Debate: Is LVEF Really that Important in Heart Failure?

PHILADELPHIA -- Left ventricular ejection fraction (LVEF or EF) was in the hot seat during a debate at the Heart Failure Society of America (HFSA) annual meeting.

Session participants convened ahead of planned efforts to update the American and European heart failure (HF) guidelines.

In one corner was Gregg Fonarow, MD, of UCLA Health in Los Angeles, arguing that LVEF is essential for the diagnosis of HF and its treatment by guideline-directed medical and device therapy.

"The use of EF is nearly ubiquitous in characterizing patients in clinical practice and research in HF. EF has and continues to be used as an indispensable component of the enrollment criteria in nearly every randomized clinical trial in HF," he noted.

"EF has proven to be of such substantial clinical and research value in the assessment and management of HF patients. There is a Class I recommendation for EF measurement and reassessment in every national and international HF guideline," Fonarow said.

But LVEF is not included in Framingham, Boston, or Gothenburg criteria for HF, countered Filippos Triposkiadis, MD, PhD, of Larissa University General Hospital in Larissa, Greece, who said that he himself does not often use it to diagnose HF.

"No index, including LVEF, should be used to subdivide HF," he emphatically told the HFSA audience. For one, EF is an index of "doubtful pathophysiological significance," he said.

He cited one study showing inter-modality variability in LVEFs measured by core labs using echocardiography, gated SPECT, and cardiovascular MRI. Investigators had reported that only 43%-54% of observations from these different imaging modalities shared LVEF similar findings (within a 5% range).

"Imagine what happens in the real world if the core labs do not agree on EF," Triposkiadis said.

Then the recent finding that links "supranormal" EF with poor outcomes is another reason not to use EF to classify HF, he added.

Ultimately, you don't need an EF to treat congestion: HF with reduced EF (HFrEF) and HF with preserved EF (HFpEF) should be treated the same way, according to Triposkiadis.

The medical management of every HF patient should begin with diuretics to treat congestion, followed by management of risk factors and comorbidities, and eventually neurohormonal blockade when necessary, he said.

It's reasonable to treat HFpEF patients with the latter as TOPCAT was felled as a trial not exactly because spironolactone (Aldactone) didn't work, but because many patients in Russia and Georgia might not have even had HFpEF or received the study drug, the presenter noted.

For the purposes of creating the next iteration of the guidelines, there may be some reconsideration of whether those with HF with "mid-range" or borderline EF (40%-50%) are necessarily different from those with HFrEF, Fonarow said, citing a recent JAMA editorial.

However, EF will continue to have an important role in the guidelines, he predicted. "We're not ready to completely throw out EF."

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