What is the management approach for a patient with an ejection fraction (EF) of 65-70 percent?

Management of Ejection Fraction 65-70%

An ejection fraction of 65-70% is normal and requires no specific cardiac intervention based on the EF value alone; management should focus entirely on the underlying cardiac condition (if any) and associated symptoms rather than the EF itself.

Understanding Normal Ejection Fraction

• EF 65-70% represents preserved left ventricular systolic function and falls well within the normal range (normal EF is typically >50-55%) 1, 2, 3
• This EF range indicates the heart is ejecting blood efficiently with no evidence of systolic dysfunction 4
• No cardiac medications or interventions are indicated based solely on this normal EF value 1, 3

Clinical Context Determines Management

The management approach depends entirely on what cardiac condition (if any) is present alongside this normal EF:

If Mitral Regurgitation is Present

• In chronic severe primary MR with EF 65-70%, the patient may still be symptomatic (dyspnea, fatigue) despite the preserved EF because MR creates volume overload and pulmonary congestion independent of systolic function 5
• The regurgitant flow increases left atrial pressure leading to pulmonary venous congestion even when LVEF remains normal 5
• Mitral valve surgery is indicated (Class I recommendation) if the patient is symptomatic with severe MR, regardless of the normal EF 6, 5
• For asymptomatic severe MR with EF 65-70%, surgery is reasonable if there is new-onset atrial fibrillation or pulmonary hypertension (PASP >50 mmHg) 6
• In MR, an EF of 65-70% may actually mask early myocardial dysfunction since the reduced afterload from regurgitation artificially elevates the EF; ideally EF should be >64% in severe MR 6, 5
• Serial echocardiography every 6-12 months is recommended for asymptomatic severe MR to monitor for progressive LV enlargement or declining EF 6

If Aortic Stenosis is Present

• With severe AS, an EF of 65-70% indicates preserved LV systolic function and appropriate compensatory hypertrophy 6
• The hypertrophic response has adequately countered the pressure overload, maintaining normal wall stress and EF 6
• Aortic valve replacement is indicated based on symptoms (dyspnea, angina, syncope), NOT the EF value 6
• Asymptomatic severe AS with this normal EF requires close monitoring but not immediate intervention 6

If Heart Failure Symptoms are Present

• Heart failure with preserved ejection fraction (HFpEF) should be considered if the patient has dyspnea, fatigue, or exercise intolerance despite EF 65-70% 1, 2, 3
• The pathophysiology involves diastolic dysfunction (impaired LV relaxation and increased stiffness) rather than systolic dysfunction 1, 2
• Management focuses on controlling hypertension, reducing LV filling pressures with diuretics, and treating ischemia 1
• Calcium channel blockers, ACE inhibitors, ARBs, and aldosterone antagonists are recommended for blood pressure control and potential improvement in LV relaxation 1
• Beta-blockers are indicated if there is atrial fibrillation for rate control or if ischemic heart disease is present 1

If Cirrhosis with Ascites is Present

• Patients with cirrhosis typically have hyperdynamic circulation with EF usually >70-75% 6
• An EF of 65-70% in a cirrhotic patient may actually represent relative cardiac dysfunction 6
• For TIPS consideration, an EF >60% is more appropriate as an inclusion criterion since patients with EF 50-60% have higher risk of post-TIPS heart failure and reduced survival 6
• Patients with EF 65-70% and diastolic dysfunction should be carefully evaluated before TIPS placement 6

Key Clinical Pitfalls to Avoid

• Do not assume normal EF means absence of cardiac disease or symptoms - many conditions cause symptoms despite preserved systolic function 5, 1, 2
• In MR, do not wait for EF to decline below 60% before considering surgery as this represents established LV dysfunction; progressive decline toward 60% warrants intervention 6, 5
• Do not use EF alone to guide management - integrate clinical symptoms, valve pathology, chamber dimensions, and pulmonary pressures 6
• In HFpEF, recognize that "normal" EF does not exclude heart failure - diastolic dysfunction is the primary mechanism 1, 2, 3

Monitoring Recommendations

• For asymptomatic severe valvular disease with EF 65-70%, perform echocardiography every 6-12 months to detect early LV dysfunction or chamber enlargement 6
• Monitor for development of symptoms, new atrial fibrillation, or pulmonary hypertension which would change management 6
• Serial assessment of LV end-systolic dimension is important - LVESD approaching 40 mm warrants consideration of intervention even with preserved EF 6