Tips for Treating Patients With Borderline Ejection Fraction

By Annette M. Boyle, Contributor
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It’s no surprise that determining how to treat heart failure patients with borderline or mid-range ejection fraction remains a bit of a mystery—the American College of Cardiology and American Heart Association (ACC/AHA) guidelines didn’t define the term until 2013. What is surprising is that this under-researched type of heart failure affects so many patients, about 1.6 million people in the U.S. alone.

Whether you go with the ACC/AHA definition of left ventricular ejection fraction (LVEF) of 41% to 49% or the European Society of Cardiology (ESC) definition of LVEF of 40% to 49%, questions remain about whether these patients are more like those with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF).

To help clinicians make the best care decisions for patients with borderline ejection fraction, researchers from the David Geffen School of Medicine at the University of California, Los Angeles, summarized what’s known and what’s recommended for these patients in an article published in JACC: Heart Failure.

Heart coronal. (Source: Creative Commons)

Generally, patients with borderline EF to have similar clinical profiles and mortality rates to patients with preserved EF. The review authors suggested that HFmrEF may be a mid-point between HFpEF and HFrEF that represents patients with slowly deteriorating function.

Patients with borderline ejection fraction share a propensity to coronary artery disease with HFrEF patients and should be screened for it, according to the researchers. They also recommended managing HFmrEF patients with coronary artery disease to prevent or slow progression of left ventricular systolic dysfunction.

Compared to other types of heart failure patients, they have an increased risk of heart failure hospitalizations caused by uncontrolled hypertension and may have some systolic and diastolic dysfunction. Consequently, clinicians should work with patients with borderline ejection fraction to lower their blood pressure, the authors wrote.

Both chronic obstructive pulmonary disease and chronic kidney disease are associated with higher mortality rates in patients with HFmrEF that with those who have other types of heart failure.

The guidelines advised using diuretics for patients who have congestion.

Because no current therapies have demonstrated efficacy in patients with borderline ejection fraction, the ACC/AHA and ESC recommendations center on management of comorbidities and risk factors.

The researchers stated, however, that the Trial of Intensified Versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF) study indicated that patients with borderline ejection fraction benefited from management based on N-terminal pro-brain-type natriuretic peptide levels. Using the biomarker to guide therapy, reduced rates of hospitalization in patients with both HFrEF and HFmrEF, though not in patients with preserved ejection fraction, the authors wrote.

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