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Assessment of left ventricular ejection fraction (LVEF)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Left ventricular ejection fraction is usually determined by echocardiography or radiographic ventriculography.

The ejection fraction is:

stroke volume = (end diastolic volume - end systolic volume)

ejection fraction = stroke volume / end diastolic volume

The ejection fraction is a good predictor of longevity in patients with heart failure but does not correlate with symptomatic limitation.

Systolic dysfunction

  • LV (left ventricular) systolic dysfunction is assessed using the EF (ejection fraction) (the percentage of the end diastolic volume ejected during systole)
    • in most cases, this is estimated by eye from all the available echo views
    • normal ejection fraction is 50%-80%, but values as low as 5% are compatible with life (end-stage heart failure)

    • what is an abnormal left ventricular ejection fraction?
      • current ACCF/AHA guidelines classify patients with a left ventricular ejection fraction (LVEF) of >=50% as having a preserved ejection fraction (1), and previous studies have found that asymptomatic patients with lower LVEF are at greater risk of developing HF
        • in a study of patients with untreated hypertension, an LVEF of <50% was associated with a 10-fold increased risk of incident HF, compared with patients with an LVEF of >50% (2)
        • the MESA (Multi-Ethnic Study of Atherosclerosis) study, an LVEF of <50% was associated with a 12-fold increased risk of HF and 3.5-fold increased risk of all-cause mortality (3)

    • classifications of heart failure using LVEF
      • Heart failure definition
        • Heart Failure with
          • Reduced ejection fraction (HFrEF) - LVEF<40%

          • Mid-range ejection fraction (HFmEF) - LVEF 40- 49%

          • Preserved ejection fraction (HFpEF) - LVEF>=50%

      • Heart failure definition
        • Systolic impairment and EF
          • Severe reduction - EF <35%

          • Moderate reduction - EF 35-39%

          • Mild reduction- 40-49%

          • Normal-EF>=50%

Diastolic dysfunction

  • if there is a normal LV ejection fraction in the presence of the heart failure syndrome leads to consideration of a diagnosis of diastolic dysfunction
  • in diastolic dysfunction typical echo findings in diastolic dysfunction are normal LV cavity size, thickened ventricle, and reversed E/A ratio

The E/A ratio

  • when flow across the MV is assessed with PW Doppler, two waves are characteristically seen
    • represent passive filling of the ventricle (early [E] wave)
    • active filling with atrial systole (atrial [A] wave)

    • classically, the E-wave velocity is slightly greater than that of the A wave
      • however, in conditions that limit the compliance of the LV, two abnormalities are possible:
        • reversal
          • the A wave is greater than the E wave
          • indicates slow filling caused by older age, hypertension, left ventricular hypertrophy (LVH), or diastolic dysfunction
        • exaggeration of normal
          • a tall, thin E wave with a small or absent A wave
          • indicates restrictive cardiomyopathy, constrictive pericarditis, or infiltrative cardiac disease (eg, amyloidosis)


  • Yancy CW, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2013; 62: e147-e239
  • Verdecchia P et al.i Asymptomatic left ventricular systolic dysfunction in essential hypertension: prevalence, determinants, and prognostic value Hypertension 2005; 45:412-418
  • Yeboah J et al. Prognosis of individuals with asymptomatic left ventricular systolic dysfunction in the Multi-Ethnic Study of Atherosclerosis (MESA) Circulation 2012;126:2713-2719
  • Walsh J. Nottinghamshire Heart Failure Traffic Light Guidelines. Nottingham University Hospitals NHS Trust (Accessed May 19th 2018)

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