases, a pacemaker may be needed to help regulate a heartbeat that is too fast or irregular. 

These issues can stem from problems with the heart’s electrical signaling, a heart defect, an enlarged or thick heart muscle, heart failure or a heart attack. 

Pacemakers are typically made of titanium and weigh as little as one ounce. They have two working parts: a pulse generator with a lithium-ion battery and one or more flexible wires called leads. 

Pacemaker surgery lasts one to two hours. The person is awake during the procedure and given a mild sedative.  

The upper chest is numbed, and the surgeon makes an incision of two to three inches near the collarbone to access a large vein. The surgeon then creates a small pocket in the skin between the shoulder and chest and inserts the pulse generator. 

The leads are connected to the pulse generator, threaded through the large vein, and attached to the heart’s surface with electrodes. These electrodes pick up the heart’s natural electric signals.  

When the heartbeat is abnormal, the pulse generator sends a programmed pulse along the leads to the heart muscle to make the necessary correction. 

The surgery is relatively minor and has become much more routine. It’s usually a same-day procedure, where you arrive in the morning and are home by that afternoon. A small bulge remains where the pulse generator was inserted.  

Although pacemakers are generally safe, rare complications can occur. These include infection, excessive bleeding, a tear in the heart, a punctured lung or a blood clot.  

Once the incision heals, there’s usually no adjustment to the person’s daily life. In general, moderate-intensity aerobic exercise such as brisk walking or cycling is acceptable for people with pacemakers. In fact, it’s likely your father’s exercise capacity will improve. 

Today’s pacemakers have evolved from fixing irregular heartbeats to helping the heart maintain its normal function, which allows many people with certain heart conditions to stay active longer. 

Howard LeWine, M.D., is an internist at Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, visit health.harvard.edu. 

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