What is the recommended management for an adult patient with a left ventricular ejection fraction (LVEF) of 55% and potential cardiovascular risk factors or existing heart disease?

Management of Patient with LVEF 55%

A patient with LVEF of 55% has normal left ventricular systolic function and does not require heart failure-specific pharmacotherapy unless there are other specific indications such as hypertension, coronary artery disease, or other cardiovascular risk factors. 1, 2

Understanding LVEF of 55%

• LVEF of 55% represents the lower threshold of normal left ventricular function, as guidelines define normal LVEF as ≥55% 1, 3, 4
• This patient does not have heart failure with reduced ejection fraction (HFrEF), which is defined as LVEF ≤40%, nor heart failure with mildly reduced ejection fraction (HFmrEF), defined as LVEF 41-49% 5, 6
• Research demonstrates that LVEF ≥55% is associated with stable cardiovascular risk, with no further risk reduction as LVEF increases above this threshold 4

Risk Stratification and Monitoring

Patients with LVEF at the lower end of normal (55%) warrant closer surveillance, as they may be at higher risk for future decline:

• LVEF of 55% carries a 3.64-fold increased risk of developing incident heart failure over 10 years compared to those with LVEF >55%, even in asymptomatic individuals 3
• Patients with LVEF ≤55% have significantly higher odds (OR 435) of progressing to mildly reduced LVEF (<50%) over time, particularly if ischemic heart disease is present 6
• Repeat echocardiography should be performed in 1-2 years to monitor for any decline in LVEF, especially if cardiovascular risk factors are present 6

Management Based on Comorbidities

If Hypertension is Present

• Initiate ACE inhibitors or ARBs as first-line agents to control blood pressure and provide cardiovascular protection 1
• Add beta-blockers as second-line therapy for blood pressure control 1
• Use diuretics as needed for volume management 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) if there is any concern for borderline systolic function 1
• Target blood pressure <130/80 mmHg 2

If Coronary Artery Disease is Present

• Assess for functionally significant coronary stenosis using stress testing or coronary angiography with FFR/iFR measurement 1, 7
• Consider revascularization if:
  • Left main stenosis is present 1, 7
  • Three-vessel disease is documented 1, 7
  • Proximal LAD involvement with single- or two-vessel disease 1, 7
  • Persistent angina despite optimal medical therapy 1, 7
• Initiate guideline-directed medical therapy including aspirin, statin, beta-blocker, and ACE inhibitor/ARB 7

If Diabetes Mellitus is Present

• Start SGLT2 inhibitor with proven cardiovascular benefit (empagliflozin, dapagliflozin, or canagliflozin) for cardiovascular risk reduction, independent of glycemic control 1, 8
• Consider GLP-1 receptor agonist (particularly semaglutide) if BMI >27 kg/m² for additional cardiovascular protection 8
• Continue ACE inhibitor or ARB therapy 1
• Avoid thiazolidinediones due to fluid retention risk, even with normal LVEF 1

If Atrial Fibrillation is Present

• Initiate anticoagulation if CHA₂DS₂-VASc score ≥2 (men) or ≥3 (women) using a direct oral anticoagulant as first choice 1
• Use beta-blockers for rate control as first-line therapy 8
• Avoid non-dihydropyridine calcium channel blockers for rate control 1, 8
• Consider AF ablation if symptoms are attributable to atrial fibrillation 1

If Cancer Therapy-Related Cardiomyopathy Risk

• For patients with cardiovascular risk factors receiving potentially cardiotoxic chemotherapy, establish baseline cardiac function and monitor serially 1
• Consider prophylactic ACE inhibitor/ARB and beta-blocker if high-risk features are present, though evidence is uncertain 1

What NOT to Do

• Do not initiate heart failure medications (ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists) solely based on LVEF of 55% without other indications 2, 5
• Do not consider ICD therapy, as this is only indicated for LVEF ≤35% 2, 8
• Do not consider cardiac resynchronization therapy, as this requires LVEF ≤35% 8
• Avoid calcium channel blockers with negative inotropic effects if any concern exists for borderline function 1

Common Pitfalls

• Misclassifying LVEF 55% as "reduced": This represents normal function by guideline definitions, though at the lower threshold 1, 4
• Failing to identify underlying etiology: Search for reversible causes such as ischemia, valvular disease, or uncontrolled hypertension 1
• Inadequate follow-up: Patients with LVEF at 55% require surveillance echocardiography to detect early decline, particularly if risk factors are present 3, 6
• Overlooking atrial arrhythmias: These can contribute to or exacerbate cardiomyopathy and require specific management 2, 8