What is the best course of action for an adult patient with a history of heart disease or risk factors, who has experienced a decline in ejection fraction from 60% to 50-55%, and should they undergo a stress test?

Should You Undergo a Stress Test with EF Decline from 60% to 50-55%?

Yes, you should undergo stress testing to evaluate for underlying coronary artery disease or ischemia, as a decline in ejection fraction—even within the "normal" range—may indicate early cardiac dysfunction that warrants investigation, particularly if you have cardiac risk factors or symptoms. 1

Understanding Your EF Decline

Your ejection fraction has decreased from 60% to 50-55%, which represents a measurable decline despite both values falling within the technically "normal" range of 50-70%. 2, 3 However, this trajectory is clinically significant for several reasons:

• A declining EF trend matters more than a single measurement, as progressive reduction over time is a poor prognostic factor even when values remain above 50%. 1
• Normal EF ranges from 50-70% with a midpoint of 60%, meaning your current EF of 50-55% sits at the lower boundary of normal. 2
• In certain cardiac conditions (like mitral regurgitation), an EF <60% actually indicates left ventricular systolic dysfunction, though this specific context may not apply to you. 4

Why Stress Testing Is Indicated

Stress testing is reasonable and appropriate in your situation based on multiple guideline recommendations:

• The 2023 AHA/ACC Chronic Coronary Disease Guidelines emphasize that noninvasive testing helps risk stratify patients, particularly when integrated with clinical variables including reduced LV function. 1
• Dobutamine stress testing is specifically beneficial for evaluating patients with reduced ejection fraction and low cardiac output, helping distinguish between ischemia and intrinsic myocardial dysfunction. 1
• Exercise stress testing can elicit exercise-induced symptoms or blood pressure abnormalities that may not be apparent at rest, particularly in patients with borderline or declining ventricular function. 1

Evidence Supporting Stress Testing in Your Context

Research demonstrates that changes in ejection fraction during stress have important prognostic implications:

• In patients with coronary artery disease and baseline LV dysfunction (EF <50%), a decrease in EF during exercise identifies those with multivessel disease and higher mortality risk. 5
• Each 4% decrease in EF during stress testing is associated with a 70% increased risk of adverse cardiac events (adjusted hazard ratio 1.7), even in patients with stable coronary disease. 6
• A decrease in EF of ≥5% during stress, or any decrease during submaximal exercise, is highly specific for myocardial ischemia rather than nonspecific ventricular response. 5

Recommended Approach

Your evaluation should proceed as follows:

1. Determine your cardiac risk profile including presence of hypertension, diabetes, smoking history, family history of coronary disease, and any symptoms (chest discomfort, dyspnea, reduced exercise tolerance). 1

2. If you can exercise adequately and have no baseline ECG abnormalities, standard exercise treadmill testing with continuous EF monitoring (nuclear imaging or stress echocardiography) is appropriate. 7, 8

3. If you cannot exercise adequately or have baseline ECG abnormalities, pharmacologic stress testing with dobutamine stress echocardiography or myocardial perfusion imaging should be performed. 1, 8

4. The stress test should specifically assess:

   • Whether your EF decreases further during stress (indicating ischemia) 5
   • Presence of regional wall motion abnormalities 1
   • Exercise capacity and symptoms 1
   • Blood pressure response 1
   • Arrhythmias during stress 1

Risk Stratification Based on Results

Your subsequent management depends on stress test findings:

• Low risk (no ischemia, EF stable or improved, normal exercise capacity): Continue medical optimization with annual reassessment. 1

• Intermediate risk (mild ischemia, modest EF decline during stress): Consider coronary angiography if symptoms present; otherwise intensify medical therapy with close follow-up. 1

• High risk (significant ischemia, EF decline >5% during stress, exercise-induced symptoms or arrhythmias): Coronary angiography is indicated to define anatomy and guide revascularization decisions. 1

Important Caveats

• EF measurement varies between modalities and interpreters, so ensure your baseline and current measurements used the same technique (preferably biplane Simpson's method on echocardiography). 2, 3
• A single borderline EF measurement may not be adequate—serial measurements using consistent methodology are more reliable for clinical decision-making. 2
• EF is load-dependent and cannot distinguish between preload, afterload, and intrinsic contractility issues, so comprehensive assessment including diastolic function and structural abnormalities is important. 2
• If you have valvular disease (particularly mitral or aortic regurgitation), different EF thresholds apply for defining dysfunction. 4