This a story from a middle aged IT professional who had recently suffered from a cardiac event. His concern is, he has an ejection fraction (EF) of 45%, finds difficult to walk to the nearby mall ,while his neighbour, also a heart patient, has only 32% EF , but goes for cycling and hiking ! He finds this very odd and totally unacceptable. .He desperately needed an answer from his cardiologist.
How is this possible, doctor? I am sort of depressed for two reasons. You are saying, I had only a mild heart attack and recovered well with no significant blocks in the angiogram, but, I still find it difficult to do routine activities. The latest EF is recorded as 45%. I am taking all your medications sincerely.
“Doctor, I feel awkward, but I can’t stop asking this question to you. More than my heart condition, it is my neighbour’s one that is bothering me. He was critically ill sometime back. Has undergone a bypass, after two early stent failures, I am seeing him daily now. So active he is, able to hike even the hill in our county. He told me his EF is just 32%. It sounds atrocious. What is the use of having more EF than him, doctor ? Do you think I need to be referred to any specialized cardiac centre ?”
“My dear patient, relax. If you want a straight-forward answer, “you are suffering from EF neurosis” Exercise capacity and overall well-being of an individual have little to do with the Ejection Fraction (EF) of the heart. Forget that number”.
“Sorry doctor, I am not clear , do you mean to say I have a mental health issue? ”
Ok , let me go little more deeper for the sake of your understanding. Hope you don’t mind. EF% can be sort of the daily weather report. It can change even beat to beat depending upon the loading conditions of the heart. We, the cardiologists are partly responsible for creating this anxiety at your level with this number .The prevailing literature and the confused google , has misled you guys, to believe that EF% is akin to “bank balance” of available heart function. Let me apologize on behalf of all of us.
There are many cardiac and non-cardiac parameters that determine one’s exercise capacity. Lung function is vital. Systemic factors like quality of your Hb%, renal function, lastly, the most important factor, the status of your skeletal muscle structure and function. If I can go technical, the degree of LV size, associated MR, the stress of LV filling, pulmonary vein compliance, the way your lung vasculature reacts, RV function, degree of PH, all that matters.
In your case, each of these parameters is good. So, I can reiterate that your heart is in fairly good condition. It is most likely that your skeletal muscles are hibernating and taking too much rest, and their mitochondria are suffering from disuse. Further, your thinking pattern also makes you easily fatigued. You must also understand dyspnoea is a cortical sensory perception defect. It depends upon the behaviour of your cerebral centres that are localized in the amygdala nuclei.
“Please doctor, I expected a practical solution from you”
“Ok, let me tell you a positive proposal which will definitely help. Trust your heart and believe in my words and the drugs you take. Ignore this EF stuff. Send a friend’s request immediately to your neighbour and join him on his daily hiking. If he can do it, you can also do it. I expect ,both the issues that is causing you depression will vanish soon. One caution, don’t overexert. Stop 10 to 20% short of your maximum possible capacity.”
“Thank you doctor , I think you’re right I am not taking enough efforts and lack confidence .Will meet you again with good news “
Final message
Unless, it is extremely low contractile function, EF% has no linear correlation with functional capacity. This is the message to all those heart failure patients. Don’t feel bad if you are labelled as LV dysfunction or ‘Heart failure’. You can steal a success story from with the help of skeletal muscle training and dyspnea sensitization program (This is not a great new discovery, it’s all there in the ancient Indian medicine, it was called pranayama, a controlled regular breathing exercise)
Reference
Dr.S.Venkatesan MD 