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State-of-the-Art Review Among patients with heart failure with reduced ejection fraction, investigators have repeatedly identified a subgroup whose left ventricular ejection fraction and structural remodeling can improve to normal or nearly normal levels with or without medical therapy. This subgroup of patients with “heart failure with improved ejection fraction” has distinct clinical characteristics and a more favorable prognosis compared with patients who continue to
have reduced ejection fraction. However, many of these patients also manifest clinical and biochemical signs of incomplete resolution of heart failure pathophysiology and remain at some risk of adverse outcomes, thus indicating that they may not have completely recovered. Although rigorous evidence on managing these patients is sparse, there are several reasons to recommend continuation of heart failure therapies, including device therapies, to prevent clinical deterioration. Notable exceptions
to this recommendation may include patients who recover from peripartum cardiomyopathy, fulminant myocarditis, or stress cardiomyopathy, whose excellent long-term prognoses may imply true myocardial recovery. More research on these patients is needed to better understand the mechanisms that lead to improvement in ejection fraction and to guide their clinical management. HFrEF left ventricular ejection fraction management outcomes ACE angiotensin-converting enzyme ARB angiotensin receptor blocker CRT cardiac resynchronization therapyAbstract
Key Words
Abbreviations and Acronyms
HFiEF
heart failure with improved ejection fraction
HFrEF
heart failure with reduced ejection fraction
ICD
implantable cardioverter-defibrillator
LBBB
left bundle branch block
LVEF
left ventricular ejection fraction
PPCM
peripartum cardiomyopathy
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© 2018 by the American College of Cardiology Foundation. Published by Elsevier.
Purpose: The overall prognosis for patients with congestive heart failure is poor. Defining specific populations that might demonstrate improved survival has been difficult. We therefore examined our patient database for patients with congestive heart failure who demonstrated sustained improvement in left ventricular function and associated resolution of signs and symptoms of congestive heart failure.
Patients and methods: We identified 11 patients with severe congestive heart failure (average ejection fraction 21.9 +/- 4.23% (+/- SD) who developed spontaneous, marked improvement over a period of follow-up lasting 4.25 +/- 1.49 years. All 11 patients were initially symptomatic with exertional dyspnea and fatigue for a minimum duration of 3 months. They form a subset of a larger group of 97 patients with chronic congestive heart failure that we have followed with sequential ejection fraction measurements. All 11 patients were treated with digitalis diuretics, and either converting-enzyme inhibitors or a combination of isosorbide dinitrate and hydralazine. Ten of the 11 patients had a history consistent with chronic alcoholism, and each reportedly abstained from alcohol during follow-up.
Results: During the follow-up period, the average ejection fraction improved in 11 patients from 21.9 +/- 4.23% to 56.64 +/- 10.22%. Late follow-up indicates an average ejection fraction of 52.6 +/- 8.55% for the group. Congestive heart failure resolved in each case.
Conclusions: We conclude that selected patients with severe congestive heart failure can markedly improve their left ventricular function in association with complete resolution of heart failure. This appears to be particularly evident in those patients with chronic alcoholism who subsequently abstain.
How’s your heart pumping today? Admittedly, most people probably don’t know that answer off the top of their head.
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But knowing — and effectively managing — your ejection fraction can make a big impact on the quality of your life and health. Keeping tabs on it not only helps your doctor treat you more effectively but also leads to better outcomes.
Cardiologist J. Emanuel Finet, MD, says it straight: “Low ejection fraction is directly proportional to survival. By improving it, you improve your survival outlook.”
Dr. Finet does the math on ejection fraction and gives seven ways to help you improve your heart’s pumping power.
What is ejection fraction?
The heart has two main muscular chambers: the left and the right ventricle. Each chamber has MVP status in the body, working together to perform jobs you literally couldn’t live without:
- Right ventricle: Pumps blood to the lungs to get oxygenated.
- Left ventricle: Pumps oxygenated blood throughout your body.
A heart at rest holds a certain amount of blood. Ejection fraction refers to the percentage of that blood your heart pumps out with each beat.
“Assuming a normal heart size and rate, when ejection fraction is normal, the heart is pumping a normal amount of blood,” Dr. Finet explains. “We can assume the blood is moving at a normal speed around the body.”
But a low ejection fraction spells trouble. “Low ejection fraction means the ventricle is not contracting sufficiently to pump enough blood out of the heart,” he says. “If the ejection fraction is abnormal, that person has some degree of heart failure.”
What’s normal ejection fraction?
Doctors calculate your ejection fraction using imaging techniques such as an echocardiogram. They measure the result in percentages. Here’s a breakdown of the numbers:
- Normal ejection fraction (50% to 70%): Your heart is getting the job done!
- Mildly below normal (41% to 49%): Though you may not have symptoms, your heart has started to struggle to pump enough oxygen-rich blood throughout the body.
- Moderately below normal (30% to 40%): Patients experience heart failure with reduced left ventricular function symptoms. “The heart can’t supply the demands of the body because it can’t eject enough blood on every beat, so it increases in size and rate to compensate,” Dr. Finet explains.
- Severely below normal (less than 30%): Patients with an ejection fraction this low frequently have significant symptoms due to the body’s inability to compensate for it. In addition, the risk of life-threatening heart rhythm disturbances is increased.
How to improve your ejection fraction
Taking care of your ticker not only helps heart failure symptoms, but it may even improve your ejection fraction and overall survival. Here are some ways to do that:
1. Partner up with a doctor
Whether it’s a cardiologist or your primary care physician, talk to a doctor about your symptoms. Doctors have many ways to help manage heart failure. From medications to implantable cardioverter defibrillators, their heart failure toolkit is chock-full of effective options to improve your heart health.
2. Be a heart detective
Put this on your doctor’s to-do list, too. By identifying and treating the underlying causes of low ejection fraction, you take major steps toward improving your quality of life. For example, if hypothyroidism is part of the puzzle, doctors can work on managing your thyroid levels. Similarly, your blood pressure or diabetes may need attention, as well as other modifiable conditions.
3. Get moving
Is there anything exercise can’t help? Physical activity, in particular aerobic exercises, can help your heart meet your body’s demands. It’s a classic case of doing more with less.
“If the heart weakens and provides the body with less oxygenated blood, the body suffers,” Dr. Finet notes. “But if we help the body use that oxygen more efficiently, we may improve your overall condition even if we are unable to change your heart function.” Talk to your doctor about joining a cardiac rehabilitation program or about where to start if you want to do it on your own.
4. Watch your weight
“Losing weight won’t necessarily improve ejection fraction, but it can make you feel better,” Dr. Finet says. Tracking your weight will also help you and your doctor determine whether fluid is being built up due to the abnormal heart function.
5. Go on a salt strike
Consuming too much sodium, or salt, can have a domino effect:
- Diseased heart muscle, or cardiomyopathy, provides less blood to the kidneys.
- The kidneys retain sodium and fluid to compensate for the low blood flow.
- Sodium traps water, which abnormally accumulates on the heart and blood vessels.
- Patients can become congested, or volume overloaded, because they have too much fluid that further impairs the functioning of the heart.
- The excess fluid goes to the lungs, legs, liver and abdomen, causing the typical heart failure symptoms, such as shortness of breath, fatigue and swelling.
“So sodium for heart failure patients is like poison,” explains Dr. Finet, who recommends keeping salt consumption to no more than 1,500 to 2,000 milligrams per day. (A 1.5-ounce bag of potato chips is around 255 mg.)
6. Just say no
Eliminate substances that can cause more damage to your heart, such as alcohol, cocaine, amphetamines and cigarettes. These vices can tank your ejection fraction and worsen your symptoms.
7. Say goodbye to stress
Stress can raise your heart rate and blood pressure, which are heart failure no-nos. “Less stress can help patients improve their heart condition and help them feel better.”