What stage of heart failure is a patient with an ejection fraction (EF) of less than 28% considered to have?

Heart Failure Staging for a Patient with EF <28%

A patient with an ejection fraction (EF) of less than 28% has Heart Failure with Reduced Ejection Fraction (HFrEF), which is classified as Stage C heart failure according to the most recent ACC/AHA guidelines. 1, 2

Classification of Heart Failure by Ejection Fraction

Heart failure is categorized based on left ventricular ejection fraction (LVEF) as follows:

• HFrEF (Heart Failure with Reduced Ejection Fraction): LVEF ≤40%
• HFmrEF (Heart Failure with Mildly Reduced Ejection Fraction): LVEF 41-49%
• HFpEF (Heart Failure with Preserved Ejection Fraction): LVEF ≥50%

With an EF <28%, this patient clearly falls into the HFrEF category, which is defined as LVEF ≤40% according to the 2022 AHA/ACC/HFSA guidelines 1.

Staging of Heart Failure

The ACC/AHA staging system for heart failure emphasizes disease development and progression:

1. Stage A: At-risk for heart failure (risk factors but no structural heart disease)
2. Stage B: Pre-heart failure (structural heart disease but no symptoms)
3. Stage C: Heart failure with symptoms and structural heart disease
4. Stage D: Advanced heart failure (refractory to standard therapy)

A patient with an EF <28% has significant structural heart disease, and assuming they have symptoms (which is likely with such a low EF), they would be classified as Stage C heart failure 1, 2.

Clinical Implications of EF <28%

An EF <28% indicates severe systolic dysfunction with important clinical implications:

• Mortality risk: Significantly increased risk of mortality compared to patients with higher EF values 3
• Treatment approach: Requires aggressive guideline-directed medical therapy
• Device therapy consideration: Meets criteria for consideration of implantable cardioverter-defibrillator (ICD) therapy (EF <30% with QRS duration ≥120ms) 1
• Advanced therapy evaluation: May need evaluation for cardiac resynchronization therapy if QRS duration is ≥150ms or between 120-149ms with mechanical dyssynchrony 1

Treatment Considerations

For a patient with HFrEF (EF <28%), guideline-directed medical therapy should include:

• ACE inhibitors or ARBs (if ACE inhibitors not tolerated)
• Evidence-based beta-blockers (bisoprolol, metoprolol succinate, carvedilol, or nebivolol)
• Aldosterone antagonists
• SGLT2 inhibitors
• Consideration for device therapy (ICD, CRT) based on specific criteria
• Evaluation for potential revascularization if ischemic etiology is present 4

Monitoring Recommendations

With such a low EF, close monitoring is essential:

• Serial echocardiographic assessment of LV function
• Monitoring of natriuretic peptide levels
• Regular clinical assessment for signs of worsening heart failure
• Renal function and electrolyte monitoring, especially with medication adjustments

Pitfalls to Avoid

• Assuming that a single EF measurement is adequate; trajectory over time is important 1
• Delaying consideration of device therapy in eligible patients
• Inadequate medication optimization before concluding medical therapy has failed
• Overlooking potential reversible causes of heart failure

Remember that while an EF <28% indicates severe systolic dysfunction, some patients may show improvement with optimal medical therapy, and the EF should be reassessed periodically to guide ongoing management.