Normal Ejection Fraction in Adults
A normal left ventricular ejection fraction (LVEF) in adults ranges from 50% to 70%, with a midpoint of 60%. 1, 2
Standard Reference Ranges
The established normal LVEF values vary slightly depending on the measurement method and guideline source:
- ACC/AHA Guidelines: Normal LVEF is 50-70% (midpoint 60%) 1, 2
- European Society of Cardiology: Normal range is 53-73% (mean 63 ± 5%) using the biplane method of discs, regardless of age, gender, or body size 1
- Lower limit of normal: Generally accepted as 50%, with values below this indicating some degree of left ventricular systolic dysfunction 2
LVEF Classification Categories
The ACC/AHA guidelines classify LVEF as follows:
- Hyperdynamic: Greater than 70% 1, 2
- Normal: 50% to 70% 1, 2
- Mildly reduced: 40% to 49% (also called "low normal" when 50-55%) 1, 2
- Moderately reduced: 30% to 39% 1, 2
- Severely reduced: Less than 30% 1, 2
Measurement Method Considerations
The biplane method of discs (modified Simpson's rule) is the recommended measurement technique, obtained from apical four-chamber and two-chamber views, as it is particularly reliable in abnormally shaped ventricles. 1
Different imaging modalities have specific normal ranges:
- 2D Echocardiography (Biplane Simpson's): 53-73% (mean 63 ± 5%) 1
- 3D Echocardiography: 52-72% for women (mean 62 ± 5%) 1
- Radionuclide ventriculography, MRI, and contrast ventriculography are also preferred modalities for quantitative LVEF measurement 1
Important Clinical Caveats
LVEF measurement varies between imaging modalities and interpreters, with potential differences of 5-7% between studies due to technical factors rather than actual changes in cardiac function. 1, 2
Key pitfalls to avoid:
- A single LVEF measurement may not be adequate, particularly for borderline values (41-49% or 50-55%), and serial measurements using the same equipment and methodology are recommended 1, 2
- LVEF is load-dependent and cannot distinguish between preload, afterload, and intrinsic contractility 1
- Higher LVEF does not always mean better cardiac function—values >70% may indicate hypovolemia, small ventricular cavity, or compensatory mechanisms rather than superior function 1
- Low normal LVEF (50-55%) carries increased risk: in asymptomatic adults, this range is associated with 3.64-fold increased risk of incident heart failure compared to LVEF ≥55%, though not increased mortality 3
Special Population Considerations
- Patients with cirrhosis: Typically have hyperdynamic circulation with EF greater than 70-75%, so an EF >60% may be more appropriate as a cutoff for normal in this population 4
- Elderly women: More commonly present with heart failure and preserved EF (≥50%), often with systolic hypertension as the underlying cause 5, 6
- Very high EF (>65%) in elderly women after acute coronary syndrome is paradoxically associated with increased mortality compared to normal EF (55-65%) 7
When to Consider Alternative Assessment
When EF appears preserved but dysfunction is suspected, consider global longitudinal strain (GLS), with normal values being more negative than -16%; values less negative than -16% indicate mild depression, and less negative than -10% indicate severe reduction. 1