What is the significance of an Ejection Fraction (EF) of 25-30%?

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DS

Dainyal Siddiqui, MD

Internal Medicine

MJ

Manuel Jimenez, MD

Cardiology

FP

Franz Pierre-Louis, MD

Infectious Disease

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Last updated: April 21, 2025 • View editorial policy

From the Guidelines

I strongly recommend treating a patient with an ejection fraction (EF) of 25-30% with a combination of medications, including an ACE inhibitor or ARB, a beta-blocker, and a mineralocorticoid receptor antagonist, as this approach has been shown to reduce mortality and improve quality of life in patients with heart failure with reduced ejection fraction (HFrEF) 1.

Key Considerations

  • An EF of 25-30% indicates moderately reduced ejection fraction, which is a significant indicator of systolic dysfunction and heart failure with reduced ejection fraction (HFrEF).
  • Treatment should include a combination of medications, such as:
    • An ACE inhibitor (like enalapril 2.5-10mg twice daily or lisinopril 10-40mg daily) or ARB if ACE inhibitor intolerant.
    • A beta-blocker (such as carvedilol 3.125-25mg twice daily or metoprolol succinate 25-200mg daily).
    • A mineralocorticoid receptor antagonist (spironolactone 25-50mg daily or eplerenone 25-50mg daily).
  • For symptomatic patients, add a diuretic like furosemide 20-80mg daily as needed.
  • SGLT2 inhibitors (dapagliflozin 10mg daily or empagliflozin 10mg daily) should also be considered.

Lifestyle Modifications

  • Regular follow-up with cardiology is essential.
  • Lifestyle modifications such as sodium restriction, fluid management, and appropriate exercise as tolerated are crucial.
  • This comprehensive approach targets multiple pathways in heart failure pathophysiology, reducing mortality and improving quality of life by enhancing cardiac remodeling and reducing neurohormonal activation 1.

Additional Considerations

  • The benefits of ICD implantation in older patients with significant comorbidities and reduced ejection fraction have been demonstrated in some studies, with a reduction in mortality 2.
  • However, the decision to implant an ICD should be individualized, taking into account the patient's overall health status, symptoms, and preferences.

From the FDA Drug Label

The mean left ventricular ejection fraction was 29%. The patient's ejection fraction (EF) of 25-30% is consistent with the mean left ventricular ejection fraction in the PARADIGM-HF study, which was 29% 3.

  • Left Ventricular Ejection Fraction (LVEF): 25-30% is considered low, indicating systolic dysfunction.
  • Clinical Implication: Patients with LVEF ≤ 40% were included in the PARADIGM-HF study, and sacubitril and valsartan tablets demonstrated a reduction in the risk of cardiovascular death or hospitalization for heart failure. However, the study does not provide direct information on the specific ejection fraction range of 25-30%.

From the Research

Left Ventricular Ejection Fraction (LVEF) and Treatment Outcomes

  • The left ventricular ejection fraction (LVEF) is a measure of how well the left ventricle of the heart pumps blood with each contraction 4.
  • Studies have shown that LVEF is a predictor of outcomes in patients with heart failure, with lower LVEF values associated with poorer outcomes 4, 5.
  • For example, a study found that patients with LVEF < 35% who received implantable cardioverter-defibrillators (ICDs) for primary prevention had a higher risk of appropriate device therapy if they had lower LVEF values and were not taking angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) 4.

Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs)

  • ACEIs and ARBs are commonly used medications for the treatment of heart failure and have been shown to improve outcomes in patients with reduced LVEF 5, 6.
  • A study found that the use of ACEIs or ARBs was associated with a higher rate of recovered ejection fraction in patients with dilated cardiomyopathy and reduced LVEF 6.
  • Another study found that initiation of ACEI therapy was associated with a lower risk of all-cause mortality or heart failure hospitalization in hospitalized older patients with heart failure and preserved ejection fraction 7.

EV 25-30% and Treatment Outcomes

  • There is limited information available on the specific LVEF range of 25-30% and its association with treatment outcomes.
  • However, studies have shown that LVEF values below 35% are associated with poorer outcomes, and that ACEIs and ARBs can improve outcomes in patients with reduced LVEF 4, 5, 6.
  • Further research is needed to determine the optimal treatment strategies for patients with LVEF values in the range of 25-30%.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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