How to manage hyperdynamic ejection fraction?

Management of Hyperdynamic Ejection Fraction

Hyperdynamic ejection fraction (LVEF >70%) requires careful assessment for underlying diastolic dysfunction and should be managed with targeted therapies addressing the specific pathophysiology.

Understanding Hyperdynamic EF

• Hyperdynamic left ventricular ejection fraction (LVEF >70%) is often a marker of diastolic dysfunction in patients presenting with dyspnea on exertion 1
• It has high specificity (96.77%) and positive predictive value (97.83%) for identifying diastolic dysfunction in patients with normal coronary perfusion 1
• Patients with hyperdynamic EF tend to be older, female, and have higher rates of hypertension and cancer compared to those with normal EF 2
• Importantly, hyperdynamic EF is associated with increased 28-day mortality in critically ill patients compared to those with normal EF 2

Diagnostic Approach

• Evaluate for underlying causes of hyperdynamic EF, particularly diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) 1, 3
• Consider advanced diagnostic methods such as:
  • Exercise echocardiography to assess for dynamic changes in filling pressures 3
  • Doppler echocardiography to evaluate diastolic parameters 1
  • Measurement of natriuretic peptides to support diagnosis of HFpEF 4
• Look for evidence of left atrial enlargement or left ventricular hypertrophy, which often accompany hyperdynamic EF in the setting of diastolic dysfunction 4

Management Strategy

First-Line Pharmacological Therapy

• SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended as first-line therapy if HFpEF is confirmed, as they reduce heart failure hospitalization by approximately 20% 5, 4
• Diuretics (typically loop diuretics) should be prescribed for patients with evidence of congestion to improve symptoms 5, 4
• Consider mineralocorticoid receptor antagonists (MRAs) which may help reduce heart failure hospitalizations in patients with HFpEF 3

Non-Pharmacological Interventions

• Exercise training is strongly recommended as it produces clinically meaningful increases in functional capacity and quality of life 5
• Weight loss should be encouraged in patients with obesity, as it can significantly improve symptoms and cardiac function 5, 4
• Patient education on heart failure self-care is essential to avoid decompensation 5

Management of Comorbidities

• Aggressive treatment of hypertension is crucial, as it's a common underlying cause of hyperdynamic EF and diastolic dysfunction 1, 2
• Manage other common comorbidities including:
  • Diabetes (preferably with SGLT2 inhibitors) 4
  • Atrial fibrillation (rate control is essential) 3
  • Chronic kidney disease (with appropriate medication adjustments) 4

Medications to Avoid

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided in patients with reduced EF but may be considered in those with preserved EF 6
• NSAIDs should be avoided as they can worsen heart failure symptoms 6
• Thiazolidinediones increase the risk of worsening heart failure symptoms and hospitalizations 6
• Certain DPP-4 inhibitors (saxagliptin, alogliptin) should be avoided due to increased risk of heart failure hospitalization 6

Monitoring and Follow-up

• Regular assessment of volume status and weight at each visit 6
• Monitor for signs of worsening heart failure, including increased fatigue, dyspnea on exertion, cough, edema, and weight gain 6
• Repeat measurement of ejection fraction may be useful in patients who have had a change in clinical status or received treatment that might affect cardiac function 6

Special Considerations

• Patients with hyperdynamic EF have increased mortality risk and should be monitored closely 2
• Asian patients with HFpEF tend to be younger and have higher prevalence of diabetes and chronic kidney disease than Western populations 4
• The presence of hyperdynamic EF should prompt a thorough evaluation for diastolic dysfunction even in the absence of other clinical signs of heart failure 1