From the Guidelines
A 5% decrease in ejection fraction (EF) warrants a comprehensive cardiac evaluation to determine the cause and clinical significance of this decline, and the patient should be scheduled for a follow-up appointment with their cardiologist for further assessment. The next steps should include a thorough review of the patient's medical history, current symptoms, and medication adherence, as well as additional diagnostic tests such as stress testing, cardiac MRI, or coronary angiography depending on symptoms and risk factors 1.
Key Considerations
- The significance of a 5% EF drop depends on the baseline EF and associated symptoms, with a drop from 40% to 35% with worsening symptoms warranting more aggressive intervention 1.
- Medication adjustments might be necessary, potentially including optimization of guideline-directed medical therapy such as ACE inhibitors/ARBs, beta-blockers, and possibly aldosterone antagonists if EF is below 40% 1.
- Lifestyle modifications should be reinforced, including sodium restriction, fluid restriction if needed, regular physical activity as tolerated, and smoking cessation.
Diagnostic Evaluation
- The patient's EF trajectory over time is important to evaluate, as a significant reduction in LVEF over time is a poor prognostic factor 1.
- The diagnosis of heart failure with mildly reduced EF (HFmrEF) or heart failure with preserved EF (HFpEF) can be challenging, and the clinical diagnosis should be further supported by objective measures such as elevated natriuretic peptide levels or noninvasive/invasive hemodynamic measurement 1.
Management
- The writing committee of the 2022 AHA/ACC/HFSA guideline proposes the addition of evidence of spontaneous or provokable increased LV filling pressures to the classifications of HFmrEF and HFpEF 1.
- The patient's treatment plan should be individualized based on their specific needs and circumstances, with regular follow-up appointments to monitor their condition and adjust their treatment plan as needed.
From the Research
Echocardiogram Results and Next Steps
If an echocardiogram shows a 5% decrease in ejection fraction (EF), the next steps would depend on the patient's current EF value and other clinical factors.
- For patients with heart failure with reduced ejection fraction (HFrEF), treatment options may include angiotensin-converting enzyme (ACE) inhibitors, angiotension receptor type 1 (AT1) antagonists, β-adrenoceptor antagonists, aldosterone receptor antagonists, diuretics, digoxin, and a combination drug with AT1 receptor antagonist and neprilysin inhibitor 2.
- In patients with stable HFrEF and EF < 35% and heart rate above 70 bpm, ivabradine may be considered as a treatment option to improve outcomes 2.
- For patients with heart failure with preserved ejection fraction (HFpEF), treatment options may include diuretics to remove symptoms, ACE inhibitors or sartans and beta-blockers to improve prognosis, and anticoagulation treatment for atrial fibrillation 3.
- A decrease in EF to 55% or less may indicate a higher risk of progression from HFpEF to heart failure with mildly reduced ejection fraction (HFmrEF) 4.
- Patients with HFrEF and worsening heart failure have a higher risk of death and hospitalization, and may benefit from newer HF therapies 5.
- Assessment of left atrial reservoir function by peak atrial longitudinal strain (PALS) may provide prognostic value in patients with HFrEF 6.
Considerations for Treatment
- The choice of treatment will depend on the patient's individual circumstances, including their current EF value, heart rate, and presence of other clinical factors such as atrial fibrillation or ischemic etiology.
- Patients with HFrEF and EF ≤ 25% may have a higher risk of death and hospitalization, and may require more intensive treatment 5.
- The use of ivabradine in patients with HFrEF and EF < 35% and heart rate above 70 bpm may improve outcomes, but may also have adverse effects such as bradycardia, atrial fibrillation, and visual disturbances 2.