What is the clinical significance of a left ventricular (LV) ejection fraction of 55-60% with impaired relaxation filling pattern, normal cardiac valvular Doppler (ultrasound) findings, and a mildly dilated ascending aorta measuring 3.7 cm?

From the Guidelines

The patient's echocardiogram findings indicate preserved systolic function with a left ventricular ejection fraction (LVEF) of 55-60%, but impaired relaxation filling pattern suggests early diastolic heart failure or heart failure with preserved ejection fraction (HFpEF), requiring careful management to prevent progression. The cardiac valves are functioning normally based on Doppler measurements, ruling out valvular disease as a cause of symptoms, as indicated by the European Society of Cardiology guidelines 1. However, there is mild dilation of the ascending aorta at 3.7 cm, which requires monitoring but is not severely enlarged.

Some key points to consider in this patient's management include:

• The impaired relaxation pattern reflects slowed early ventricular filling due to stiffened heart muscle, often associated with aging, hypertension, or coronary artery disease, as described in the guidelines 1.
• The dilated aorta may be related to hypertension, age, or connective tissue disorders.
• Lifestyle modifications are crucial, including:
  • Sodium restriction (<2g/day)
  • Regular aerobic exercise
  • Weight management if overweight
• Blood pressure control is essential, targeting <130/80 mmHg with medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily) or ARBs (e.g., losartan 50-100 mg daily), as recommended by the guidelines 1.
• Diuretics such as hydrochlorothiazide 12.5-25 mg daily may help manage fluid retention and symptoms.
• The mildly dilated aorta should be monitored with repeat echocardiography in 6-12 months.
• If the patient experiences symptoms like chest pain, shortness of breath, or palpitations, these should be evaluated promptly, considering the potential for underlying conditions such as coronary artery disease or cardiac arrhythmias, as suggested by the guidelines 1.

Management should focus on controlling blood pressure, reducing sodium intake, promoting regular exercise, and monitoring for signs of disease progression, with the goal of improving quality of life and reducing morbidity and mortality. Regular follow-up with echocardiography and clinical assessment will be essential to adjust the management plan as needed, based on the latest guidelines and evidence 1.

From the Research

Clinical Significance of Left Ventricular Ejection Fraction

• A left ventricular (LV) ejection fraction of 55-60% is considered low normal or borderline, and its clinical significance depends on various factors, including the presence of symptoms, comorbidities, and other echocardiographic findings 2.
• Impaired relaxation filling pattern, as seen in this case, is a common finding in patients with preserved LV ejection fraction and is associated with diastolic dysfunction 3, 4.
• Diastolic dysfunction is a condition where the heart has difficulty relaxing and filling during diastole, leading to increased filling pressures and potential symptoms of heart failure 3, 4.
• The presence of a mildly dilated ascending aorta measuring 3.7 cm may be a contributing factor to the development of diastolic dysfunction, although its significance is unclear in this context.

Diagnostic and Prognostic Implications

• The diagnosis of heart failure with preserved ejection fraction (HFpEF) is based on the presence of symptoms of heart failure, normal or near-normal LV ejection fraction, and evidence of diastolic dysfunction 4, 5.
• The prognosis of patients with low normal LV ejection fraction is uncertain, but studies suggest that it may be associated with an increased risk of incident congestive heart failure (CHF) compared to those with normal LV ejection fraction 2.
• The optimal treatment of patients with HFpEF has not been defined, but control of systolic hypertension, avoidance of fluid overload, and empiric use of medications such as angiotensin-converting enzyme inhibitors and beta-blockers may be beneficial 4, 5.

Echocardiographic Findings

• Normal cardiac valvular Doppler findings suggest that valvular disease is not a contributing factor to the patient's symptoms or echocardiographic findings 2.
• The presence of impaired relaxation filling pattern and low normal LV ejection fraction suggests that diastolic dysfunction is the primary abnormality in this patient 3, 4.
• Further evaluation of LV systolic and diastolic function using advanced echocardiographic techniques, such as strain imaging, may provide additional insights into the patient's condition 6.