Systolic congestive heart failure is a serious condition that occurs when the heart does not pump blood effectively. There are 4 stages of congestive heart failure.

Congestive heart failure may happen when the heart muscle is too weak or when another health problem prevents it from circulating blood efficiently. Over time, systolic congestive heart failure, or heart failure (HF), can lead to dysfunction of other organs due to inefficient pumping.

This article discusses how HF progresses over time and explains the outlook for people with this condition. It also examine the causes, symptoms, treatment options, and stages.

There are four different stages of systolic heart failure: A, B, C, and D.

When the condition progresses to the next stage, a person’s chance of surviving decreases.

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People with stage A HF do not yet have dysfunction of the pumping activity of the heart but have a high risk of developing HF due to related conditions, such as chronic high blood pressure, diabetes, and coronary artery disease.


A person usually has no symptoms of HF at this stage but may experience symptoms of their chronic conditions, including:

  • shortness of breath
  • difficulty breathing
  • swelling in the hands, feet, and ankles


People with this stage HF have no problems with the structure of the heart or how their heart works. Treatment should focus on managing risk factors.

Structural heart disease develops at this stage, such as reduced pumping function of the heart, which can lead to an enlarged left ventricle. It can also result from a previous heart attack.


Most people at stage B still do not show symptoms of HF.


A doctor may prescribe medication at this stage for the management and prevention of future problems. It is common for a doctor to prescribe ACE inhibitors/ARB or ARNI and beta blockers at this stage.

People at this stage will show symptoms of HF linked to underlying structural heart disease, including fatigue or breathlessness. These symptoms usually occur due to problems with the squeezing function of the left ventricle, or the pumping chamber of the heart.

Stage C HF also includes people who no longer show symptoms but are currently undergoing treatment for previous symptoms, such as those who spent time in the hospital with heart failure exacerbation.


Common symptoms include:

  • fatigue
  • breathlessness
  • difficultly breathing


A doctor will definitely prescribe medication at this stage for the management and prevention of future problems. It is common for a doctor to prescribe diuretics, ACE inhibitors/ARB/ARNI and beta blockers, mineralocorticoid receptor blockers, or SGLT2 inhibitors at this stage.

A doctor also may consider implantable cardioverter-defibrillators and cardiac resynchronization therapy at this stage.

At stage D, people will have advanced structural heart disease and display significant symptoms, even when they are at rest.


Symptoms may include:

  • shortness of breath
  • difficulty breathing
  • swelling of legs, arms, hands, and ankles
  • fatigue
  • nausea
  • rapid heartbeat
  • weight gain
  • lightheadedness
  • persistent cough


This stage is severe and may require advanced specialized treatment. such as mechanical circulatory support, continuous inotropic infusion to make the heart squeeze harder, cardiac transplant, or hospice care.

The most common type of HF is left-sided HF. The left side of the heart must work harder to move the same volume of blood around the body. This may cause a fluid buildup in the lungs and make breathing difficult as it progresses.

These fluids give congestive heart failure its name.

There are two kinds of left-sided HF.

With systolic heart failure, the left ventricle cannot contract normally, limiting the heart’s pumping ability. The stages of HF only refer to systolic heart failure and not the other types.

With diastolic heart failure, the muscle in the left ventricle stiffens. If the muscle cannot relax, the pressure in the ventricle increases, causing symptoms.

Right-sided HF is less common. It occurs when the right ventricle cannot pump blood to the lungs. This can lead to blood backing up in the blood vessels, which may cause fluid retention in the lower legs and arms, abdomen, and other organs.

A person can have left-sided and right-sided HF at the same time. However, HF usually begins on the left side and can affect the right side if a person does not receive effective treatment.

Symptoms of HF range from mild to severe but may get worse over time if not managed medically.

Lifestyle strategies can reduce the risk of developing HF and can also slow its progress.

To prevent or slow the progression of HF, people should take the following steps:

  • Maintain a healthy body weight: Excess body weight can place strain on the heart and increase the risk of more damage to the heart.
  • Exercise regularly: The AHA recommends getting 150 minutes of moderate-intensity exercise every week. Individuals with heart failure should talk to their doctors about getting an individualized exercise “prescription.”
  • Manage stress: Meditation, therapy, and relaxation techniques can help a person manage stress, which can have adverse effects on the heart.
  • Eat a heart-healthy diet: Daily food intake should be low in trans fats, rich in whole grains, and low in sodium and cholesterol. Experts often recommend that people with heart failure limit their sodium intake to 2,000 milligrams (mg) daily. However, individuals should check with their doctor to determine what their sodium and fluid intake should be.
  • Monitor blood pressure regularly: A doctor can do this at regular check-ups. However, doctors also recommend people use home blood pressure monitors, or sphygmomanometers.
  • Vaccinations: Be sure to stay on top of vaccinations for influenza and pneumococcal pneumonia.
  • Risk factors: Treat and manage risk factors such as hypertension, smoking, alcohol, drugs, and diabetes

People who already have HF should take the following steps to prevent further progression:

  • avoiding alcohol
  • limiting caffeine and other stimulants
  • getting adequate rest
  • tracking changes in their symptoms and exercise capacity
  • monitoring daily weights
  • checking blood pressure and heart rate at home

Without treatment, HF can be fatal. Even with adequate treatment, HF may get worse over time, triggering dysfunction of other organs throughout the body.

HF is more likely to occur in people with other conditions or lifestyle factors that weaken the heart.

Risk factors for HF include:

  • congenital heart anomalies
  • high blood pressure or cholesterol
  • obesity
  • asthma
  • chronic obstructive pulmonary disease (COPD) and coronary heart disease
  • cardiovascular conditions, such as valvular heart disease
  • heart infection
  • reduced kidney function
  • a history of heart attacks
  • irregular heart rhythms or arrhythmias
  • abuse of alcohol or illicit drugs
  • smoking
  • older age

A doctor or cardiologist will perform a physical exam. This involves listening to the heart, checking for fluid retention, and looking at the veins in the neck to see if there is extra fluid present in the heart. They may order other diagnostic tests, including:

  • Electrocardiogram: This records the heart’s electrical rhythm.
  • Echocardiogram: This is an ultrasound test that can help a doctor determine if a person has a leaky heart valve or a heart muscle that is not squeezing or relaxing properly.
  • Stress tests: These tests show how the heart performs under different levels of cardiac stress, such as during exercise. Sometimes, they involve using medications that stimulate the heart to beat faster and harder or cause the blood vessels to relax.
  • Blood tests: A doctor may request these to check for infections, assess kidney function, and levels of brain natriuretic peptide (BNP). BNP is a “stretch” hormone that indicates stretching or increased pressure that occurs with HF.
  • MRI: This can provide high-resolution images of the heart and can assess for structural changes and scarring.
  • Cardiac catheterization: This can help a doctor identify blockages in the arteries, one of the most common causes of HF. A doctor may check blood flow and pressure levels in the ventricles at the same time.

Different medications can help symptoms of and prognosis in HF. These include:

  • Blood thinners: These reduce the risk of blood clots, which might break loose and travel to the body, heart, lungs, or brain. Blood thinners carry risks such as increased bleeding.
  • Angiotensin receptor-neprilysin inhibitors (ARNI): These help reduce the risk of mortality and decrease congestion in the heart.
  • Mineralocorticoid receptor antagonist (MRA): They can lower blood pressure, reduce congestion, and block the effects of hormones from the adrenal glands that can damage the heart.
  • ACE inhibitors: These relax the blood vessels and help reduce the impact of heart failure.
  • Angiotensin receptor blockers: These work to reduce tension in the blood vessels.
  • Anti-platelet drugs: Doctors prescribe these to stop blood clots. They prevent platelets in the blood from sticking together.
  • Beta-blockers: These drugs lower the heart rate, the force of the heartbeat, and blood pressure, helping to “rest” the heart.
  • Sino-atrial node modulators: These can help further reduce the heart rate in people who are already taking beta-blockers.
  • Sodium glucose co-transporter 2 (SGLT2): These can help reduce the risk of cardiovascular death and heart failure hospitalization.
  • Statins: People use these to reduce levels of low-density lipoprotein (LDL), or “bad” cholesterol, and increase high-density lipoprotein (HDL), or “good” cholesterol levels.
  • Diuretics: These help the body excrete excess fluid in the urine and remove it from the heart and lungs. They also reduce swelling and prevent shortness of breath.
  • Vasodilators: These reduce the amount of oxygen that the heart needs to dilate. They can also ease chest pain.

People with advanced HF might need more intensive treatment. Medical procedures that may help include:

Implantable devices

A surgeon might implant a medical device, such as:

  • An implantable defibrillator: These can prevent arrhythmias.
  • A pacemaker: These address electrical problems in the heart to help the ventricles contract more regularly.
  • Cardiac resynchronization therapy: This helps to regulate heart rhythm and reduce arrhythmia symptoms.
  • A left ventricular assist device (LVAD): This supports the pumping ability of a heart when it cannot do this efficiently on its own. People once used LVADs on a short-term basis but can now use them as part of long-term treatment.

Other procedures

A doctor may recommend other procedures for treating HF, including:

  • Percutaneous coronary intervention to open a blocked artery: The doctor may place a stent to help keep the vessel open.
  • Coronary artery bypass surgery: This reroutes some of the blood vessels so the blood can travel to supply oxygen to the heart while avoiding diseased or blocked blood vessels.
  • Valve replacement or repair surgery: A doctor can replace or repair an inefficient or diseased valve with a mechanical valve or one developed from living tissue.
  • Heart transplant: This may be the only remaining option if other treatments are not effective.

Not everyone with HF is an appropriate candidate for a transplant, and people often have to wait a long time before having one.

Heart surgery can be dangerous and invasive but is sometimes necessary, in combination with medications, to help treat HF in the best possible way.


Will HF always cause symptoms before it becomes dangerous?


Not always; it depends on the cause of HF. Sometimes advanced HF is indolent and presents with symptoms only in its very advanced stages.

For this reason, it is essential to control risk factors that may cause stage A HF and follow up regularly with your doctor.

Dr. Payal Kohli, MD, FACC Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

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Systolic congestive heart failure occurs when the heart does not pump blood effectively. It may happen for a variety of reasons such as a weak heart muscle or underlining health problems.

There are several stages of systolic congestive heart failure and each stage requires a different treatment. Lifestyle changes, medication, and surgery are typical methods of treatment.

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