From the Guidelines
A hyperdynamic left ventricular (LV) ejection fraction greater than 70% with impaired relaxation filling pattern necessitates management focusing on addressing the impaired relaxation component, primarily through rate control medications and treatment of underlying causes, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. This condition often indicates underlying diastolic dysfunction despite preserved or enhanced systolic function. Key management strategies include:
- Rate control medications such as beta-blockers (e.g., metoprolol 25-100mg twice daily or carvedilol 3.125-25mg twice daily) or calcium channel blockers (e.g., diltiazem 120-360mg daily or verapamil 120-360mg daily) to prolong diastole and allow more time for ventricular filling.
- Treating any underlying causes such as hypertension, diabetes, or coronary artery disease.
- Blood pressure control targeting levels below 130/80 mmHg using ACE inhibitors or ARBs, as recommended by recent guidelines 1.
- Lifestyle modifications including sodium restriction (<2g daily), regular moderate exercise, and weight management. The diagnosis and management of this condition can be challenging, and the classification of heart failure based on left ventricular ejection fraction (LVEF) is crucial, with LVEF ≥50% indicating heart failure with preserved ejection fraction (HFpEF) 1. Echocardiographic follow-up every 6-12 months is recommended to monitor for progression of diastolic dysfunction, and the use of Doppler echocardiography can help estimate systolic pulmonary artery pressure and assess ventricular filling patterns, as described in the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 1. Given the potential for this condition to lead to heart failure symptoms despite the seemingly robust contractile function, careful monitoring and adherence to guideline-recommended management strategies are essential to improve morbidity, mortality, and quality of life outcomes.
From the Research
Hyperdynamic LV Ejection Fraction
- A hyperdynamic left ventricular (LV) ejection fraction is defined as an ejection fraction above the normal range, typically greater than 70% 2.
- This condition can be associated with diastolic dysfunction, which is characterized by impaired relaxation filling pattern and increased resistance to filling with increased filling pressures 3.
Clinical Characteristics
- Patients with hyperdynamic LV ejection fraction are often older, more likely to be women, and have a higher prevalence of hypertension, diabetes, and obesity 2.
- They may also have a higher heart rate, smaller ventricular size, and increased relative wall thickness 2.
- Diastolic dysfunction is common in these patients, with a high prevalence of abnormal functional or structural parameters, such as reduced relaxation, longer deceleration time, and higher LV end-diastolic pressures 2, 4.
Prognosis and Outcomes
- Hyperdynamic LV ejection fraction has been associated with reduced survival and increased 28-day mortality in critically ill patients 2, 5.
- The presence of hyperdynamic LV ejection fraction may be a marker of diastolic dysfunction and heart failure with preserved ejection fraction, which can have a significant impact on patient outcomes 4.
Treatment and Management
- Beta blockers can improve left ventricular diastolic function and long axis motion in patients with arterial hypertension, particularly when a significant heart rate reduction is achieved 6.
- However, the optimal treatment strategy for hyperdynamic LV ejection fraction and diastolic dysfunction is not well established and may depend on the underlying disease and individual patient characteristics 3.