What is the management approach for a patient with a Left Ventricular Ejection Fraction (LVEF) of 50-55 percent?

Management Approach for LVEF 50-55%

For patients with a Left Ventricular Ejection Fraction (LVEF) of 50-55%, continue current management if NYHA class I-II, as this represents preserved ejection fraction. 1

Classification and Risk Assessment

• LVEF 50-55% falls within the normal to mildly reduced range:

  • According to the 2022 AHA/ACC/HFSA guidelines, this would be classified as:
    • Heart Failure with Preserved Ejection Fraction (HFpEF) if ≥50% 1
    • Or at the upper end of Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF) if 41-49% 1

• Risk assessment considerations:

  • LVEF 50-55% represents a potential transition zone with increased risk
  • Research shows patients with LVEF ≤55% have higher risk of progressing to HFmrEF in the future (OR 435,95% CI 52.65-10,614) 2
  • Low normal LVEF (50-55%) is associated with 3.64 times higher risk of incident heart failure compared to normal LVEF (≥55%) 3

Management Algorithm

Step 1: Assess Symptoms and Functional Status

• If NYHA class I-II (minimal or mild symptoms):

  • Continue current management 1
  • Schedule regular follow-up every 6-12 months 1

• If NYHA class III-IV (moderate to severe symptoms):

  • Evaluate for obstructive physiology
  • If non-obstructive, proceed with treatment intensification 1

Step 2: Medication Management Based on Symptom Class

For NYHA Class I-II:

• Continue current management with regular monitoring 1
• Consider preventive therapies:
  • Blood pressure control with beta-blockers, ACE inhibitors, or ARBs if hypertensive 1
  • Address modifiable risk factors (diabetes, coronary artery disease)

For NYHA Class III-IV:

• SGLT2 inhibitors (empagliflozin 10mg daily or dapagliflozin 10mg daily) are beneficial to decrease HF hospitalizations and cardiovascular mortality 1, 4
• Consider evidence-based medications used for HFrEF, particularly for LVEF at the lower end of this range (closer to 50%):
  • Beta-blockers (metoprolol succinate, bisoprolol, carvedilol)
  • ACE inhibitors, ARBs, or ARNI (sacubitril/valsartan)
  • MRAs (spironolactone, eplerenone) 1, 4

Step 3: Address Comorbidities and Contributing Factors

• Evaluate for coronary artery disease:

  • Consider revascularization if angina or demonstrable ischemia is present 1
  • PCI including chronic total occlusion revascularization may improve LVEF 5

• Manage atrial fibrillation if present:

  • Rate control with beta-blockers, verapamil, or diltiazem 1
  • Anticoagulation with DOACs as first-line option or vitamin K antagonists as second-line option 1

• Evaluate for significant mitral regurgitation:

  • If severe MR with suitable anatomy, consider intervention 1
  • Optimize GDMT before intervention for secondary MR 1

Monitoring and Follow-up

• Short-term (2-4 weeks): Monitor renal function, electrolytes, and blood pressure 4
• Medium-term (3-6 months): Reassess symptoms and medication tolerance 4
• Long-term (6-12 months): Repeat echocardiography to assess LVEF trends 1, 2
  • Pay particular attention if LVEF is at the lower end of the range (50-52%)
  • More frequent monitoring may be warranted for patients with LVEF ≤55% due to higher risk of progression to HFmrEF 2

Special Considerations

• Cardiac myosin inhibitors (e.g., mavacamten) should be discontinued if LVEF falls below 50% 1
• Negative inotropic agents (verapamil, diltiazem, disopyramide) may need to be discontinued if systolic dysfunction develops 1
• Consider device therapy (ICD, CRT) only if LVEF declines to ≤35% with appropriate indications 1

Common Pitfalls to Avoid

• Underestimating the significance of "low-normal" LVEF (50-55%)
• Failing to recognize that LVEF 50-55% may represent a transition phase requiring closer monitoring
• Inadequate dose titration of medications when indicated for symptomatic patients
• Not repeating echocardiography to monitor for LVEF decline, especially in patients with ischemic etiology 2
• Overlooking the importance of treating comorbidities that may contribute to heart failure progression

By following this structured approach, clinicians can appropriately manage patients with LVEF 50-55%, recognizing both the generally favorable prognosis and the need for vigilance in monitoring for potential progression to more reduced ejection fraction.