by Alain Bouchard, MD 20 Comments
Heart function including ejection fraction (EF) is important in clinical practice because it is related to prognosis. Whether the patient suffers from valvular heart disease or ischemic heart disease, a measure of heart function including ejection fraction (EF) can predict future clinical outcome and assist in risk stratification. Several approaches to detect patients at risk for cardiac events have proven to be of value. These include exercise testing, assessment of exercise capacity, and determination of left ventricular function.
Ejection fraction (EF) is a percent measurement of how much blood the left ventricle (LV) pumps with each contraction. The left ventricle (LV) does not empty out with each contraction. Normally the left ventricle (LV) ejects between 50% and 70% of the blood it contains. Below is an echocardiogram of a patient with a normal ejection fraction (EF= 55-60%).
The stroke volume (SV) is calculated by taking the amount of blood estimated when the left ventricle is completely filled (end diastole= LVEDV = 131 ml) and subtracting the amount of blood remaining within the left ventricle when it is finished contracting (end-systole = LVESV = 55 ml). The derived stroke volume (SV = 76 ml) is then divided by the amount of blood contained when the left ventricle is completely filled (LVEDV = 131 ml) to obtain the ejection fraction (EF = 58%) (diagram below).
Patients with normal heart function and ejection fraction (EF) usually feel comfortable with exercise activity unless the patient is deconditioned and suffers from being sedentary. Another condition where patients can be suffering from shortness of breath but have a normal ejection fraction is called diastolic heart failure. The patients with this condition usually have a left ventricle with thicker and stiffer walls. The heart holds a smaller amount of blood and cannot meet the body’s needs. This is also called “heart failure with preserved ejection fraction” (HFPEF). Several elderly patients with hypertension and diabetes can be affected by this condition. Below is an MRI study followed by an echocardiogram of a patient with severe left ventricular hypertrophy and normal heart function and ejection fraction. You can see how such a thickened myocardial wall can lead to increased in stiffness and reduced compliance and elevated pressure within the left ventricle during diastole or when it is trying to fill.
A borderline heart function and ejection fraction (EF) (41-49%) can result from a cardiomyopathy, valvular heart disease or ischemic heart disease (pts with coronary artery blockages). This usually leads to shortness of breath during activity. Below is a patient with coronary disease and critical stenosis of the proximal LAD. There is hypokinesis or reduced contraction in the distal anterior wall and apex. This also contributes to a mildly reduced heart function and ejection fraction at 49%. This patient experienced shortness of breath running up a hill.
The MRI below was performed at Brookwood Baptist Medical Center at Princeton. The patient suffered an anterior myocardial infarction few months prior. Dr Bracer obtained the images using a 1.5T GE MRI system. We can see some hypokinesis of the anterior wall and overall mildly reduced heart function and ejection fraction.
A reduced heart function and ejection fraction (EF) (<40%) usually manifests as fatigue and shortness of breath, sometimes even at rest. It is usually a manifestation of a cardiomyopathy and it can be ischemic or non-ischemic. Below is an example of a patient with severe non-ischemic cardiomyopathy and ejection fraction of less than 20%. The echocardiogram depicts an enlarged and weakened left ventricle.
Below is an MRI of a patient who suffered an extensive myocardial infarction. The patient presented as an anterior STEMI with total occlusion of the LAD. Despite early intervention and PCI with coronary stenting of the LAD, the patient suffered extensive damage with a large scar involving the distal antero-septum, apex and distal antero-lateral walls (yellow arrow). Notice the thinning and absence of contraction of these walls. The global function is severely reduced and there is evidence of clinical heart failure with bilateral pleural effusions (blue arrow). In addition, there is a small pericardial effusion surrounding the right ventricle and in part the right atrium (red arrow).
In patients with valvular insufficiency or ischemic heart disease, the enlargement of the left ventricular volume (particularly end-systolic LVESV) can be related to a poor prognosis. For this reason, serial measurements of left ventricular size and function are used to follow these patients so that surgical intervention can be performed prior to irreversible damage to the heart is done. Similarly, patients recovering from a large myocardial infarction can develop adverse left ventricular remodeling leading to irreversible damage and the development of clinical heart failure. Below is an MRI study of a patient who sustained a large anterior myocardial infarction. At baseline(upper image), the left ventricular end-diastolic volume (LVEDV) measured 250 ml, the end systolic volume (LVESV) 173 ml with reduced heart function and ejection fraction (EF) 30%. One year later, another MRI study (lower image) was performed on the same patient and revealed an enlargement of left ventricular size with LVEDV of 314 ml, LVESV of 241 ml and a weakening of the heart function and ejection fraction EF of 23%. This is called adverse remodeling and has a poorer prognosis in patients after a myocardial infarction.
Assessing regional function or wall motion of the left ventricle allows for the detection of ischemic heart disease (patients with coronary artery blockages). It can also detect areas of myocardial fibrosis or scarring. Regional wall motion abnormality has been linked to prognosis. In the Strong Heart study for example, men older than 60 years of age with segmental wall motion were found to have a 2.5 fold increase in coronary vascular events.
The normal wall motion of the heart is represented by a normal wall thickening during the contraction of the left ventricle. Regional heart function abnormality can be described as a weakening of the contraction of some parts of the heart muscle. This does not always lead to weakening of the global heart function. It usually depends on the degree and the extent of the heart walls involved. Below are two MRI studies depicting extensive antero-apical scars (yellow arrows). These patients suffered anterior STEMIs caused by occlusion of the proximal LAD or widow maker. This results in a large area of myocardial damage with thinning and absence of contraction (akinesis) of the walls. The area of damage is large and affects the global function of the heart. The left ventricle is enlarged and the heart function and ejection fraction EF is severely reduced (<20%).
Experimental studies have shown that a reduction of coronary blood flow resulting from transient occlusion or progressive constriction of a coronary artery results in the segmental wall motion abnormality. Studies by Gould have shown that such a reduction of coronary blood flow at rest is not present until the severity of the stenosis or narrowing exceeds 85%. Restoration of normal flow is associated with an eventual return to normal wall motion. In patients with coronary artery disease and without a previous myocardial infarction, segmental wall motion abnormality increases with decreased coronary blood flow. Myocardial perfusion using nuclear imaging technique correlates well with segmental wall motion analysis. In patients without a prior myocardial infarction, resting or stress-induced wall motion abnormalities, occur almost exclusively in regions with jeopardized perfusion. These regional abnormalities are potentially reversible when treated with myocardial revascularization (PCI or CABG). Recovery of segmental wall motion is seen also in patients treated after a myocardial infarction. Below is a patient treated with a non STEMI myocardial infarction. The wall motion abnormality (akinesis or absence of thickening) (yellow arrow, upper image) was restored toward normal (hypokinesis, yellow arrow, lower image) by reopening his artery using percutaneous coronary intervention and potentially by the stem-cell therapy that he may have received as part of the Athersys trial.
If you like the information in this article, make sure you read: Can heart attack damage be reversed? Stem cells in the treatment of a heart attack: a non-STEMI. Surviving a heart attack; the Big one and Stem cells in the treatment of Heart Failure.
We would like to acknowledge the expertise of Jay Roberson at VitalEngine and Dr Ricardo Bracer for the MRI imaging.
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FAQs
Heart Function Including Ejection Fraction (EF) • MyHeart? ›
Ejection fraction (EF) is a percent measurement of how much blood the left ventricle (LV) pumps with each contraction. The left ventricle (LV) does not empty out with each contraction. Normally the left ventricle (LV) ejects between 50% and 70% of the blood it contains.
What EF is considered heart failure? ›Ejection fraction is measured as a percentage of the total amount of blood in your heart that is pumped out with each heartbeat. A normal ejection fraction is 50 percent or higher. An ejection fraction below 40 percent means your heart isn't pumping enough blood and may be failing.
What is the normal range for EF? ›According to the American Heart Association: A left ventricle (LV) ejection fraction of about 50% to 70% is categorized as normal. A mildly reduced LV ejection fraction is usually between 41% and 49%. A reduced LV ejection fraction is usually 40% or less.
What is a good ejection fraction for a 70 year old? ›A normal ejection fraction of 55 to 65% is considered a sign of a healthy heart. People with an ejection fraction lower than 50% might be suffering from systolic heart failure. This is also termed Heart Failure with reduced ejection fraction.
How can I improve my EF heart function? ›- Eat a heart-healthy, low-sodium diet.
- Quit smoking (or don't start)
- Avoid alcohol or reduce intake.
- Exercise regularly, such as daily walks.
- Get to and stay at a healthy weight.
Additionally, how much blood a person's heart pumps out per beat, known as the ejection fraction (EF), may affect life expectancy. Doctors will note a patient's EF as a percentage, with a normal output falling between 50–70% . Patients with an EF under 40% may be at a greater risk of dying from CHF.
Can exercise improve ejection fraction? ›While physical activity and exercise are beneficial for patients with Heart Failure with Reduced Ejection Fraction (HFrEF) or Heart Failure with Preserved Ejection Fraction (HFpEF), there is a lack of consensus regarding the most effective intensity.
What happens if EF is low? ›A low ejection fraction (or low EF) is typically 45 or less and can be evidence of heart failure or cardiomyopathy (a disease of the heart muscle). The heart's ejection fraction (EF) refers to the amount – or percentage – of blood pumped (or ejected) out of the heart's left ventricle with each contraction.
What drugs improve ejection fraction? ›The mainstay of medical treatment for patients with heart failure with reduced ejection fraction (HFrEF) are beta blockers (BB), angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and mineralocorticoid receptor antagonists (MRA).
What foods improve ejection fraction? ›The DASH diet emphasizes consumption of fruits, vegetables, whole grains, poultry, fish, nuts, and low-fat dairy products and minimizes consumption of red meat, sweets, and sugar-sweetened beverages. The DASH diet has attracted much attention due to its evidence-based beneficial effects on blood pressure [13–17].
What is the lowest ejection fraction you can live with? ›
A low number can be serious. If your ejection fraction is 35% or below, you're at high risk of developing a dangerous arrhythmia or even heart failure.
Is 45 EF considered heart failure? ›Many doctors consider a normal ejection fraction to be 55% to 75%. If yours is 50% or lower, it's a sign that your heart -- usually your left ventricle -- may not pump out enough blood. There's a gray area when your EF is between 50% and 55%. Some experts call this borderline.
Is 80 ejection fraction bad? ›What is a normal ejection fraction? Ejection fraction in a healthy heart is 50% to 70%. With each heartbeat, 50% to 70% of the blood in your left ventricle gets pumped out to your body.
What is the best exercise for heart failure? ›Ms Eriksen recommends doing an aerobic activity (something where you're moving most of your body, which will increase your heart and breathing rate a little, such as moving to music or walking around) and resistance work, where you add light weights to build muscle strength.
Can your heart recover from low ejection fraction? ›Abstract. It has been recently recognized that recovery of left ventricular ejection fraction (EF), termed "recovered EF", occurs in a proportion of heart failure patients with reduced EF (HFrEF), and is associated with better prognosis.
How long does it take for EF to improve? ›In this study, significant improvements were seen in left ventricular ejection fraction (LVEF). At 12 months, the LVEF increased from a median of 28.2% to 37.8% (difference, 9.4% [95% CI, 8.8 to 9.9%]). A significant 5.2% increase in LVEF was also seen as early as 6 months (5.2%, 95% CI, 4.8% to 5.6%).
Can stress affect ejection fraction? ›Background A decline in left ventricular (LV) ejection fraction in response to mental stress and exercise is regarded as an indicator of myocardial ischemia. In patients with LV dysfunction, the ejection fraction is sensitive to afterload, which increases during stress.
Can you live 20 years with heart failure? ›In general, about half of all people diagnosed with congestive heart failure will survive 5 years. About 30% will survive for 10 years. In patients who receive a heart transplant, about 21% of patients are alive 20 years later.
What is the most common cause of heart failure with reduced ejection fraction? ›Chronic conditions that damage or weaken the heart muscles are the main cause of heart failure with reduced ejection fraction. For example, coronary heart disease or a heart attack can prevent your heart muscle from getting enough oxygen.
How do you reverse low ejection fraction? ›- Partner up with a doctor. Whether it's a cardiologist or your primary care physician, talk to a doctor about your symptoms. ...
- Be a heart detective. Put this on your doctor's to-do list, too. ...
- Get moving. ...
- Watch your weight. ...
- Go on a salt strike. ...
- Just say no. ...
- Say goodbye to stress.
What is the best exercise for low ejection fraction? ›
- Light stretching or light yoga.
- Walking on a flat surface or around your home.
- Walking a dog around your block.
- Pilates or a gentle exercise class at the gym.
- Swimming or water walking.
- Gentle biking on a flat road.
Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation.
Does low EF increase risk of stroke? ›Patients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable.
Can low ejection fraction cause memory loss? ›Post hoc multivariate analysis showed that verbal delayed recall and recognition were the components of memory most affected by low EF.
What vitamins help low ejection fraction? ›Carnitine. Carnitine is important for cardiac energy metabolism. Clinical trials have shown that carnitine supplementation improved cardiac efficiency, left ventricle ejection fraction, and 3-year survival rates in heart failure patients.
Is Coffee good for the heart? ›According to the American College of Cardiology, drinking two to three cups of coffee per day is associated with maintaining a healthy heart.
Does vitamin D increase ejection fraction? ›Supplementation with vitamin D can increase ejection fraction for 3.304% [95%CI 0.954, 5.654] in heart failure patients.
What drinks are good for your heart? ›- Sparkling water (try adding chopped fruit or herbs; for example, fresh mint).
- Unflavoured milk.
- Plant-based milks with added calcium, like soy, almond, oat, rice milk.
- Tea.
- Coffee.
- Small glass (125ml) of 100% fruit or vegetable juice.
LV concentricity and ejection fraction increased with age. Whether the increase in concentricity represents normal healthy aging or subclinical disease remains to be investigated.
Is EF 40 bad? ›EFs between 50% and 70% are considered normal for the left ventricle. An EF under or equal to 40% means the muscle is weakened and you may have heart failure. This is called heart failure with reduced ejection fraction.
What is the treatment for ejection fraction of 35? ›
In symptomatic patients with an LVEF ≤ 35% defibrillator implantation is recommended in order to prevent sudden cardiac death.
What is a normal echo test report? ›A normal EF is about 55-65 per cent. It's important to understand that “normal” is not 100 per cent. Measuring the EF helps your doctor to understand how well the heart is pumping. Generally an EF below 40 per cent is considered a sign that the heart is not pumping as well as it should.
Does ejection fraction predict mortality? ›Left ventricular ejection fraction (LVEF) is an important predictor of mortality in heart failure (HF) patients and is used to define many drug and device therapeutic indications.
What is end stage heart failure? ›In end stage heart failure, the body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery. A person may find it difficult to breathe even when they are resting.
Can echo test detect heart blockage? ›Doppler echocardiogram.
This part of the test measures the speed and direction of blood flow within the heart and vessels. It can help show blocked or leaking valves and check blood pressure in the heart arteries.
Walking helps congestive heart failure patients in several ways: Reduces heart attack risk, including cutting the risk of having a second heart attack. Strengthens their hearts and improves lung function. Long term, aerobic activity improves your heart's ability to pump blood to your lungs and throughout your body.
Should I rest with heart failure? ›BHF researchers have shown the value of regular, deliberate, physical exercise in heart failure - this not only reduces everyday symptoms but seems to prevent sudden deterioration and even deaths. Feel free to take a break when you need to, but it is the exercise and not the rest that does you good.
How can I make my heart stronger after heart failure? ›- Modify daily activities and get enough rest to avoid stressing the heart.
- Eat a heart-healthy diet that is low in sodium and fat.
- Don't smoke and avoid exposure to second-hand smoke.
- Don't drink alcohol or limit intake to no more than one drink two or three times a week.
- Lose weight.
Coronary artery bypass grafting (CABG) has shown to be superior to medical therapy alone for low EF patients, demonstrating significant clinical improvement and long-term survival.
Can a pacemaker improve heart failure? ›A pacemaker can slow down the progression of heart failure. It may help keep you out of the hospital and help you live longer. If you get a pacemaker, you still need to take medicines for heart failure. You'll also need to follow a healthy lifestyle to help treat heart failure.
Can you have reduced EF without heart failure? ›
Left ventricular (LV) remodeling and reduced ejection fraction (EF) should be distinguished from the syndrome of clinical heart failure (HF). When LVEF is reduced (! 40%), but there are no signs and symptoms of HF, the condition frequently is referred to as asymptomatic LV dys- function (ALVD).
What is the new wonder drug for heart failure? ›Today, the U.S. Food and Drug Administration approved Jardiance (empagliflozin) to reduce the risk of cardiovascular death and hospitalization for heart failure in adults.
Is low EF considered heart failure? ›A low ejection fraction (or low EF) is typically 45 or less and can be evidence of heart failure or cardiomyopathy (a disease of the heart muscle). The heart's ejection fraction (EF) refers to the amount – or percentage – of blood pumped (or ejected) out of the heart's left ventricle with each contraction.
Is EF 35 heart failure? ›Ejection fraction (40% to 54%): This percentage shows that your heart's pumping ability is slightly below normal. Ejection fraction (35% to 39%): This percentage shows that your heart's pumping ability is moderately below normal. This could mean that you have heart failure with reduced EF (HF-rEF).
What is the range for heart failure with reduced ejection fraction? ›40% to 49% is mid-range ejection fraction: The heart's pumping ability is slightly below normal. You might not experience heart failure symptoms. Or, you may have symptoms with physical activity but not at rest. 39% or less is heart failure with reduced ejection fraction (HFrEF): Pumping ability is below normal.
How bad is an ejection fraction of 20? ›In heart failure, the EF number can become very low. An EF of 20% is about one-third of the normal ejection fraction. The heart is not pumping all the oxygen-rich blood the body needs. The blood that is not ejected from the ventricle can back up into the lungs and cause shortness of breath.
How does a low ejection fraction make you feel? ›With a low ejection fraction, you might have: Fatigue (feeling tired all the time) Shortness of breath. Rapid heartbeat.
How long does it take to improve ejection fraction? ›At 12 months, the LVEF increased from a median of 28.2% to 37.8% (difference, 9.4% [95% CI, 8.8 to 9.9%]). A significant 5.2% increase in LVEF was also seen as early as 6 months (5.2%, 95% CI, 4.8% to 5.6%). Importantly, 25% of patients experienced an absolute LVEF increase of more than 13%.
Can you live with an ejection fraction of 35? ›If your heart failure involves a reduced ejection fraction, your doctor will watch that number closely. If it drops too low, to 35% or below, you have a higher risk of a possibly life-threatening heart rhythm. Staging.
How long can you live with 30 percent ejection fraction? ›With this model, patients whose only risk factor was EF ≤30% had a 2-year total mortality risk of only 6.2% and a 2-year risk for arrhythmic death or cardiac arrest of only 3.5%.
How do you treat EF less than 35? ›
In symptomatic patients with an LVEF ≤ 35% defibrillator implantation is recommended in order to prevent sudden cardiac death.
What stage of heart failure is 30 ejection fraction? ›Normal EF is in the range of 55% to 70%. As the percentage falls, it tells the doctor that the heart failure is getting worse. In general, if the EF falls below 30%, it's relatively severe. A reading of 20% or below is very severe heart failure.
What is the life expectancy of a person with 20 percent heart function? ›So, with 20% heart function a person is said to have a life expectancy of about 2-5 years depending on the age, previous medical history and life aids provided.
Does ejection fraction mean blockage? ›Low ejection fraction causes
Coronary artery disease, where plaque builds up in the two main arteries that supply blood to your heart and blocks blood flow. Heart attack, when blood flow to your heart muscle became blocked and damaged.
And some of the devices that can be combined with the defibrillator can also improve ejection fraction or help improve the ejection fraction beyond medical therapy.