What's true about ejection fraction??

[Leah]

Hello. I've done a little private messaging on this topic in addition to a recent exchange within Aaron's "random newbie" thread on this forum.

Some members (indeed some particularly well-informed members) have articulated a belief that a normal ejection fraction (defined as 50-70%) which is at the upper end of normal suggests evidence that aortic stenosis is starting to take a toll. (This may be a gross paraphrase; I'm trying to capture the gist of the issue.) This conflicts with the responses I've gotten to my own lab results, where a consistent EF of 65-70% over the past four years (during which my AS went from "mild-to-moderate" to severe) was considered one piece of evidence that my heart function was not compromised. I'm posting, below, the same material from Cleveland Clinic's website that I posted on Aaron's thread. I'm not concerned about this for my decision-making, which has already led me (for other reasons) to conclude that it's "time" - but I'm curious to learn more about this since presumably my EF will continue to be measured for the rest of my life.

Are there sources that contradict the simple presentation from Cleveland, below? I'm looking forward to your posts.
Leah

http://my.clevelandclinic.org/heart/...nfraction.aspx

What is ejection fraction?
Ejection fraction is a test that determines how well your heart pumps with each beat.

Left ventricular ejection fraction (LVEF) is the measurement of how much blood is being pumped out of the left ventricle of the heart (the main pumping chamber) with each contraction.

Right ventricular ejection fraction (RVEF) is the measurement of how much blood is being pumped out of the right side of the heart to the lungs for oxygen.

In most cases, the term ?ejection fraction? refers to left ventricular ejection fraction.

What do the numbers mean?
Ejection fraction is usually expressed as a percentage. A normal heart pumps a little more than half the heart?s blood volume with each beat.

A normal LVEF ranges from 50-70%. A LVEF of 65, for example, means that 65% of the total amount of blood in the left ventricle is pumped out with each heartbeat.

The LVEF may be lower when the heart muscle has become damaged due to a heart attack, heart muscle disease (cardiomyopathy), or other causes

 

[tobagotwo]

It's a dichotomy, and it exists. 65% EF can be good or bad. When dealing with heart patients taken from an average population (like VR.com), it's a matter of probabilities.

65% -70% used to be considered above normal by most cardio sources (and still is by quite a few). It's only recently being considered normal because some very healthy, athletic people (and a very few by a unique heart shape they were born with) have that level of EF. The appearance is that it's inconvenient to deem them abnormal, because they then get lumped in with those who are unhealthy, and it leads to unnecessary concern in the healthy patients.

But are they really normal? Or are they just included for convenience? And what about the people for whom a 70% EF is not a good thing? Does it disguise their issues, make them feel safe when they’re not?

Let's say "normal" for EF were based on what most people are. That is what normal is supposed to mean, as I remember the term (Webster's: "conforming to a...regular pattern" and "occurring naturally").

Most people fall somewhere between 55%-64% in ejection fraction (that's the “regular pattern”).

In a person who has developed a 65%-70% EF from exercise (cycling, running, etc.), the EF will drop back from 65%-70% to 55%-64% over time, if the person stops the special exercise. So that’s what “occurs naturally,” when we don’t put unusual stress on the heart. So by both tests, people who have a 70% EF would not be considered "normal."

So now we’ve taken these folks out of “normal.” How does that help? It helps inthat it signals doctors to look for the reason the person has such a high EF. It’s a signal that these people need to be divided into two groups: those for whom it's good abnormal, and those for whom it's not so good. And that mostly depends on whether the enlargement of the left ventricle (which is required to increase the EF to 70%) is benign. In this case benign basically means it reaches a plateau and stops, rather than being progressive.

Well, the 36-year-old in-training exerciser with the 70% EF got that way by building up his heart muscle through physical stress (running, cycling, etc.). He basically has some level of benign left ventricular hypertrophy (although his LV isn’t necessarily outside the "normal" range of size).

However, the enlargement is conditional on the exercise. If the runner stops running, the EF and the VH will slowly subside back to the "normal" values.

So if the EF value doesn't comply with the "regular pattern" and it isn't "occurring naturally," it isn't normal. However, Arnold Schwartzenegger and Lance Armstrong are also "not normal" in similar ways, and it's been shown to be a physically good thing. So these heavily exercising people are abnormal in a physically good way.

The 52-year-old, mildly active office worker should have a 55%-64% EF. But instead, he also has a 70% EF. He also got it through physical stress to the heart, but his VH is not benign. It's not a temporary, plateaued VH and EF produced by exercise. It's caused by increasing stenosis and/or regurgitation in the valves that is increasingly stressing the heart muscle. It won't go back to 65%-70% on its own if he stops exercising. It will continue to grow over the years until it fails over and plummets to heart failure, unless it is corrected by surgery first.

In him, the 70% EF flags the early-to-mid stages of a years-long cycle of continued ventricular expansion that eventually leads to heart failure and death. So, should he be told that 70% is normal, even great, because Lance Armstrong’s heart is okay? Wouldn't it be better if it were considered warning track, so doctors felt compelled to investigate its cause? A different term, perhaps, like blood pressure: “PreHypertension,” in this case: “PreHypertrophy,” or even a more politically correct: “Divergent EF.”

In my nonmedical opinion, that 52-year-old patient should not leave the office thinking his EF is normal, good, or excellent. He should have the right to know that his 70% EF really means that his heart is coping with his condition capably today, but that the hypertrophy that is allowing it to function now will continue to progress over five to ten years to a point where his heart will fail, unless the underlying valve problem is corrected by surgery before then.

For those who will ask, there is a similar diagnostic dichotomy at the 50-54% end of “normal.” It could be fine for that person, or could be a problem or one developing. It just means that these bands of EF% should act as flags that the heart function should be further investigated to be certain the value has benign origins.

It’s many things, but it ain’t simple.

Best wishes,

 

[tobagotwo]

There is no final resource. The most agreed-upon values would be somewhere on the American College of Cardiologists site or the American Heart Association site. If you go from cardio site to cardio site on the web, you will still find quite a bit of variation in what each place considers "normal" EF values, although they are beginning to homogenize, because they don't want to stand out as different. As little as three years ago, CCF and Mayo's numbers still differed (you should be able to search that on the site).

Understand that the 65%-70 in a mildly-moderately active person with valve disease does mean that the heart is adjusting to and handling the load caused by the valve problem. In that way, it's a good thing. Right now: at this time. This part of the cycle is adaptive and positive.

It's just that over the course of years, the process doesn't stop, and the heart eventually develops beyond a point where it loses its mechanical advantage, and the size becomes a negative factor.

It's important to look at the Left Ventricle size in conjunction with the EF to determine where in the cycle you are.

Best wishes,

 

[skeptic49]

What a great discussion. I really am enjoying the reading on this site.

So, is EF as important of a marker as valve area, jet velocity, and the pressure gradient measurement?

Thank you guys and gals.

Jim

 

[Mary]

What a great discussion. I really am enjoying the reading on this site.

So, is EF as important of a marker as valve area, jet velocity, and the pressure gradient measurement?

Thank you guys and gals.

Jim

In relation to stenosis, no.

 

[Leah]

So now we?ve taken this folks out of ?normal.? How does that help? It helps inthat it signals doctors to look for the reason the person has such a high EF. It?s a signal that these people need to be divided into two groups: those for whom it's good abnormal, and those for whom it's not so good. And that mostly depends on whether the enlargement of the left ventricle (which is required to increase the EF to 70%) is benign.

So, on this theory, if there's no LV hypertrophy the "higher normal" EF would be read as benign? Or is that an oversimplification?

Thanks, too, for a fascinating parsing out of the issue. Can you pass on any research/studies that conclude this actually is the case? The logic makes sense - but, again, I haven't seen it written up this way in any literature I've read. It seems very logical that the very same EF number could indicate either a very high functioning heart or a heart that's starting to be stressed - but where in the literature does it say what the "cut-off point" is for this phenomenon and whether it is documented?

 

[tobagotwo]

So, on this theory, if there's no LV hypertrophy the "higher normal" EF would be read as benign? Or is that an oversimplification?

That's a trick question. You wouldn't be able to define "no LV hypertrophy" appropriately, if you're only using the one high-water mark that cardiologists use to mark it in everyone (>5.7 cm LVEDD).

If you start out with an LV end diastolic diameter of 3.5 cm (normal), and it's now 5.6 cm (still normal range), does that mean that you have no LVH? By the usual working definition, it does. I disagree.

If another person starts at 5.6 cm LVEDD (normal) and is now 5.8 cm LVEDD (hypertophic), do you think his 5.8 cm LVEDD is worse than your 5.5 cm LVEDD?

I certainly don't. Yours is 60% larger than it's supposed to be (for you). His is just a teeny 3.6% larger.

Yet he would be classified as hypertrophic, and you would not. He would be pulled aside for special attention. You would be told that yours is still in the normal range, and might not even get a second glance. He goes home concerned. You leave feeling you must be okay. Does that make sense?

My own definition of LV hypertrophy includes significant growth of the LV, regardless of whether it spans beyond the theoretical Magic Number.

So, you have to qualify, "no LV hypertrophy."

Of course, you would need the LVEDD from an echo that was done before or when you first started with the valve issue to know what your real starting point was.

Remember that LVH was only a tagalong that is tied loosely and belatedly with EF. Still, you can follow it through the same, whole, EF thought process: if you have significant LV expansion and you don't have a strong exercise reason (as in "six weeks into serious training for another race" - not, "I'm doing three days a week at the gym"), you have a huge potential that something is wrong, and it needs to be determined what it is and how bad it is before you are finished with your tests. Specifically, if you know you have AS or AR, it would mean that the chances are phenomenally high that you are in the adaptive phase of the LVH valve disease cycle.

My corollary: If you're a valve patient and are not highly physically active in a competitive sport, and you have a high EF or significant LV expansion, it is almost certain that you are in the adaptive LV phase of valve disease.

Best wishes,

 

[tobagotwo]

So, is EF as important of a marker as valve area, jet velocity, and the pressure gradient measurement?

EF wouldn't correspond directly to the valve area in AS. It would, however, bear a strong relation to the severity of your heart's response to the extra work it is forced to do to move blood through the restricted valve opening. Every heart responds differently to the stress, up to a point.

EF and LVH are strong measures of how much difficulty your heart is having with the valve problem, and how well it's coping with it. The estimated valve area and the pressure gradient are the primary measures of the severity of the stenosis itself. A combination of those measurements, along with any symptoms the patient is having (shortness of breath, angina pain, dizziness, palpitations, etc.) is used to determine the optimal timing of surgery.

Best wishes,

 

[Bina]

During my years of stenosis, I watched my valve area measurement.....as it decreased, my symptoms steadily worsened.
Surprisingly, not everyone has this happen.

 

[tobagotwo]

Yes, but you can't always trust what people say about their symptoms. Some symptoms, such as angina and SOB are often internalized by people, and they don't realize that they are having them, or what they are. Other people seem to pick up every symptom they hear about, even if they don't have the disease.

A primary example is angina, which most people seem to feel is a pain in the left chest or left arm that causes you to gasp and collapse. However, angina is a referred pain from the heart, and can often show up instead as jaw pain (frequently in women - dentists sometimes refer them to cardiologists), a sensation of a somewhat tight throat or of breathing cold air, a pain in the back, or even the neck. It's often not severe, but minor and nagging instead. Contrary to belief, it's not always felt during or after exertion, and sometimes visits when you're not doing anything noticeably strenuous at all.

Shortness of Breath is often ignored or explained away as getting older or out of shape. It's hard to tell if you've got SOB when you reach the top of the steps, because it seems like everyone is huffing and puffing by the time they get there.

There've been a number of people on the site who didn't realize that what they were feeling was symptoms until they compared it to what others were feeling, and how they themselves used to feel. There are some who hide them from themselves, because they are internally denying that they are sick (especially the young). And there are some, I suppose, who are just deaf to their body's messages.

We're our own worst judges of symptoms. We tend to either overemphasize and even invent them, or ignore them ruthlessly, no matter how plain they may be to others around us.

Best wishes,