What does an ejection fraction (EF) of 25-30% indicate?

What an Ejection Fraction of 25-30% Means

An ejection fraction (EF) of 25-30% indicates severely reduced left ventricular systolic function, classifying the patient as having heart failure with reduced ejection fraction (HFrEF) and placing them at significantly elevated risk for cardiovascular mortality and hospitalization. 1, 2

Classification and Severity

• EF of 25-30% falls into the "severely diminished" category (defined as <30% by ACC/AHA guidelines), representing profound impairment of the heart's pumping ability 3, 1, 2
• This is well below the normal range of 50-70% and indicates the left ventricle is ejecting less than one-third of its blood volume with each contraction 1
• Patients with EF ≤35% meet criteria for advanced heart failure therapies and device consideration 4

Clinical Implications and Prognosis

• This level of dysfunction carries substantial mortality risk, with 5-year survival rates after hospitalization for HFrEF as low as 25% without optimal medical therapy 5
• The severely reduced EF reflects advanced adverse cardiac remodeling with progressive left ventricular dilatation 5
• Patients are at high risk for:
  • Recurrent heart failure hospitalizations 5
  • Sudden cardiac death from ventricular arrhythmias 5
  • Progressive pump failure 5
  • Development of secondary mitral regurgitation 3

Immediate Management Priorities

Patients with EF 25-30% require aggressive guideline-directed medical therapy (GDMT) and consideration for device therapies:

Foundational Pharmacotherapy

• Initiate or optimize a β-blocker (unless contraindicated) as foundational therapy 5
• Start an angiotensin receptor-neprilysin inhibitor (ARNI), ACE inhibitor, or ARB as neurohormonal blockade 5
• Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone) for persistent symptoms 5
• Initiate an SGLT2 inhibitor (dapagliflozin or empagliflozin), which significantly reduces cardiovascular and all-cause mortality regardless of diabetes status 5

Additional Therapies for Specific Situations

• Ivabradine is indicated if the patient remains in sinus rhythm with heart rate ≥70 bpm despite maximally tolerated β-blocker therapy (or has β-blocker contraindication) 4
• Vericiguat should be considered in high-risk patients following recent heart failure hospitalization 5
• Diuretics are essential for managing volume overload and congestion 5, 6

Device Therapy Considerations

• Implantable cardioverter-defibrillator (ICD) should be strongly considered for primary prevention of sudden cardiac death, particularly in ischemic cardiomyopathy 5
• Cardiac resynchronization therapy (CRT) is indicated if QRS duration is prolonged (≥150 ms with LBBB pattern), as it can improve both symptoms and survival 5
• Transcatheter mitral valve repair may benefit patients with severe secondary mitral regurgitation 5

Important Caveats and Pitfalls

• EF measurement can vary between imaging modalities (echocardiography, MRI, nuclear imaging), so confirm the measurement method and consider repeat assessment if clinical picture doesn't match 3, 1
• Some patients can demonstrate marked spontaneous improvement in EF with optimal medical therapy and removal of reversible causes (particularly alcohol abstinence in alcoholic cardiomyopathy), with EF potentially recovering to >50% 7
• Identify and treat reversible causes: ischemia, uncontrolled hypertension, valvular disease, alcohol use, tachycardia-induced cardiomyopathy, and medication non-adherence 3, 6, 7
• Avoid medications that worsen heart failure: NSAIDs, most calcium channel blockers (except amlodipine/felodipine), and certain antiarrhythmic drugs 6
• Monitor closely for bradycardia and conduction abnormalities when initiating multiple negative chronotropic agents 4

Monitoring Strategy

• Serial natriuretic peptide measurements (BNP or NT-proBNP) to monitor disease activity and guide therapy 3
• Repeat echocardiography at 3-6 months after optimizing medical therapy to reassess EF and guide device therapy decisions 3
• Regular assessment for signs of decompensation: weight gain, worsening dyspnea, orthopnea, edema 5
• Evaluate for atrial fibrillation development, which occurs at increased rates in advanced heart failure and requires rhythm monitoring 4