Is an ejection fraction (Ej) of 25 to 30% indicative of systolic or diastolic dysfunction?

Ejection Fraction of 25-30% Indicates Systolic Dysfunction

An ejection fraction (EF) of 25-30% definitively indicates systolic dysfunction, not diastolic dysfunction. 1 This low EF value represents significant impairment of the heart's ability to pump blood effectively during contraction.

Understanding Ejection Fraction and Heart Failure Types

• Systolic dysfunction is characterized by a reduced ejection fraction (typically <50%) and represents impaired contractile function of the heart 1
• In the European Society of Cardiology guidelines, an EF <50% is specifically identified as indicating left ventricular global systolic dysfunction 1
• Diastolic dysfunction (also called heart failure with preserved ejection fraction) is characterized by normal or near-normal ejection fraction (typically ≥50%) with impaired ventricular filling 2, 3

Clinical Implications of EF 25-30%

• An EF of 25-30% represents severe systolic dysfunction and is associated with:
  • Increased mortality risk 1
  • Higher risk of sudden cardiac death 1
  • Need for consideration of device therapy (ICD) 1
• Patients with EF ≤30% should be evaluated for implantable cardioverter-defibrillator (ICD) therapy according to American Heart Association recommendations 4
• This level of systolic dysfunction typically requires aggressive medical management with ACE inhibitors, beta-blockers, and aldosterone antagonists 1, 5

Diagnostic Considerations

• Echocardiography is the standard method for assessing ejection fraction and differentiating between systolic and diastolic dysfunction 1
• When EF is 25-30%, additional parameters should be evaluated:
  • LV end-diastolic and end-systolic volumes (typically increased in systolic dysfunction) 1
  • Regional wall motion abnormalities (often present in systolic dysfunction) 1
  • Left ventricular mass index (may be increased) 1

Treatment Implications

• Patients with EF 25-30% require:
  • ACE inhibitors or ARBs as first-line therapy 1
  • Beta-blockers with proven mortality benefit 1, 4
  • Aldosterone antagonists like spironolactone, which reduced mortality by 30% in patients with severe systolic dysfunction (median EF 26%) 5
  • Evaluation for device therapy (ICD) when EF is ≤30%, especially if QRS duration is ≥120ms 1

Important Distinctions and Pitfalls

• While patients with EF 25-30% have systolic dysfunction, they may also have concurrent diastolic dysfunction 6
• Diastolic dysfunction is present in >90% of heart failure patients regardless of ejection fraction 6
• Once EF falls below 20%, further decreases in EF may not predict additional mortality risk 7
• The term "heart failure with reduced ejection fraction" (HFrEF) is now preferred over "systolic heart failure" to describe this condition 1

Monitoring Considerations

• Serial echocardiography is essential to monitor ventricular function and remodeling 4
• Regular assessment of BNP/NT-proBNP levels can guide therapy and assess treatment response 1, 4
• Close monitoring of electrolytes and renal function is crucial, particularly when using ACE inhibitors and aldosterone antagonists 1, 5