The Left Ventricular Ejection Fraction (LVEF) measures how effectively the heart’s main pumping chamber, the left ventricle, pushes blood out to the body with each beat. Expressed as a percentage, it represents the fraction of blood leaving the ventricle compared to the total amount that filled it. A reduced LVEF often signals that the heart muscle is not functioning strongly, a condition known as Heart Failure with Reduced Ejection Fraction (HFrEF). While an HFrEF diagnosis is serious, the heart muscle often has the capacity for recovery. Comprehensive treatment plans involving medication, device therapies, and lifestyle changes can improve LVEF, reducing symptoms and improving long-term health outcomes.
Understanding LVEF and Its Significance
A normal LVEF typically falls within the range of 55% to 70%. An LVEF below 50% suggests the heart is not pumping efficiently, and 40% or less is used to diagnose HFrEF.
The primary objective of heart failure treatment is to increase this percentage, a process called reverse remodeling. An improved LVEF indicates the left ventricle is regaining strength, allowing it to move blood more effectively. Successfully increasing LVEF is associated with reduced symptoms, a decreased risk of hospitalization, and improved survival.
An LVEF below 35% is concerning because it significantly increases the risk of dangerous irregular heart rhythms, or ventricular arrhythmia. Improving LVEF helps mitigate this risk, making it a fundamental measure in guiding cardiovascular care.
Pharmacological Interventions
Medication forms the foundational treatment strategy for improving LVEF in patients with HFrEF. The current standard of care involves a combination of four major drug classes, often called the “Foundational Four,” which reduce strain on the heart and promote reverse remodeling. These medications are recommended to be started early to maximize benefit.
One cornerstone is the use of Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), or alternatively, ACE inhibitors or Angiotensin Receptor Blockers (ARBs). These drugs block the harmful effects of hormones that cause the heart muscle to weaken and enlarge. ARNIs, such as sacubitril/valsartan, are often preferred because they enhance natural peptides that relax blood vessels and reduce fluid retention, offering superior outcomes.
Beta-blockers are an essential class, working by slowing the heart rate and reducing the force of contraction. Reducing the heart’s workload over time allows the muscle to rest and recover, promoting an increase in LVEF. Mineralocorticoid Receptor Antagonists (MRAs), such as spironolactone, block the effects of aldosterone, a hormone that causes scarring and fluid buildup.
The fourth foundational class is the Sodium-Glucose Co-transporter 2 (SGLT2) inhibitors. These drugs, including dapagliflozin and empagliflozin, significantly benefit heart failure patients regardless of their blood sugar status. SGLT2 inhibitors offer substantial reductions in cardiovascular death and heart failure hospitalizations. The combined use of all four classes significantly reduces all-cause mortality compared to no treatment.
Device Therapies and Advanced Procedures
For patients whose LVEF remains low despite optimal medical therapy, or who are at high risk of sudden cardiac death, device-based treatments are necessary. An Implantable Cardioverter-Defibrillator (ICD) is surgically placed to continuously monitor the heart rhythm. If the heart enters a dangerously fast rhythm, the ICD delivers an electrical shock to restore a normal heartbeat, preventing sudden death.
The Cardiac Resynchronization Therapy (CRT) device, often combined with a defibrillator (CRT-D), is used when the ventricles are not contracting in a coordinated manner (ventricular dyssynchrony). The CRT device uses electrical impulses to stimulate both ventricles simultaneously, improving pumping efficiency. Patients with an LVEF of 35% or less are often candidates for CRT, and those who receive it have a higher likelihood of LVEF improvement.
When LVEF is severely compromised and other treatments fail, advanced options like a Left Ventricular Assist Device (LVAD) or a heart transplant may be considered. An LVAD is a mechanical pump implanted next to the heart to help the left ventricle circulate blood. While an LVAD does not directly improve LVEF, it significantly reduces the heart’s workload, sometimes allowing the native muscle to recover strength (myocardial recovery). Heart transplantation remains the definitive treatment for end-stage heart failure.
Essential Lifestyle Modifications
Alongside medical and device therapies, lifestyle adjustments are indispensable for maximizing LVEF improvement and managing symptoms. Strict sodium restriction is one of the most important changes, typically aiming for no more than 1,500 to 2,000 milligrams per day. Reducing salt intake prevents the body from retaining excess fluid, which decreases volume overload and strain on the heart muscle.
Managing fluid intake is also critical, as a high fluid load worsens congestion and symptoms. Patients should monitor their weight daily, as a rapid increase of several pounds signals fluid retention requiring immediate medical attention. This proactive tracking helps manage fluid balance before it further stresses the heart.
Regular physical activity, often initiated through a formal cardiac rehabilitation program, is a powerful tool for improving cardiorespiratory fitness and LVEF. Moderate-intensity exercise, such as walking for 20 to 40 minutes several times a week, strengthens the heart muscle and improves its function. Cessation of smoking and alcohol consumption is mandatory, as both substances are directly toxic to the heart muscle and can rapidly worsen LVEF.